Nursing Assessment Research Essay

Nursing Assessment Research Essay

Nursing Assessment Research Essay

Nursing assessment is the gathering of information about a patient’s physiological, psychological, sociological, and spiritual status by a licensed Registered Nurse. Nursing assessment is the first step in the nursing process. A section of the nursing assessment may be delegated to certified nurses aides. Vitals and EKG’s may be delegated to certified nurses aides or nursing techs. (Nurse Journal, 2017) It differs from a medical diagnosis. In some instances, the nursing assessment is very broad in scope and in other cases it may focus on one body system or . Nursing assessment is used to identify current and future patient care needs. It incorporates the recognition of normal versus abnormal body physiology. Prompt recognition of pertinent changes along with the skill of critical thinking allows the nurse to identify and prioritize appropriate interventions.[1][2] An assessment format may already be in place to be used at specific facilities and in specific circumstances.[3]Nursing Assessment Research Essay

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The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care.

An RN uses a systematic, dynamic way to collect and analyze data about a client, the first step in delivering nursing care. Assessment includes not only physiological data, but also psychological, horticultural, spiritual, economic, and life-style factors as well. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.

The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.Nursing Assessment Research Essay

Outcomes / Planning
Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.

Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.

Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

Nurses often come across patients with complex health problems. The majority of patients expect patient-centered care from nurses. What nurses should realize is that they need to know their patients better to fully understand their problems and requirements. Nurses should assess a patient systematically, so that they can identify the root cause of the problem and proceed with the treatment plan.Nursing Assessment Research Essay

Assessments don’t stop after the first interaction; it is something that a nurse has to do every single time they interact with the patient. A nurse already knows the basics of patient assessment, likely learned while pursuing Postgraduate Nursing Programs. Regardless of whether the patient is in the hospital for surgery, with pneumonia or abdominal pain, patient assessments will give you a lot of information and help you stay on top of your game.

There are few basic assessments that nurses perform on a patient during a critical situation. They check for –
  • Airway obstruction: The first thing nurses check is airway obstruction. It may be accompanied by no breathing sounds and an absence of chest movement. There may also be a partial airway obstruction along with noisy breathing.
  • Patient’s disability: Nurses check for the patient’s level of consciousness where the patient is graded as alert, voice responsive, pain responsive and unresponsive depending upon the consciousness level. They also check the patient’s limb movements.
  • Breathing: Nurses check for the patient’s raised respiratory rate. Along with this, the symmetry of chest movements, absence of air entry or additional breath sounds must also be analyzed. Check the patient thoroughly for the signs of respiratory distress. This can also include sweating, central cyanosis, abdominal breathing and inability to talk in long sentences.Nursing Assessment Research Essay
  • Blood circulation: As soon as the patient is brought in for medical care, the nurse checks the patient for the color and warmth of the patient’s hands, feet and limbs. The patient’s pulse rate, rhythm and volume are also determined manually. It is also important to measure the patient’s body temperature and blood pressure.
  • Check fluid status: Checking the patient for reduced urinary output.
  • Observing the skin: Minutely checking the skin, both front and back for any scars, sores, ulcers, wounds or rashes.
  • Inspecting eyes: Carefully checking the eyes for the pupil response indicating any signs of jaundice, bleeding oedema and infection.
  • Assessing thoracic region: With the aid of a stethoscope, nurses check for lung and cardiac sounds from the front and back. They gently palpate the chest wall for any tenderness.

Patient assessment is a systemic way to collect and analyze information about the patient. It is also the foremost step in delivering the right care.

As found in the work of Barrett et al assessment is a procedure in which the nurse will need to gather information from questions that are asked during the assessment process and on-going observations. This gathered information provides a comprehensive description of the patient. It focuses on the patient’s needs at that moment in time and possible needs that may need to be addressed in the future. It’s a fair and accurate account of the individual and their life. Overall it’s a way of delving deeper into a patient’s illness and preventing more problems from arising.Nursing Assessment Research Essay

The gathering of information for the assessment can pose problems if the patient is suffering from an injury or illness which can affect their speech. Thus meaning that the process is delayed and any time constrictions which are laid down during the assessment process are affected. To resolve this problem nurses use past medical history to complete the assessment. Although this may mean that this information is not up to date as the patient’s needs may have differed from the last time they used medical services.

Yura and walsh (1967) initialized the importance of the nursing process. It was seen as a problem solving approach to nursing care. The nursing process provides a methodical approach to examine patient’s problems and looks at ways of resolving these problems. The nursing process can be applied to all nursing settings, although the way in which it can be applied depends on patient needs and the environment at that time. It consists of four stages and is cyclical in nature.Nursing Assessment Research Essay

Assessment is the first stage of the nursing process and enables the nurse to undertake a holistic assessment of the patient considering all of the individuals needs in order to identify their problems.

Planning is the second stage and is the process that the nurse and patient set achievable goals and plan how they can be achieved. The goals may be short term, for example, nil by mouth prior to surgery or long term, for example, what implementations will be in place for discharge.

Implementation is the third stage of the process where clear direction is given about what is to be done, when it is to be done and by whom. This gives the patient a clear picture of the care and encourages them to take part.

Evaluation is the final stage and is the most important of the whole process as it informs the patient whether goals have been achieved or are being achieved. At this stage some problems may be noted and so the cycle must start again with assessment.

New son suggests that for the process to commence a model of assessment is utilized. This model needs to be holistic in all aspects of the patients needs. Therefore attention needs to be paid to the biological, psychological and social situations of the patient. Roper Logan Tierney’s twelve activities of daily living is one if the more common models that are used by healthcare professionals.

The patient will be asked questions, during the assessment process, surrounding the twelve activities and it will be established as to how the patient usual does these tasks. It acts as a guide and ensures that all areas of the assessment process are covered (Dougherty et al).Nursing Assessment Research Essay

Skills required.

National Institute for Health and Clinical Excellence (2007) suggests that that good communication between healthcare professionals and patients is essential. It should be supported by evidence-based written information tailored to the patient’s needs. Treatment and care, and the information patients are given about it, should be culturally appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.

If the patient agrees, carers and relatives should have the opportunity to be involved in decisions about treatment and care. Carers and relatives should also be given the information and support they need.Nursing Assessment Research Essay

Adult patients in acute hospital settings, including patients in the emergency department for whom a clinical decision to admit has been made, should have: physiological observations recorded at the time of their admission or initial assessment a clear written monitoring plan that specifies which physiological observations should be recorded and how often. The plan should take account of the: patient’s diagnosis presence of comorbidities agreed treatment plan. Physiological observations should be recorded and acted upon by staff who have been trained to undertake these procedures and understand their clinical relevance. Physiological track and trigger systems should be used to monitor all adult patients in acute hospital settings. Physiological observations should be monitored at least every 12 hours, unless a decision has been made at a senior level to increase or decrease this frequency for an individual patient. The frequency of monitoring should increase if abnormal physiology is detected, as outlined in the recommendation on graded response strategy. Staff caring for patients in acute hospital settings should have competencies in monitoring, measurement, interpretation and prompt response to the acutely ill patient appropriate to the level of care they are providing. Education and training should be provided to ensure staff have these competencies, and they should be assessed to ensure they can demonstrate them.

The nurse needs to adopt various skills in order for the assessment to be carried out appropriately as suggested by Barrett et al. Some of the skills may become second nature to the nurse and others will be developed over time.Nursing Assessment Research Essay

Visual observational skills are required to note the patient’s general well being for example, the color of their skin or how well they have been caring for themselves.

Sense of smell is needed to decide if the patient has stale breath or whether they have been drinking alcohol or smoking.

Sense of touch should be used to feel if the patient is hot or cold or whether their skin is clammy or dry.

Sense of hearing is required to detect if the patient has noisy breathing or whether they have slurred speech.

Measuring skills to record accurate information from the patient i.e. how much fluid intake the patient has had or even how much they weigh. The nurse must also be able to interpret the results of the measurements i.e. what do they mean, how serious are they and what is normal?Nursing Assessment Research Essay

Interviewing skills are also required and is fundamental. The nurse must learn to empathize and be must be able to listen and take in information.

Communication skills are required as the nurse needs to be able to talk and listen to patients, carers, relatives and the multi-disciplinary team. Must also have the ability to refer and report information to others, ability to seek advice, establish a relationship, trust and confidentiality.

Record keeping and documentation skills needed to write and record information accurately and to be truthful and IT literate.

Overall the nurse must work in a professional manner and abide by the policies set out by the trust, NMC (2002) code of professional conduct and government legislation. It also suggests that the recording of information is essential and could lead to potential consequences for the individual if their standards are not met.

Potter and Berry (2005) argue that if inaccurate, incomplete or inappropriate data is recorded then the overall care of the patient may be affected, including wrong diagnosis and even wrong treatment.Nursing Assessment Research Essay

Primary and secondary sources of information. How are these used to inform the assessment. Objective and subjective information. (625 words)

To collect all the relevant information different sources can be used. The main (primary) source would be from the patient or advocate and secondary sources would be from the patient’s relatives, patient notes or any documentation on the patient file.Nursing Assessment Research Essay

Objective data is information that is measurable such as pulse, blood pressure, respiration’s and weight. Subjective data is descriptive information that forms an opinion and is the sort of information that can be gained by asking someone ‘How do they feel?’ or ‘What is worrying you?’. It is also information that be gathered by the nurse and their perceptions at the time of the assessment. (Barett et al 2009)

Observed information is information that can be gathered whilst observing the patient. This might include the condition of the patient’s skin or their ability to walk and move. Observing the patient will also give you some information about how well they can communicate.

Clinical information: this might include vital signs, medical diagnosis, blood results, X-Ray or scan results. (Barrett et al 2009) Nursing Assessment Research Essay.

All this information will be considered and recorded in the patient notes. Ideally the nurse should record their findings in a non-judgemental way and consideration needs to be paid to other members of the multi-disciplinary team who may need to see the notes.

Assessment tool – one that i’m interested in and understand. Describe how the tool may support the assessment process and the benefits of the tool. Say why they are valuable – universal, scientific approach. (625 words)

Assessment tools are used by all healthcare practitioners. The aim of the tool is to help pick out certain information which may not have been picked up during initial observations of the patient. Most assessment tools have a scoring system, the scores are added up to give an overall score. Depending on that score would depend on the care for the patient or medical intervention. The tool should complete the overall assessment process and will depend on the needs of the patient and the type of clinical setting to which tool is used as found in the work of (Brooker et al).Nursing Assessment Research Essay

Early warning scoring systems aim to predict which patients are in need, allow preventive management, and determine who might need a step up to higher levels of care. It is as important to be able to identify patients for whom such care will be futile to give enough time for appropriate discussions to take place with the patient and family. The number of patients who can be accommodated in the intensive care and high dependency units is limited. Selecting the patients who may benefit from critical care is, therefore, crucial.

A bewildering array of methods to quantify the severity illness are available. The first was developed in Australia, and several other systems have since been developed around the world, incorporating many physiological variables and trigger algorithms.

Early warning systems rely on observations of the physiological status of the patient, reflecting a clinical evaluation of oxygen delivery and organ perfusion. The rationale for choosing specific physiological variables is based on studies of the relation between physiological abnormalities and mortality. This concept is not new, but ensures that small deviations from the norm are noticed. Rather than wait for an obvious change in an individual variable the trend over time can be objectively observed. It also enables the response to primary interventions to be monitored. However, they do not predict outcome.Nursing Assessment Research Paper

Of all the parameters, respiratory rate is thought to be the most sensitive indicator of a patient’s physiological well being. This is logical because it reflects not only respiratory function but cardiovascular upset for example, pulmonary o edema and metabolic imbalance as seen in diabetic ketoacidosis.

The modified early warning scores system is an updated version of the early warning scores system, adding two parameters, a patient’s urine output and deviations from their normal blood pressure. If the total score exceeds a predefined cut-off this triggers immediate actions, including calls for experienced senior clinical advice and critical care outreach assessment.

Physiological observations should be monitored at least every 12 hours unless a decision has been made at a senior level to increase or decrease this frequency for an individual patient. Monitoring should be more frequent if abnormal physiology is seen.

In the UK the early warning scores system and the modified system trigger a call to the patient’s own team or an intensive care unit outreach team. The aim of outreach teams is to monitor and help in the management of acute patients and provide support and advice about critical care. The UK Department of Health and others use such teams to try to avert admissions to critical care, as well as to help in their discharge. Nurses need to familiarize themselves not just with local early warning scores system but also with local outreach services because they are there to help to make important early decisions.

The tool has had some criticism and has been suggested that it may not work. It has been said that nurses should be able to use their nursing intuition to assess whether a patient is deteriorating. The student British Medici al Journal would argue that the Early Warning Score does work and recent research found that 84% of patients had documented observations of clinical deterioration within eight hours of cardiopulmonary arrest. On these grounds it is essential that the tool works to help detect early signs of deterioration in critically ill patients.

Positive professional relationship. Talk about the importance of communication, appropriate behaviour, code of conduct, confidentiality, diversity all things that build up a positive relationship. Barriers – disabilities, language barriers, cultural barriers. (625 words)

The nurse-patient relationship should be started from the initial assessment. This is the first stage of the nursing process and therefore any issues affecting the patient can be identified. The relationship relies on specific components being in place including rapport, empathy, genuineness, warmth and positive regard.Nursing Assessment Research Essay

Castle dine (2004) argues that the nurse-patient relationship is extremely important within the healthcare setting as it’s helps the patient to make informed decisions, it avoids isolation and de-humanization, acts as an advocate for vulnerable patients, helps with the patient assessment and problem solving, helps patient undertake, or carry out for them, activities of daily living and human needs, teach and promote health education and learn about new ways of nursing and caring for people in a changing world.

In nursing, the use of language must be appropriate to the patient and be clear, free from jargon and encourage feedback. We want to find out not only patient’s immediate medical symptoms but also their nursing history, including their strengths, weaknesses and ways that they have adapted and coped with their life and health problems. Castle dine (2002)

Peplau (1998) emphasizes the importance of the nurse as a skilled communicator, using both verbal and non verbal levels to develop their relationship with the patient.

Members of the public cannot always see the difference between a student nurse and someone who is qualified and registered with the NMC . That is why a student’s conduct is important in upholding the reputation of the professions, both when studying and in personal life. (CAIPE 2010)

An appropriate environment needs to be established to ensure privacy, dignity and patient comfort. This will help build up a rapport with the patient and allow them to feel more at ease in an unusual environment. (While 2002)

Empathy means that the nurse takes on the patients feelings in order to understand them, but does not let the experience affect how the nurse is going to help the individual. Too much sympathy for a patient may result in the nurse crossing boundaries which allow the patient and nurse to engage in a therapeutic caring relationship as argued by Castle dine (2004)

Genuineness and trusting relationships are instrumental in reducing anxiety and helping patients to cope with pain. Nurses can help to build a trusting relationship by listening to the patient, believing the patients pain experience, acting as a patient advocate and providing patients with appropriate physical and emotional support. Ken worthy et al (2002) writes that positive regard refers to the idea that there should be no conditions to acceptance and care for the people. People should be accepted for who they are no matter what their background is. This is extremely important as nurses because they care for people from all walks of life from rich to poor.

The Nursing and Midwifery Council (2002) recognizes the importance of the nurse-patient relationship in the code of professional conduct. Registered nurses are responsible for ensuring that they safeguard the interests of their patients and develop and maintain appropriate relationships.

The Importance Of Needs Assessment In Nursing Practice Nursing Essay

Patient assessments concern the collection of data about an individual’s health state that identifies and defines patient problems in order for solutions to be planned and implemented in line with their preferences (Roper el at 2000). Therefore, a clear idea about health is important because this determines which assessment data should be collected. The World Health Organization (WHO) (2001) defines health as a state of complete physical, mental and social well being and not merely the absence of disease or infirmity. Whilst this is a broad definition, it implies that the nursing approach to health care is holistic in nature and therefore health assessments should reflect the whole person and their circumstances. Nurses are obliged to take in to consideration a patients physical, emotional, spiritual, social and intellectual needs when making an assessment (UK Department of Health, 2003). `Nursing Assessment Research Essay

When nurses are conducting a health assessment on a person it may require knowledge of techniques of collecting and analyzing subjective and objectives data to include both what the person says about themselves and physical assessment funding from inspecting, percussion and palpating during physical examination (UK Department of Health, 2003). Potter and Berry (2005) argue that if inaccurate, incomplete or inappropriate data is recorded then the overall care of the patient may be affected, including wrong diagnosis and even the wrong treatment. The Nursing and Midwifery Council (NMC) (2002), Code of Professional Conduct, urges all nurses to work in a professional manner and abide by the policies set out by the trust they work in. It suggests that recording or the documentation of information is essential and any deviation could lead to potential consequences for the individual if standards are not met. The purpose of health assessment is to make a judgement or diagnosis because all health treatments and decisions are based on the data gathered during assessment. It is vital that the assessment is accurate and complete, providing the foundation for clinical decision making (RCN, 2007). This gathered information provides a comprehensive description of the patient. It focuses on the patient’s needs at that time and possible needs that may need to be addressed in the future (NMC, 2007). It should be a fair and accurate account of the individual and their life. Overall assessment is a way of delving deeper into a patient’s illness and preventing more problems from arising.

Case study 2 about a 68 year old Afro Caribbean retired bus driver male called Carl, who has being married for 45 years with 5 grown up children and 8 grand children. He smokes 20 cigarettes a day and enjoys nightcap before sleep. His vital signs observations were respiratory 20 bpm, blood pressure 168/105, pulse 92bpm, Spo2 95%, BMI was 32kg/m2 and medication are statins, beta blockers, aspirin and frusemide. Recently, his wife noticed Carl seems to have forgetfulness and he cannot remember his way home from the supermarket and kept losing items. He is getting frustrated and taking it out on his wife and grand children, especially when he cannot read them a story.

Fairy (2006) suggests that, for a process to commence a model of assessment is utilized and this model needs to be holistic in all aspects of patients needs. Therefore, proper attention needs to be paid to the biological, psychological and social situations of the patient. It is important that the health assessment includes a thorough examination of the patient’s ‘activities of daily living ( Department of Health, 2002) .The twelve activities of daily living (ADLs) are communication, safe environment, breathing, eating and drinking, elimination, washing and dressing, temperature, death and dying, mobility, working and playing, sexuality and sleep (Roper, Logan and Tierney model 1996). It is important to remember that all ADLs about individual life activities are interlinked and when one or more activity is affected due to illness, then most of the activities can become compromised. (Montague el at 2005)Nursing Assessment Research Essay

The ADLs that are appropriate to assess Carl’s needs are communication, breathing, eating and drinking, elimination, working and playing, safe environment and mobility,. The rest are important but not needed by Carl at the moment. Communication is essential for building a nurse – patient relationship (Sulla and Dallas 2005). For Carl, due to his state of forgetfulness, memory lost, out of character behaviour and frustration especially when he cannot read for his grandchildren, he may need referral to see opticians for eye check, and the behavioral therapist.

Breathing is the first sign every health professional look for during patient assessment. Being able to breathe normally ensures that we can attempt other activities without any difficulties, for example running. For Carl his breathing may be affected by smoking for 20 pack years as well as his higher BMI both of which can cause shortness of breath. Referral to the NHS stop smoking service or radio graphs for chest x-ray to check for infection will be essential. The use of early warning score (EWAS) tool will check all vital signs including the use of peak flow meter to check the lungs. A nebulous may be considered.

Ensuring adequate hydration and nutrition is essential if health is to be maintained and in Carl’s case he has a higher BMI and he is in a state of confusion which may relate to fluid intake. Waugh and Grant (2006) suggests that dehydration as well as urinary tract infection (UTI) can contribute to his state of confusion. The (MUST) tool can be used to assess nutrition levels and the (MMSE) tool for assessment of possible dementia (NICE 2012). Referrals can be made by nurses for Carl to see the dietician and also physiotherapist for physical exercise regime.

Elimination is very important, and in Carl’s situation review of his medication will be important since some may cause constipation or frequent urination. Higher BMI as a result of being obese as well as chronic chest problems can cause urinary incontinence (Kamm, 1998). Also in males, disease of the prostate may lead to the obstruction of the flow of urine (Abrams el at 2002). The Bristol stool chart can be used to assess constipation, the dipstick tool can also be used to check for infection or UTI and the fluid balance chart can be use to assess for dehydration by checking input over output.

Mobility can be a problem since Carl has a history of forgetfulness and the need to urinate frequently due to some of his medication. Fear of not being able to find his way home, being incontinent in public and even fear of falling in a new environment may stop him from mobilizing. Human assistance will be needed and the fall assessment tool would appraise his risk of a fall. Carl may need an assessment on working and playing since he is retired, has memory impairment and get upset when he cannot read for his grand children. Referral to psychologists and also arranging for Carl to meet with other people in day centers may be an option, if Carl agrees. It will be important to assess these areas when talking to Carl to establish possible needs (Brooker and Nichol 2003). Nursing Assessment Research Essay.

According to the RCN (2004), nurses will always need an assessment tool to guide their daily nursing practice in terms of their professional accountability and responsibility. In Carl’s case the Mini- Mental State Examination (MMSE) will be essential for his current needs. The rationale for using this assessment tool is that it is found to be appropriate for assessing elderly people with Dementia by the practice placement. The multi professional team also found the tool reliable and considered it to meet the patient’s needs and ensured clinical effectiveness and evaluation. The MMMSE tool is the most commonly used instrument for screening cognitive function. The tool has a series of questions that tests a number of different mental abilities, including a person’s memory, attention, language, orientation, calculation, registration, recall, visual construction and the ability to follow a three step command each of which scores points if answered correctly (Folstein 1975). In general, scores of 27 or above (out of 30) are considered normal, 21-24 as mild, 10-20 as moderate and less than 10 as severe impairment (Folstein 1975). He continuo that, a score below this does not always mean that a person has dementia or delirium but their mental abilities might be impaired. The MMSE was found to be highly reliable in detecting cognitive impairment and is now used around the world and in many clinical settings and by General Practitioners (Hunte 2004).

Thirty seven studies were carried out over ten years using the MMSE to show progress of patients with dementia and an average change of score was3.3 points, Tom burgh and McIntyre (1992). The MMSE has its limitations , it is found that cognitive performance as measured by the MMSE varies within population by age and education, with lower scores for oldest age groups and those with less education and it is insensitive to very mild cognitive decline particularly in highly educated individuals, (Miller et al, 1997).Nursing Assessment Research Essay.

To ensure a successful assessment, quiet and pleasant environment is needed. Questions needs to be spoken clearly and words needs to be repeated for clarity. Proper communication has to take place to ensure Carl understands what is about to happen and consent for it. Questions such as what is your name can be asked due to his state of confusion to establish a conversation (Stevenson 2006). In orientation, Carl was asked to give the year, season, date, month and the day (1 point for each correct answer) and he was also asked to tell where he lives, state, country, town, hospital and floor (1 point for each correct answer). Under registration three objects were mentioned, apple, door, table and Carl were asked to repeat them (1 point for each correct answer). In attention and calculation, Carl was asked to subtract 7 from 100 then repeat from result and continued five times for example 100, 93,86, 79, 65 ( I point for each correct answer). Recall, Carl was asked for the three objects he has learned earlier (one point for each correct answer). Under language, Carl was ask to name a pencil and a watch (2 points), again he was ask to repeat no, if’s, ands or buts(2 points). He was further asked to follow a 3 stage commands ‘take a paper in your right hand, fold it in half, and put it on the table (3 points). He was asked to read and obey instructions such as ‘close your eyes (1 point), write a sentence (1 point). Finally, he was asked to copy a drawing of intersecting pentagons (1 point) (REF).

Carl’s overall score was 11/30.Nursing Assessment Research Paper He scored 5/9 on language, 0/3 on recall, 3/10 on orientation, 1/3 on registration, 2/5 on attention and he scored 0/1 on copying. Carl’s MMSE result is under 20 reflecting a poor cognitive function and memory problems. His needs require a holistic nursing care based on physical, psychological, social, and spiritual needs (Department of Health 2002). For example referral to physiotherapist for regular physical activities such as walking will help maintain good weight. Also referral to the occupational therapist to arrange for cognitive behavioral therapist will be essential since they are known to treat people with depression associated with dementia ( Small 2002). In the long term, implying cognitive stimulation will help. This may involve his family, by talking to him and allowing him to discuss his feelings and thoughts, and introduce recreational activities such as problem solving activities that may enhance his quality of life and well being (Pepperoni and Vapes 2000). Also referral to the reminiscence therapy is known to help people with mild to moderate dementia.

In conclusion, this essay has looked at the importance of needs assessment and how it plays a major role in the prevention and administration of quality care. It has looked at how different tools can be used to aid in patient needs and provide satisfactory result for both patient and professionals. This will help greatly in the future when making patient assessment.

is important and often first step in identifying the patient’s problem. Health assessment helps to identify the medical need of patients. Patients health is assessed by conducting physical examination of patient.Nursing Assessment Research Essay

A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history. There are different from diagnostic tests which are done when someone is already showing signs and/or symptoms of a disease. The major health assessments are Initial Assessment in which determine the nature of the problem and prepares the way for the ensuing assessment stages. Focused Assessment, which expose and treats the problem. Time-Lapsed Assessment, which ensure that the patient is recovering from his malady and his condition has stabilized. Emergency Assessments focus on rapidly identifying the root causes of concern for the patient and assessing the airway, breathing and circulation (ABCs) of the patient.

Holistic medicine, frequently referred to as integrative health and medicine, has been steadily gaining traction among patients. And as more patients realize the benefits of this model, the need for nursing staff capable of providing such specialized care increases. Specifically, nurses would be well-served to develop a deeper understanding of the role of holistic health assessments as well as the overall benefits of holistic care.Nursing Assessment Research Paper

According to the Academy of Integrative Health and Medicine (AIHM), holistic medicine is the “art and science of healing that addresses the whole person — body, mind, and spirit.” It utilizes a combination of traditional and alternative treatments and ultimately seeks to promote disease prevention through maintaining ideal health and wellness in all areas of life.

Holistic health assessments are integral components of patient care under this model. Composed of physical examinations and a series of well-designed questions, these assessments are used by nurses to evaluate how each area — body, mind and spirit — is affecting the patient’s overall health.Nursing Assessment Research Essay

Nurses play a vital role in obtaining this information from patients and recording it in the medical chart. For example, the nurse may:

  • Conduct a thorough physical examination (body).
  • Encourage the patient to share their concerns about their condition (mind).
  • Ask the patient about their spiritual or religious beliefs and how their disease has affected their faith (spirit).

By asking these types of questions and taking on the role of an active, empathetic listener, the nurse is able to establish a deeper relationship with the patient and better evaluate the entirety of their situation. This can lead to several positive outcomes. If the patient is able to discuss stressors that are affecting their health, for example, the nurse can help them identify appropriate coping mechanisms or direct them to other valuable resources like counseling.

Likewise, if the patient would benefit from spiritual encouragement or guidance, the nurse is able to swiftly recognize that need — one that might have otherwise gone unnoticed without a holistic health assessment.

The concept of holistic nursing is often attributed to the work of Florence Nightingale, a 19th century nurse who provided patient care at a British hospital during the Crimean War. She held a strong belief that a patient’s relationships and surroundings heavily influenced their overall health and wellness. She became one of the earliest healthcare advocates, and many consider her among the first holistic nurses.

In 2006, holistic nursing earned official recognition as a nursing specialty by the American Nurses Association (ANA). The specialty status meant that a scope and standards of practice specific to holistic nursing was also established.

Today, the American Holistic Nurses Association (AHNA) defines holistic nursing as “all nursing practice that has healing the whole person as its goal. This practice recognizes the totality of the human being — the interconnections of body, mind, emotion, spirit, social/cultural, relationship, context, and environment.”

As mentioned previously, holistic nurses strive to form a deeper bond and partnership with their patients. They listen carefully to the patient’s feelings and experiences and honor their values and beliefs. They seek to learn all aspects of a patient’s situation rather than simply focusing on their disease or illness.

In doing so, nurses in this specialty are more likely to incorporate the principles of CAM — complementary and alternative modalities — with mainstream, traditional treatments. The modalities are frequently classified into four domains, including:

  1. Manipulative and body-based practices such as acupuncture, dance therapy, massage, qi gong and aromatherapy.
  2. Mind-body medicine such as art therapy, guided imagery, meditation and euro-linguistic programming.
  3. Biologically-based practices such as biofeedback, hydrotherapy, and nutritional counseling.
  4. Energy medicine such as prayer, reiki and therapeutic touch.Nursing Assessment Research Paper

A fifth category — whole medical systems — applies to all four domains and includes homeopathy and osteopathic medicine.

By combining traditional and CAM philosophies, holistic nurses hope to achieve the highest level of healing for their patients’ physical, psychological and spiritual ailments. Nurses provide this type of care in a number of healthcare settings as well. A 2011 AHNA study showed that 48 percent of holistic nurses work in hospitals or clinics, 14 percent in private practice, 13 percent in an academic setting, and 7 percent in home care or hospice.Nursing Assessment Research Essay

Furthermore, AIHM estimates that more than 40 percent of hospitals now offer inpatient integrative services, along with a significant rise in the number of services offered on an outpatient basis. Commonly used to treat cancer, depression and chronic pain, more than one-third of U.S. adults use some form of integrative health and medicine.

Given the growing popularity of holistic medicine and treatments among patients and healthcare organizations, current and prospective nurses are encouraged to learn more about this specialty. Lamar University’s online RN to BSN program offers coursework that covers comprehensive holistic health assessments. Students learn the skills necessary to properly conduct the assessment in today’s healthcare settings.

A comprehensive assessment is the first stage of the nursing process. In rehabilitation nursing, it provides the foundation for care that enables individuals to gain greater control over their lives and enhance their health status. The place of the older person and significant carers/family members in assessment cannot be overestimated, as each should be empowered to fulfill the role of imparting expert knowledge about the person’s life experience and views. This article examines some pertinent issues in relation to nursing assessment and emphasizes that identification of needs and the use of appropriate assessment tools, in conjunction with the knowledge, skills and clinical judgement of the practitioner, are required in assessment.

Understanding CV Assessments

Ever wonder why people refer to their heart as the ‘old ticker’? The rhythmic tick tock, tick tock of a clock sounds a bit like that heart that beats in our chest for the duration of our life. The heart works nonstop pumping blood and oxygen to the body and is part of the cardiovascular (CV) system. This process is essential to every organ in the body and to human life itself. It makes sense then that a thorough cardiovascular assessment includes far more than just listening to the heart beat.

A registered nurse is responsible for thoroughly assessing a patient’s physical condition and using that information to guide care. Subjective data is the patient’s report including symptoms and complaints. Objective data is the physical findings that the nurse can see, feel, or hear.

It’s often best to begin with collecting subjective data, because the patient’s responses can prompt the focus of the objective assessment. For example, asking about pain during palpation. Both subjective and objective findings, as well as data like vital signs, cardiac rhythms, and lab results are important to the overall clinical picture of the patient.

To help, it’s helpful to first review the patient history to learn about current medications and any chronic diseases or recent hospitalizations, which can help direct the assessment.Nursing Assessment Research Essay

Patient Interview

Issues with the heart present as various symptoms in the patient, but a few things should always be considered with a cardiovascular assessment. First, ask the patient about current or recent chest pain. Pain in the chest, or even the jaw or arm can be a manifestation of ischemia, which is lack of blood flow to tissue caused by a blockage. Pain in these areas can also be symptoms of other problems, so it’s important to compare symptoms to other clinical findings.

Next, ask the patient about dizziness, palpitations, sweating, or shortness of breath. These may be symptoms of an irregular heart rhythm or heart failure. Ask the patient about pain, numbness, and tingling to extremities (usually to the calves and feet), as this may reflect circulation issues. Report and document any abnormal symptoms.

Heart Sounds

The cardiovascular physical assessment begins with the heart itself. Listening to heart sounds, usually with a stethoscope, is referred to as auscultation. Auscultation can tell you if the rhythm sounds regular or irregular, how fast the heart is beating, and whether there are flow abnormalities, like murmurs. Murmurs refer to extraneous sounds of abnormal blood flow in the main vessels or through inadequate valves and can take a trained ear to detect and differentiate. Basic heart sound auscultation is done in four spots on the chest: aortic, pulmonic, tricuspid, and mitral. As you listen in each area, think about the anatomy of the heart; each auscultation point is over a valve and allows for assessing a different part of the heart’s function.


The heart sends blood to the farthest points of part of the body. Assessing perfusion, or blood circulation, is done in a few ways. Palpating pulses can assess whether efficient blood flow is making its way to the extremities, which are your arms and legs. Radial pulses in the wrists and dorsalis pedis pulses on the feet represent the most distal, or farthest from the heart, pulses. Compare the rhythm and rate of these pulses with heart sounds to determine if each beat is pumping all the way to the distal extremities. The strength of the pulse is described as absent, weak, strong, or bounding (very strong) on a scale from 0 to 4.

Circulation can also be assessed by the color of the extremities. Well-per fused tissue, like feet and toes, should be pink, feel warm, and have brisk capillary refill. Capillary refill is tested by pressing or pinching the tissue and then releasing. The tissue should turn white and then quickly return to a pink color as the blood rushes back into the capillaries.

Baseline data that is collected after the health history and before the complete head to toe examination includes a general survey of the client. The general survey includes the patient’s weight, height, body build, posture, gait, obvious signs of distress, level of hygiene and grooming, skin integrity, vital signs, oxygen saturation, and the patient’s actual age compared and contrasted to the age that the patient actually appears like. For example, does the patient appear to be older than their actual age? Does the patient appear to be younger than their actual age?Nursing Assessment Research Essay

Nurses prepare and position clients for physical examinations. Nurses provide privacy, explain and reinforce the procedures to the client and insure that the client is as comfortable as possible during the physical examination.

As with all other aspects of nursing care, all data and information that is collected with the health history and the physical examination are documented according to the particular facility’s policies and procedures. Some facilities use special forms for this data and information.

Registered nurses, advanced practice nurses such as nurse practitioners, and doctors typically do the complete head to toe physical assessment and examination and document all of these details in the patient’s medical record; however, licensed practical nurses review these details and compare this baseline physical examination data and information to the current patient status as they are providing ongoing care. They also report and document all their significant physical examination results to the supervising registered nurse and/or the patient’s health care provider.

The four basic methods or techniques that are used for physical assessment are inspection, palpation, percussion and auscultation. Inspection is a visual examination of the patient; palpation is done when the person doing the assessment places their fingers on the body to determine things like swelling, masses, and areas of pain. Palpation can include light and deep palpation. Deep palpation is cautiously done after light palpation when necessary because the client’s responses to deep palpation may include their tightening of the abdominal muscles, for example, which will make the light palpation less effective for this assessment, particularly if an area of pain or tenderness has been palpated.

Percussion is tapping the patient’s bodily surfaces and hearing the resulting sounds to determine the presence of things like air and solid masses affecting internal organs. The sounds that are heard with percussion are resonance which is a hollow sound, flatness which is typically hear over solid things like bone, hyper resonance which is a loud booming sound, and tympanum which is a drum type sound.

Nursing assessment protocols are used quite frequently in jails, prisons and juvenile detention facilities across the country as a tool to guide nurses in the assessment of patients. Standard E-11 provides guidance for the proper use of these protocols, which are defined as written instructions or guidelines that specify the steps to be taken in evaluating a patient’s health status and providing intervention.

Protocols may include acceptable first-aid procedures for the identification and care of ailments that would ordinarily be treated with over-the-counter medicine or through self-care. They may also address more serious symptoms such as chest pain or shortness of breath. Protocols specify a sequence of steps to be taken to evaluate and stabilize the patient until a clinician is contacted and orders are received for further care.

Management of Nursing Assessment Protocols
Once developed, protocols must be reviewed annually by the nursing administrator and responsible physician. A signed declaration by both parties is often used to indicate that this review has been completed. When protocols are changed, they must be individually signed by the nursing administrator and responsible physician.

Nurses must be trained in the use of protocols during orientation and when protocols are introduced or revised. The training must include a demonstration of a nurse’s knowledge and skills in protocol use. There must also be an annual review of skills for all nurses who use the protocols. The annual review is intended to be more than a staff in-service where all protocols are reviewed and staff sign in to show proof of attendance. Rather, the annual review is to be an individual evaluation of a nurse’s skill in use of the protocols. Individual evaluations may be accomplished by the administration of written tests, documentation review and/or demonstration of knowledge and skills. The annual review must also be documented and kept on file for each nurse.

Pushing the Limits
Although standard E-11 clearly defines how nursing assessment protocols should be used, the environment of correctional health care sometimes lends itself to their misuse. One example would be to permit non health staff to use the protocols. Nursing assessment protocols are meant for nurses and must be appropriate to the level of skill and preparation of the nursing personnel who will carry them out. They must also comply with relevant state practice acts. They are not meant to be used by custody staff or child care workers in the absence of nurses.

Another common misuse of nursing assessment protocols is the inclusion of standing orders, which are written instructions that specify the same course of treatment for each patient suspected of having a given condition and that specify the use and amount of prescription drugs. For example, all patients who present at sick call with a suspected ear infection are given the same antibiotic without consulting a provider. Often these standing orders include a blanket statement to call a provider before initiating the treatment, but this practice may lead to nurses using the standing orders freely, without consulting a provider first. This potentially places nurses in a situation where they are acting beyond their scope of practice. Treatment with prescription medication should be initiated only on the written or oral order of a licensed clinician.

Standard E-11 does permit the use of prescription medication such as nitroglycerin or epinephrine in emergency, life-threatening situations. The types of emergency medications to include in nursing assessment protocols is a decision that must be made by the facility’s responsible physician, and the assessment protocols should clearly outline the findings that could lead to the administration of emergency medication. A subsequent clinician’s order is required when emergency medication is used.

Finally, standing orders may also be used for preventive medicine practices such as immunizations.

It is important to note that treatment protocols or algorithms used by clinicians such as physicians, physician assistants and nurse practitioners are not addressed in this standard.

The intent of standard E-11 is to ensure that nurses who provide clinical services are trained to do so under specific guidelines. When used properly, nursing assessment protocols can be very helpful in the clinical management of patients. Nursing Assessment Research Paper

This assessment is to be utilized by a Registered Nurse RN) in assessing adults with significant ID/DD challenges. This assessment is designed for individuals needing an ICF level of care or 24 hour staff supports. In addition, the Director of Nursing in any setting may decide to use this form in order to best assess an individual’s health care status.Nursing Assessment Research Essay

This assessment will enable the RN to develop desired health outcomes for the Health Care Management Plan (HCMP). The HCMP is the concluding part of this assessment, and is an integral part of it. No assessment will be considered complete unless the HCMP is attached.

Full document, Nursing Health and Safety Assessments includes the following documents to assess nursing care:

  • Nursing Assessment Form A and Guidelines
  • Nursing Assessment Form B and Guidelines

The goal for nursing practice has always been to heal the whole person in body, mind and spirit. The focus on the wellness and interrelationship of people and the environment dates back to the practices of Florence Nightingale, a 19th century nurse who is considered the founder of . Yet it wasn’t until 2006 that the American Nursing Association (ANA) recognized holistic nursing as a .

The incorporation of a holistic, person-centered approach to patient care continues to gain importance, especially with the ongoing changes in healthcare reform. The practice of viewing the individual, family and community as an interconnected system can help with disease prevention. It encourages patients to become more involved in self-care to work on their long-term health and wellness goals. Lamar University recognizes the importance of a comprehensive holistic health assessment and includes this course within its online RN to BSN curriculum.

A holistic health assessment goes beyond focusing solely on physical health. It also addresses emotional, mental and spiritual health. The whole condition of the patient is taken into consideration for ongoing wellness across the lifespan. The development of a relationship with the patient begins with open, therapeutic communication. This supportive, non-judgmental method of assessment recognizes that the patient’s stress levels, diet and relationship issues can often exacerbate many ailments.

A holistic health assessment allows the nurse to gain information essential for diagnosis, planning and implementation. It shows respect for the patient’s preferences and preserves the patient’s dignity. The six aspects of a holistic assessment include:

  1. Physiological: Complete a physical assessment.
  2. Psychological: Review potential stressors that might exacerbate the ailment.
  3. Sociological: Discuss family networks and who can help at home.
  4. Developmental: Consider how psycho social and cognitive development may affect the patient’s response to the health issue.
  5. Spiritual: Respectfully ask about religious and spiritual practices and determine if nursing care will need to be altered.
  6. Cultural: Discuss special diet, values or culture-specific requests.

Integrating the six aspects of a holistic assessment into the nursing assessment can help identify an underlying cause of the illness or whether other factors are delaying recovery. Nurses can use this approach to glean information regarding the patient’s family dynamics, values, beliefs and other factors that would inform the care delivered and the patient’s healing. This can result in more effective treatment and optimal health. Lamar University offers an online comprehensive holistic health assessment course in its RN to BSN program that can help nurses build upon existing assessment skills.

The practice of holistic health nursing is based on the premise that self-care is necessary to effectively care for others. Nurses who practice holistic nursing incorporate a philosophy of responsibility to the self and a commitment to integrate self-care into their personal life. They strive to increase their awareness of their connection to the environment and remove barriers to the healing process. This allows them to provide more comprehensive care.

Holistic nurses combine mainstream and complementary, or alternative healing modalities (CAM). Some of these modalities include meditation, massage, deep breathing, natural products, yoga or music. Offering more treatment options suitable for different lifestyles provides patients a greater healing potential.Nursing Assessment Research Essay

More hospitals recognize and utilize integrative health services. Unlike other specialties that are defined by a client group or a disease category, holistic nursing can be practiced in almost every area of care and in all settings. This patient-centered, practical and sustainable approach to well-being can be beneficial to patients of any age. The authentic, real relationships developed by utilizing the practices of holistic nursing can be beneficial to the patient and rewarding for the nurse.Nursing Assessment Research Essay.


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