Holistic Assessment of a Patient in a Clinical Setting Essay

2852 Words Jul 9th, 2011 12 Pages
PRINCIPLES AND PRACTICE OF NURSING 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 …show more content…
She responded to questions by pointing, nodding, shaking her head or making sounds with her mouth. There was no real communication system in place for understanding her requirements and frustration tended to set in a lot of the time. Other details relating to her normal skin, sight and hearing conditions were also noted. Enquiries about any gender related problems such as breast lumps were included in the assessment (Peate, 2005). Mrs P was also continually observed for any changes in mood or body language. Non-verbal information “can provide valuable data to the assessment process” (Peate, 2005). Once the assessment was completed, nursing diagnosis took place (McGee, 1998). By prioritising her condition it was deemed important to firstly gain control of Mrs P’s blood sugar levels. She would also need to be re-educated on the importance of maintaining a strict diet and ensuring that she took her insulin as prescribed to prevent any future problems. Her carer package would also need to be reviewed concerning her diabetes, nutrition and hydration needs. It was also decided that she would benefit from using flash cards depicting general everyday matters to assist with communicating her daily wishes to her carers. Moving onto the goal of nursing care, this section will concentrate on Mrs P’s admittance into hospital for hyperglycaemia and dehydration. Her diabetes is controlled via daily insulin injections and her other

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