Holistic Assessment of a Patient in a Clinical Setting

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This essay provides a written account of the holistic assessment used when admitting a patient onto a respiratory ward. A brief outline is also included of the processes involved together with the resources used for collating information. Using the Roper, Logan and Tierney activities of daily living (ADL’s), eating and drinking, has been identified as one goal of nursing care. A short reflection has also been included based on experiences gained on a first clinical placement on the ward. For the benefit of this essay the selected patient will be referred to as Mrs P in order to maintain confidentiality.

The first part of the nursing process is the assessment stage where information is collated, organised and examined about the patient (Peate, 2005). The person is assessed holistically by taking all the different elements that make up the individual into consideration (Siviter, 2004). Roper, Logan and Tierney’s ADL’s was used on the respiratory ward as the model for the nursing processes.

Mrs P was admitted onto the ward having been diagnosed with hyperglycaemia. This is defined as an excess of glucose in the bloodstream (Oxford Dictionary of Nursing, 2004). On admitting Mrs P it is decided to conduct a mini assessment (Dougherty and Lister, 2004). It is suggested by (Ahern & Philpot, 2002) that according to (Norman and Cook, 2000) a mini assessment allows the nurse to focus on the “patients condition in order of priority”.

By performing a quick visual and physical assessment (Dougherty and Lister, 2004), it was noticed that Mrs P was aware of her surroundings and alert but complained of a headache. Her skin and lips were dry indicating poor hydration. It was also noted that she had difficulties with communicating and appeared to be paralysed on her right side and in both her legs. Mrs P was also able to breath air without the aid of oxygen. She had also had a right breast mastectomy at some point in her life. Her charts showed that her blood sugar was last monitored four hours earlier. High blood sugar levels can cause the individual to fall into a coma so priority needed to be given to carrying out a blood test to ensure that her glucose levels were constant (Diabetes Care Group, 2007). She was also encouraged to drink plenty of water for rehydration. Full observations were also carried out at this stage and included taking her blood pressure, oxygen saturation levels, pulse, respiratory rate and temperature. Observations are important in providing a “starting point for the individual’s basic biophysical measurements” (Peate, 2005). This allows for comparisons to be made during the later stages of treatment.

Once it was established that Mrs P’s condition was stable a full subjective and informal interview could be conducted in order to collate further details so that care could be planned (Peate, 2005). The purpose of the interview is to “obtain information about factors such as lifestyle and social background” (McGee, 1998). Questions for the subjective interview are found on care plan forms. Mrs P had difficulties communicating and was only able to gesticulate with her left hand, make sounds with her mouth, blink and nod her head in response to questions. So permission was obtained, from her, to contact her carers to assist with answering further questions in order that a full history and accurate diagnosis could be made.

Whilst waiting for the carers to arrive information was sort from her past medical history, doctors referral letter and previous hospital notes. She had suffered a stroke ten years previously, which caused her to become paralysed and to have aphasia which is defined as a “disorder of language affecting the generation and content of speech and its understanding” (Oxford Dictionary of Nursing, 2004). She was an insulin dependant diabetic and had been hospitalised on numerous occasions for chest...
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