NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay

This assignment will discuss and analyse the nursing care given to an 85 year old female patient, during a four week hospital practice placement. In order to fully comply with the Nursing and Midwifery Council (NMC) Code of Conduct (2008), full consent has been verbally granted by the patient to utilise personal clinical information for the purpose of this case study. To ensure patient anonymity, throughout this assignment the patient will be referred to as Rose (Swift). NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay
Chapelhow et al (2005) states, in order for a novice to become an expert practitioner there are several enablers which are fundamental to the nursing care that Rose received. These are: communication, assessment, managing risk, documentation, decision making and managing uncertainty. For the purpose of this assignment, the enablers of assessment and communication in relation to the care that Rose received will be discussed. NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay

Background
Rose Swift is a retired teacher, a widower and is a mother of two sons. Rose was admitted to the accident and emergency department (A&E) via ambulance following an unexplained fall at home. Upon admission to A&E, Roses’ medical notes stated Rose had recently been diagnosed with Dry Macular degeneration, which is an age related chronic eye disease, causing loss of vision in the centre field (Samuel, 2008, Watkinson, 2010). After a short stay in a general medical ward for treatment of a urinary tract infection, Rose was transferred to an intermediate care ward for further rehabilitation, before being discharged home with a care package. Prior to admisson Rose lived alone, was independantly mobile with a stick and would cook her own meals. NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay
Assessment
The Royal Marsden (2011), regards initial nursing assessments as a step to providing an individualised patient centered nursing care plan. By conducting nursing assessments, key information is obtained to aid the improvement of Roses’ health and develop a plan of care, which will ultimatly enable Rose to establish control of her own health (The Royal College of Nursing (RCN), 2004). However, as cited by Chapelhowe et al (2005) nursing assessments are far from static. As part of the nursing assessment process, a set of individualised outcomes are agreed, in collaboration with the nurse, Rose and the multidisiplinary team. These outcomes are continously evaulated by the nurse, in order to moniter Roses’ progress and where nessescary clincal judgement will be used to adjust these outcomes to suit the needs of Rose (Estes & Ellen, 2013). NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay
For a successful assessment to take place, it is argued a sufficient baseline knowledge is required by the nurse (Peate, 2012). In contrast however Chapelhowe, et al (2005) argue that base line knowledge alone is not enough. Irrespective of how knowledgeable a nurse maybe, without effective communication and interpersonal skills, the care the nurse provides to Rose will be limited as Roses’ individual needs may not be met. It is therefore considered that a combination of the two is thus required (NMC, 2010).
Throughout Roses’ hospital journey, there are several assessments that took place. During Roses’ initial admission to A&E, the nurse conducted a systematic `mini’ assessment to obtain a rapid outline of Rose from both a visual and physical point of view (The Royal Marsden NHS Foundation Trust, 2011). As the resusitation council (2005) points out, inital nursing assessments in acute settings enable preservation of life, by providing fast intervention where required, using the Airways, Breathing and Circulation (ABC) algorithm. By asking Rose questions and obtaining qualitive information, the nurse established that Rose was breathing, had a clear airway and brain perfusion as well as establishing vital background information to aid diagnosis (Fawcett & Rhynas, 2012). In addition, the nurse was also able to quickly access Roses neurologial state using the Modifed Glasgow Coma Scale (MGCS) (Jennett & Teasdale, 1977). NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay
When a patient such a Rose sustains a head injury, the National insititute of Health and Care Excellence (NICE) (National Insitiute for Health and Care Excellence, 2014) recommends the use of MGCS. According to Pillay (2013), MGCS provides a tangible way of noting the concious state of Rose, it is a widely recognised and accepted standarised practical assessment tool, designed for ease of use (Jennett & Teasdale, 1977) which has been used for many years at both a national and international level. When used repeatedly, MGCS can indicate the progression of a brain injury (Teasdale, et al., 2014), this in turn can aid decision making (Nursing Times, 2014). Recently however, there has been some criticism against MGCS regarding the tools ease of use (Mattar, et al., 2013). McLernon (2014) questions if the MGCS tool is still fit for purpose, citing reduced reliability due to lack of clinical consistency and poor communication between professionals. It is therefore suggested that a remedy of a uniformed approach and concise communication between professionals is essential, to ensure safe theraputic practice. NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay
Whilst conducting Roses’ MGCS assessment the nurse noted a reduced score on account of Rose presenting symptoms of delirium. Farne, et al., (2010) states new confusion in patients can often be caused by underlying medical conditions. By utalising this knowledge, this enabled the nurse to apply her professional decision making skills, in order to continue with further assesssments which included a set of observations.
Observations (also known as vital signs) enables the nurse to check Roses’ basic bodily functions such as temperature, pulse, respiration rate and blood pressure (The Royal Marsden NHS Foundation Trust, 2011). A fundamental part of the asessment process, observations allow the nurse to obtain a baseline figure in order to carry out a continous assessment and evaluation, and enable the nurse to establish the level of care that Rose requires (Wheatly, 2006). To identify the risk of Rose deteriorating further, as per Nursing and Midwifery Council (2008) guidelines, each quantitive result was charted correctly, concisely and legiblibly by the nurse and given a score using a modified early warning score (MEWS) (Department of Health, 2000). After combining all results, the nurse was then able to establish that Rose was scoring a MEWS for a raised temperature and increased pulse in addition to a reduced MGCS. By drawing on previous experience and knowledge, the nurse was able to evaluate the overall asssessment, to establish that the presenting symptoms could indicate Rose has some form of an infection. This could be the reason for the fall and delerium (Schroeder, 2010). To rule out a urinary tract infection, a urine dip stick test on a midstream urine sample was conducted. This test showed positive for leukocytes and nitrates, indicating a positive infection result (Little, et al., 2009). NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay
In order to treat Roses’ symptoms the doctor prescribed antibiotics, providing treatment under the biomedical model. Considered a dualistic approach, this model treats the mind and body as separate entities. Fast acting in its approach it treats the immediate problem (Mehta, 2011). However, in order to provide truly effective care the biomedical model alone is simply not enough. It is considered by many professionals that a holistic viewpoint should be taken (The Royal Marsden NHS Foundation Trust, 2011). Id est, in addition to Roses’ physical requirements, consideration should also be given to her emotional and social needs (Chapelhowe, et al., 2005). The psychosocial model should therefore also be considered, in order to treat Rose from a holistic perspective (Chapelhowe, et al., 2005).
Given Roses’ confused state of mind, unsteady gait and MEWS score it was decided to admit Rose to a general medical ward. In order to assess Roses’ psychosocial and cultural needs, the Activities of Daily Living (ADL’s) model (Roper, et al., 2000) was used. ADL’s is a systematic framework, which recognises Roses individuality and beliefs. It considers twelve fundamental concepts and provides a continuum in recognition that dependency can change throughout time (Roper, et al., 2000). Kearney (2001) argues however, that the care Rose receives maybe jeopardised using this model, due to its inflexibility and complex structure. To alleviate this, The Royal Marsden (2011) therefore advises that the nurse should use a pragmatic approach, and use the ADL framework as a guideline for professional decision making. In Roses’ case the nurse was able to utilise the ADL framework to identify a change in care needs. Due to Roses confused state and unsteady gait, assistance would now be required with washing, dressing, mobilising and other essential care needs as defined by the Department of Health (2010) in the Essence of Care guidelines. NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay
Communication
Effective communication is an essential skill which enables the expert nurse to build a therapeutic relationship with Rose (Chapelhowe, et al., 2005). According to Dwamena, et al., (2012), communication is considered to be a significant factor in the rapid recovery of Rose. Throughout Roses hospital journey there are many ways in which the nurse interacts with Rose. However, as cited by The Royal Marsden (2011), interpersonal communication skills are the most widely used medium in nursing and arguably the most important skill.
In order for interpersonal skills to be effective Arnold & Underman Boggs (2011), states the nurse must consider several elements such as, verbal and non-verbal exchanges of information, active listening and observation skills. As the initial assessment process is often the first interaction Rose may have with the ward staff, Rose maybe reluctant to share information (Perry Black, 2013). The Royal Marsden (2011), recognises this could be a potential barrier for the nurse to deliver effective care to Rose and key communication factors such as environmental and nurse time restraints maybe contributory to Roses’ unwillingness to share information. To aid the nurse in overcoming this issue, (Cotoi & Ilkiescu, 2013) suggests a trusting environment should be created. Trusting environments enable Rose to feel safe and supported and provide a platform where Rose will feel comfortable and confident in sharing information with the multi-disciplinary team (The Royal Marsden NHS Foundation Trust, 2011). NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay
In order to assimilate meaningful information from Rose, the nurse utilised her communication skills effectively in a number of different ways. An example of this would be, during the initial assessment process. When Rose was admitted to the ward, in line with NMC (2010) Code of Conduct to ensure privacy and dignity is maintained, the assessment took place in a cubicle, with the door closed thus creating a quiet environment. The Royal Marsden (2011) states a quiet environment during assessments is essential to enable Rose to maintain optimum concentration and remain complicit in her responses. Past research has shown discrepancies can often occur between the nurses understanding and that of Rose during assessments (Lauri, et al., 1997). A quiet environment therefore enables the nurse to focus solely on Roses responses, to maintain a meaningful interaction and deliver effective individualised therapeutic care (The Royal Marsden NHS Foundation Trust, 2011).
To ensure effective non verbal communication takes place, body language should also be considered. White, et al., (2011) states body language can be a powerful means of sending a message to Rose, therefore a postive open posture should always be maintained. Throughout Roses hospital journey it was noted the nurse positivly adapted her body language to suit the needs of Rose. An example of this would be when conducting assessments the nurse sat facing Rose, kept an open posture and maintained regular eye contact. These interations are considered by Egan (2002), to be fundamental elements of non verbal exchanges, in order to achieve optimum levels of communication. NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay
As specified by the nursing and midwifery Code of Conduct (2008) optimum communication is an essential nursing skill. To be proficient, the nurse should respect Roses right to be involved in the decisions of her care (NMC, 2010). During discharge planning the nurse demonstated the proficient use of communication, when a conflict occurred between Rose and her family. Acting as an advocate, the nurse conveyed the wishes of Rose to return to her home against her sons wishes. Xxx xxx states during discharge planning, conflict can often occur due to lack of communication. To remedy this, the nurse utalised her commuication skills by asking open ended questions to asscertain the reasons behind the familys anxieties. Questions that are open ended allow the answer given by the receiver to be expanded and explored xxxxx xxxx. However XXX XXX states questions alone are not enough. In order to gauge the true meaning of the answer, non verbal signals should also be observed xxx xxxx.
In conclusion in order to provide effective nursing care to Rose the nurse must ensure that a thourgh assessment is conducted. This cannot be fully completed however, without effective communication skills, concise documentation and decision making. Each enabler is therefore interlinked to provide individualised holistic nursing care to Rose. As a nurse, good communication is vital to build a positive theraputic relationship with Rose and to enhance the relationship there are a number of factors the nurse should be aware of such as enviroment and non verbal communication prompts. Good interpersonal skills are therefore an essential nursing skill to aid the recovery of Rose. NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay

Specific health assessment refers to an assessment of a specific problem and it may be the initial assessment or an ongoing assessment (Bayoumi., 2009). A risk assessment is a type of assessment that uses an individual ‘s personal data, genetic and environmental information to determine the risk of developing a specific disease such as cervical cancer, breast cancer, pancreatic cancer etc. (Duke, 2010). The objective of this essay is to discuss about a type of specific assessment which is pain assessment. In order to answer this question, first of all, the essay will touch on the differences between comprehensive health assessment and specific assessment. Later, the essay will discuss on the purpose and intent of pain assessment, how this pain assessment contributes to a person’s comprehensive health assessment and three abnormal findings when performing the pain assessment. Lastly, it will discuss the actions that I can take for each of the three abnormal findings. NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay

Body

A comprehensive health assessment is a thorough head-to-toe physical examination which includes a review of the medical history , a complete physical examination , a complete laboratory tests, body fat assessment, exercise tolerance test, nutrition assessment, fitness assessment and stress management. (Glymph, 2010). It is usually the initial assessment. On the other hand, a specific assessment is problem oriented . It focuses on a specific problem and not a general health (Bayoumi., 2009). If a patient’s condition does not permit a comprehensive health assessment, a specific assessment of the patient’s current health problem is done. It is done frequently to monitor and evaluate the patient’s progress (Bayoumi., 2009). A specific assessment is a part of a comprehensive health assessment. When the patient’s condition is favorable again, a comprehensive health assessment is carried out. For example, one day, a 65-year-old man came to the emergency department with acute chest pain. Instead of performing a comprehensive health assessment, I have to perform a specific pain assessment for this patient since his condition is not favorable. I should focus on chest pain assessment, perform an electrocardiography test and laboratory tests like complete blood count, biochemistry test, creatinine kinase test and test for troponin (Fogoros, 2009). Comprehensive health assessment is not suitable in this situation as it will provide less accurate information. It should be done when the patient’s condition has gotten better . Among the tests for a comprehensive health assessment are urine analysis, chest x-ray, abdominal ultrasound, fitness test, ankle brachial index, visual acuity test etc (Billinkoff, 2012). NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay

According to the Australian and New Zealand College of Anaesthetists, pain assessment has been identified as the 5th vital signs when assessing a patient (Wood, 2008). Pain assessment is important in providing an effective management. Pain assessment involves factors that may influence patient’s experience and expression of pain, the process of describing pain, and factors that may affect nurses in pain assessment such as inadequate knowledge or skills about pain, patient’s poor attitude, patient’s age, type and stage of disease and misconceptions about pain like the fear that patients will be addicted to pain medication (Wood, 2008). Pain assessment can be carried out using an assessment tool that identifies the quantity and quality of the patient’s experience of pain (Wood, 2008). A pain scale from 0-10 where 10 represents worst possible pain can be used. NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay

The first abnormal finding when I perform a pain assessment in a 55-year-old man is an acute chest pain. Generally, acute chest pain is an emergency situation as it can be life-threatening. Acute chest pain is a warning symptom for heart attack, angina pectoris, aortic dissection, pulmonary embolism, spontaneous pneumothorax , perforated viscus, pericarditis, pneumonia and other esophagus related causes (Cunha & Stoppler, 2012). As a professional nurse, first of all, I should assess the patient’s airway, breathing and circulation (Lynda, 2009). This is the primary assessment. Secondary assessment includes location of pain, the nature of pain, characteristics of pain, chronology of pain, the situation at the time of pain, provoking and relieving factors and other symptoms in association with chest pain (Lynda, 2009). In this patient, his airway and circulation are clear but he has shortness of breath. The pain started substernally after exercising and radiates to the jaw, left arm , back and neck. The pain is dull in character. The pain is continuous and constant. It lasts for more than 30 minutes and is not relieved by rest. According to the patient, he rates the pain as 8/10 according to the pain scale. For interventions, I should have the patient rests on the bed in Fowler or Semi-Fowler position (Nanda, 2009). Later, I will perform 12 leads electrocardiography to rule out the causes of the patient’s chest pain (Nanda, 2009). Also, I will observe his 5 vital signs such as body temperature, blood pressure, pulse, respiratory rate and pain (Nanda, 2009). If necessary, I will give patient oxygen or pain killer to relieve pain. At the same time, I will observe the side effects of the medications. Besides, I will set up an intravenous drip to rehydrate patient and take blood samples for further laboratory investigations. It is necessary for me to try and reduce environmental stimuli such as noises and be calm when dealing with this patient. I should continuously monitor the patient’s vital signs and look out for any complication if there is any (Nanda, 2009). NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay

Secondly, the patient has headache. As a professional nurse, I should start my assessment from collecting subjective data from the patient. Subjective data that I should collect are like trying to understand the causes of the headache, aware of trigger factors, measures to reduce headache, location, frequency and pattern of pain, beginning of the attack, accompanying symptoms and family history (Nanda, Nursing Assessment and Nursing Diagnosis of Headaches , 2012). The objective data include the patient’s behavior like anxious, changes in ability to perform daily activities and body temperature (Nanda, Nursing Assessment and Nursing Diagnosis of Headaches , 2012) . It is found that the patient is constantly stressed out. He always takes one or two tablets of paracetamol when he has a headache. Often, the headache is located frontally but sometimes it involves the whole head. The pain is throbbing, moderate intensity, lasts about 4 hours each time and has 2-4 attacks each month. He had the first attack 10 years ago. Migraine headache runs in his family. Objective examination shows that the patient is anxious and is not able to perform his daily activities when he has an attack. The patient also experiences fatigue and has loss of appetite too in association with migraine headache. The interventions that can be taken for this patient include ensure that the patient takes medication when he has migraine attack, advise the patient to make a record of the attack, discuss the physiological dynamics of stress and anxiety with the patient, instruct the patient to acknowledge me when the pain is severe, place patient in a dark and quiet room, put a cold compress on his head, massage his head if necessary, employ techniques of therapeutic touch and stress reduction, observe for any complications and give icy drinks containing carbonate to the patient (Nanda, Headache Nursing Care Plan Interventions, 2012). NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay

Also, during the pain assessment, it is found that the patient experiences pain during urination. To assess the patient, subjective data that need to be collected are asking the patient whether he experiences pain during urination, frequency of urination, color of urine, the amount of urine each time, the presence or absence of odor, presence or absence of pain in the abdomen and other associated symptoms (Johny, 2011). Objective data include the vital signs of the patient such as the temperature, pulse, respiratory rate, blood pressure and urine output and presence or absence of abdominal muscle guarding (Johny, 2011). A urine analysis should be carried out. If necessary, an abdominal x-ray should be scheduled. It is found that the patient has moderate pain during urination, urinate 3 times per hour, yellow colour urine, small amount of urine each time, presence of foul smell and pain is felt at the back. Patient experiences fever and malaise as well. His vital signs are normal and there is no abdominal muscle guarding. Urine analysis shows that the patient has pyelonephritis. As a professional nurse, I should constantly monitor his urine output, monitor the results of repeated urine analysis, record the location,duration and intensity of pain, provide comfort measures such as massage, encourage the used of focused relaxation breathing, provide perianal care as well as give antibiotics and analgesics according to the doctor’s order (Wiwik, 2009). NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay

Conclusion

In conclusion, a comprehensive health assessment involves an assessment from head-to-toe while a specific assessment is problem oriented. The specific assessment is carried out when the patient’s condition is not favourable for a comprehensive health assessment. During the pain assessment in a 55-year-old patient, I found that he has an acute chest pain, migraine headache and pain during urination. As a professional nurse, I should carry out subjective assessment, objective assessment and laboratory tests for each abnormal findings. There is a specific care plan for each abnormal finding with the main objective which is to provide comfort to the patient and to reduce the pain. NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay

The purpose of this paper is to discuss the results of a comprehensive health assessment on a patient of my choosing. This comprehensive assessment included the patient’s complete health history and a head-to-toe physical examination. The complete health history information was obtained by interviewing the patient, who was considered to be a reliable source. Other sources of data, such as medical records, were not available at the time of the interview. Physical examination data was obtained through inspection, palpation, percussion, and auscultation techniques.NUR 634: Advanced Healthy Assessment and Diagnostic Reasoning with Skills Lab Essay