Assessment is a core activity of nursing practice. It includes gathering information about the health status of a patient/client, analyzing/inspecting and interpreting the data and deciding how to use the information in the patient's plan of care, and evaluating the quality of the plan of care. It also includes assessing community, or population and using the information in planning and delivering care.
***How has your practice in nursing enabled you to apply the principles of Physical/Health Assessment and Health Education? Provide examples.
Nursing assessment is considered to be vital and fundamental in the delivery of nursing care. Considered as the first step of the Nursing Process, assessment is the basis of the interventions and health education that will be provided to our patients. This is a skill that each and every nurse must master so as to provide quality care to our patients. This skill includes gathering of health history through interview as well as review of medical records and a comprehensive physical examination with the use of our clinical eyes. Assessment can be applied anywhere and the best example wherein Assessment is critical is in the Emergency Room. This is where we admit patients therefore our assessment will be essential to the health care providers.
***Scenario: (briefly describe and experience from your nursing practice)
I was assigned to the emergency room. As an Emergency Room nurse, you must be able to determine urgency of a patient’s condition so proper prioritization could be done.
There are a lot of admissions on that day. A patient was rushed into the department because of abdominal pain and was catered by a medical intern. Upon history taking, it was found out that patient ate 3 mangoes and consumed a bottle of soda early morning of that day.
With that, the medical intern considered the case as less urgent, advised patient to take a rest first and catered other patients as there were too many waiting on line.
However, I was not certain of medical intern’s judgment so I went to that patient and reassessed. After my assessment, it was revealed that the patient had episodes of vomiting prior to admission. Also, further assessment of the pain reveals that it is localized on the right lower quadrant and is aggravated y coughing or moving. There were also slight increase in patient’s blood pressure and he was slightly febrile.
Having a background of gastrointestinal disorders, I can conclude that the patient is presenting signs of appendicitis and needs immediate intervention. I reported my assessment to the physician and his findings agrees with mine. The patient was then scheduled for an emergency surgery.
After the surgery, it was revealed that it was an unruptured appendicitis. If not immediately intervened, it could have lead to a rupture appendicitis which could cause further complications like peritonitis.
***Rationale: (please provide rationale for your interventions)
As health care providers, accurate assessment should always be done no matter what the situation is. We must never take for granted minimal symptoms and consider them as less urgent cases. In the case of this patient, abdominal pain could be due to a lot of reasons therefore we must assess further. Let then patient describe the pain as it is subjective and acknowledge his/her description of the pain. Determine what the cause is and what provokes it. Also assess where it is localized, how intense the pain is and what other symptoms were experience.
If the patient’s condition was taken for granted, that could’ve lead to a more severe condition.
A thorough and accurate assessment will be the basis of our nursing care plan. If assessment were inaccurate, then we will surely deliver the wrong care to the patient. But if otherwise, quality health care will be provided.
HEALTH PROMOTION AND ILLNESS PREVENTION
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