Assessment Of Patients Via Nurses Case Study By New Assignment Help!
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Assessing a patient's issues, needs or problems is very basic for health care proceedings; it is an integral part of the treatment or providing required service to a certain patient. It is also important as it helps in ensuring patient's health-wise safety during the appointment. Also, each of the practices associated directly or remotely with the assessment process is dedicated to maintaining safety, and mitigate the scope of any injuries or accidents. In the case of nursing assessment, the practices include performing a medical history background check and then conduct specific physical exams, these exams are not just to detect the relevant symptoms, it also helps in ensuring that no potential medical risk would predispose while the actual procedure or surgery will take place relevant to the medical emergency or requirement. Also as the Nurses are the key elements of providing the required care, assessment helps them in forming a care plan and to plan that the nurses need to examine the patients holistically and then detect their actual needs. Also, nurses proceed by assessment as it helps them in incorporating the recognition of abnormal versus normal body physiology.
As it is mentioned that the assessment is the most basic and integral part of the primary care plan and with the implementation of the care plan and with the help of devising strategies the patient would be able to cope up with the symptoms and overcome the respective physical or mental barriers. Also assessing patients is a very regular task, as it can help the nurses to keep track of the progress and the impact of the care plan and according to those reviews, they can revise the care plan and perform a further deep assessment of patients medical condition or situation.
Evaluation is also very vital in the context of healthcare, as it focuses on the evidence-based approach towards the practice delivery (Moule et al. 2017). It can provide the most accurate judgment on the ongoing procedure and identify the aspects which are working as well as the ones which are not working, this is how the nurses can revise their care plan and make the necessary adjustment. Also, it helps the nurses in providing their judgment or opinion about the effectiveness of the treatment or services provided to the patient towards their superior, mostly to the doctor.
Main Body
This report is going to discuss the implementation of underlying concepts and strategies within the assessment of the patients by the nurses, also the report is going to interpret how the assessment process helps in providing the care plan and how the knowledge of physiology, anatomy, the pathophysiology of a respective professional nurse can help him or her in assessing the patient needs and imply care plan (Zeid Abadi et al. 2017). To make the report more accurate and specific this report is going to provide those above-mentioned insights in regards to two specific case studies from two different patients
The first case study is about a woman, from chesterfield. At the time of the assessment, she is 34 years of age and a single mother. She is not on any medication and also she is physically very fit and well, her weight is just above the average, nothing to worry about in that part. Also, vocal background checks up provided information like, she have not been majorly sick for a while, no history of major accidents or incident which can physical hurt her (Rachel et al. 2019). She is unaware of her allergies, or whether she has any. She is a single mother to two children, of the respective ages of three and five. Also by profession, she is a teacher. She teaches children in a local primary school. So it is evident that her life is stressful, as it takes a lot of effort and time to take care of two kids, specifically kids under six years of age and she also has to manage her work and in work also she has to take care of class full of kids.
Although physical stress is not the key problem, the patient is struggling to live her daily life and her mental health is deteriorating.
As it is very evident from the previous medical history and her statements that the woman does not have any physical health condition. Some of the issues she is facing could indeed be associated with physical conditions, such as feeling tired, this can be hormonal like some the haemoglobin level can influence people's sleep or thyroid hormones can cause influence too (Bdair and Maribbay, 2020). Although after the primary conversation the preferred tools or methods for accurate assessment would be, first there would be some physical examination and relevant blood tests, so the presence of any physical illness can be eliminated completely and the focus could be on the mental condition of the patient. In this case, the preferred tools would be
As the methods and tools would be adequate to recognise the symptoms and associated diseases. In this case, the woman is facing many problems and her daily tasks are becoming a burden for her, so the conversation or interview is not easy to analyse and utilise the problem. Instead, effective communication and active listening help her in trusting the process and open up (Pölkki et al. 2018). Then with the help of observation and tools like a checklist and standardised test it becomes identified that she needs professional help, the basic knowledge of psychology helps in detecting the disease from the potential symptoms, such as; excessive sadness, unable to find peace, or happiness within anything, anxiety within familiar places, even between closed ones, feeling tired or unwilling to do anything, crying all day. All these symptoms and the knowledge can help the nurses to assess that she is going through post-traumatic disorder after she lost her loved one suddenly. She requires proper treatment in form of consultant and psychologist sessions and medication in regards to major depression, panic disorder, anxiety disorder, chronic insomnia.
The potential problem regarding this case study is that the patient is not clear about her own answers, only thing that is clear that she fails to cope up with her loved one’s death and now she fails to do anything from her daily routine in normal manner. Although assessment helped in understanding the symptoms, but as they are so many and related to myriad mental illness, that from a nursing perspective, it became complex to focus on too many diseases and complete the assessment.
As it is mentioned that even after making the conversation as a safe place for the patient, in this case, the patient is going through a wised range of negative emotions and going through many symptoms so it is hard to assess the accurate and specific ones, as all of them are co reacted but still with tool and observations such as questionnaires helps in assessing that she feels tired all the time but she can barely sleep and also observation helps in assessing the tiredness within her so it makes it easy for the nurse to assess that she is experiencing insomnia and the checklist confirms it and rate scale suggest that it can be acute or transient insomnia (Skog et al. 2020). Also, the observation and checklist help in understanding how the present loses all her will to perform her basic daily tasks and also standardised test result suggested that she is extremely upset from her loss and still stand on the same ground and all of these suggested that she is going through post-traumatic conditions and rating scale helps in detecting the major depression. These assessments then can be passed as integral information about the patient and further treatment can be specific to her issues (aacnjournals.org, 2020).
For this case study, the chosen patient is completely different and the problems faced by the patient are also very different from the previous one. This case study is about a 88 years of age Man from Bakewell. The patient lives on his own although he once had a wife and took care of her until she dies. Right now the most concerned family member of the patient is his daughter, who is the one who needs to be informed about the patient’s condition on daily basis and that is also a responsibility of health care professionals, mostly done by the nurses. He also has some problems with his hearing, his left ear is partially deaf, and wears a hearing aid (Kendall-Raynor, 2017). The patient has been admitted to the hospital via A&E within the acute medical ward. He had a terrible fall in his house. The patient was very confused during the admission, so his daughter helps in conveying some relevant primary information, such as the patient was an active human being, he loves gardening, and has a social life too. Although the biggest concerns are his age, the fall could have broken his bones and at this age, it is hard to recover from that, also one of the concerns is the patient's state of mind, as he is very confused and is not oriented to place, time or person. Also one of the important pieces of information about the patient is that he takes medication as "Calcichew D3 forte 500mg OD”, but he and his daughter also is unaware of any allergies. He however gone through a previous surgery of hip replacement for the left hip in 2011
At first, some baseline observation has been conducted on the patient with the help of basic tools such as;
Also through the help of “Computerized Tomography (CT)” the nurses measure the BMI rate of the patient, it is not the most necessary but as the patient suffers from a fall injury, so surgery can take place as a potential treatment so BMI and all of those previously mentioned measurements are vital.
In this case, the assessment is dependent on most of the tests; most of the tests provided a baseline observation which includes Blood pressure, pulse, oxygen saturation, BMI, and temperature. These are remotely connected with the fall, and the direct assessment, in this case, is connected with the bruises in the face, and those need to be cleaned and stitched in some places. Although this is only based on the results from baseline observation (Ng and O’Brien, 2017). Then the behaviour of the patient shows some frequent and familiar symptoms associated with Alzheimer’s disease and with the help of previous medical history it is confirmed that he is suffering from Alzheimer's disease. Although the primary care the patient needed is some medication to relieve the pain, stitches in the face, and medication for lowering the blood pressure and complete rest. Also, the medication used by the patient is "Calcichew D3 forte 500mg OD” which helps in preventing vitamin D deficiency. Thus assessment can surely predict that calcium deficiency can be one of the reasons behind the fall, however, the care plan would include providing medicine for potential osteoporosis, and calcium-rich medication would also be prescribed.
The most common potential problem within this is that the patient was very confused during his admission, and as he is a fall patient, the nurses needs to investigate lots of basic queries and the patient was unable to cooperate, although the external wounds are limited to his face so the wounds can be cleaned and stitched up, but the test results shows that the man is suffering from chest infection, which needed further attention, but the assessment become hard as most of it depends on the test results and due to the confused behaviour, the patient could not cooperate as much as a primary nursing assessment requires.
As this case is very different from the previous case, in this case, the fall does cause some wounds but the assessment can not just focus on those, it requires a lot of test results which include x-ray and blood test results. That is why at first the assessment is limited about the wounds, and mostly based on the baseline observations, such as the elevated blood pressure (Olasoji et al. 2017). Then the previous case history is assessed critically and the medication for calcium deficiency is recommended as part of the care plan. Also, the X-rays suggest that the patient has chest infection so that becomes the biggest finding from assessing the patient and it would be a great help in further treatment of the patient, as well as the other assessed baseline information can guide the future treatment too (wiley.com, 2020).
Conclusion
The report has already gone through how assessing patient is the most basic part of primary care. The report critically presented the importance of assessing the patients. As it is mentioned that the patient is most of the time unaware of the specific problems even they can not always state the symptoms so it is important for the diagnosis that the nurses do some primary assessment, this helps in forging the further care plan. This care plan considers all the direct and remote aspects the nurses can find through their primary assessment. To provide a lucid image of the procedure and how that impacts detecting the diseases and designing the care plan, this report critically analyses two case studies (Mwebe, 2017). In these two case studies the report focuses on two patients and the case studies are ideal for the cause as they cover a wide range of the respective context in regards to assessing patients, First of all, both the patient's problem belongs to two different categories, one is suffering from mental illness and other is suffering from physical problems. Both are different from each other in regards to their demographic characteristics, such as; age and gender. Also one of them has barely any medical history and the other has a rich medical history so it helps the report is showing how the nurses need to consider different aspects and also how myriad tools and methods are used to assess the patient. This fulfils the first learning outcome, as this is how in these two cases, the respective nurses uses their conceptual ability to assess the patient primarily. Also, the report covers the discussion on how the results from those professional observations, reviews, and evaluations help in forming a plan for care specific to the respective patient and the plan is designed following the assessment and professional judgment. This is how the respective nurses fulfil the second learning outcome as they interpret their evaluation of patients and prepare care plan. At the end the knowledge of psychology for the first case study and knowledge of physical anatomy helped in understanding that the first patient is suffering from depression and the second patient have wounds in his face and have chest infection too, this is how the third learning outcome fulfils. In the conclusion this report is going to state that assessing the patient is not just a vital part the whole treatment process starts with this step, this saves time in further treatment and also guides the further treatment in a certain direction, that is why assessment of the patient is important and useful for the sake of the patient as well as for the future treatment process.
References
Journals
Online Article
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