4020 Assignment
The purpose of this assignment is to discuss the phase of the nursing process in which assessment and care planning will be focused and also discuss the importance of communication and interpersonal skills within this process. The nursing process is a systemic approach used to improve the quality of nursing care (RCN, 2016). It consists of mainly five steps which are assessment, diagnosis, planning, implementation and evaluation (RCN, 2016). The basic pharmacology and nurse’s responsibility in administering medication will also be discussed. This essay will also discuss how the theory can link with the practice by using a case study. Finally, it will examine how the personal reflection …show more content…
After that in order to comply with the NMC (2016) code of conduct, the consent was obtained from Anne to carry out the assessment process. The assessment is first and important part of the nursing process (RCN, 2016). It is a complex process, which includes the data collection, verification, organization, interpretation and documentation (DeLaune and Ladner, 2002). The comprehensive nursing process assists the clinical decision for making nursing diagnosis and for planning personalised care (Wallace, 2013). Moreover, Richard and Natalie (2014) argue that the assessment should be carried out by a holistic approach, considering the patient as an individual in order to provide the patient care. In the holistic approach the six main areas which are physiological, social, developmental, psychological, spiritual and cultural are considered (Wallace, 2013). Furthermore, RCN (2016) states that, in addition to the initial assessment, throughout the patient care episode reassessment of patient needs should to be carried out. The initial part of the assessment is data gathering where the nurse collects the subjective and the objective data (Wallace, …show more content…
During the interview, information regarding the present medical history, past medical history and the activities of daily living were collected. Anne seemed very anxious and worried during the interview. The pain assessment was carried out with the help of the pain chart and she scored 2, which indicated a moderate level of pain. Yvonne and Liza (2013) states that, pain is an unfavourable experience and each individual perceives and reacts to the pain differently. Moreover, according to RCN (2016) the activities of daily living should be evaluated, as it is a vital element in the holistic approach. Anne lives alone at home. As she was experiencing pain in the last two weeks, her nutritional and hygiene needs were difficult to manage.
The objective data is the measurable and observable information, which can be obtained by the physiological observations (DeLaune and Ladner, 2002). The physiological observations reveal the function of the whole system of the body (DeLaune and Ladner, 2002).In the process of observations Anne’s vital signs were checked and recorded that pulse 78 beats per minute, temperature- 36 degree Celsius, oxygen saturation 98 percentages and blood pressure 120/70. She was alert and all the observations were recorded on the News chart (RCP,
The purpose of this assignment is to discuss the phase of the nursing process in which assessment and care planning will be focused and also discuss the importance of communication and interpersonal skills within this process. The nursing process is a systemic approach used to improve the quality of nursing care (RCN, 2016). It consists of mainly five steps which are assessment, diagnosis, planning, implementation and evaluation (RCN, 2016). The basic pharmacology and nurse’s responsibility in administering medication will also be discussed. This essay will also discuss how the theory can link with the practice by using a case study. Finally, it will examine how the personal reflection …show more content…
After that in order to comply with the NMC (2016) code of conduct, the consent was obtained from Anne to carry out the assessment process. The assessment is first and important part of the nursing process (RCN, 2016). It is a complex process, which includes the data collection, verification, organization, interpretation and documentation (DeLaune and Ladner, 2002). The comprehensive nursing process assists the clinical decision for making nursing diagnosis and for planning personalised care (Wallace, 2013). Moreover, Richard and Natalie (2014) argue that the assessment should be carried out by a holistic approach, considering the patient as an individual in order to provide the patient care. In the holistic approach the six main areas which are physiological, social, developmental, psychological, spiritual and cultural are considered (Wallace, 2013). Furthermore, RCN (2016) states that, in addition to the initial assessment, throughout the patient care episode reassessment of patient needs should to be carried out. The initial part of the assessment is data gathering where the nurse collects the subjective and the objective data (Wallace, …show more content…
During the interview, information regarding the present medical history, past medical history and the activities of daily living were collected. Anne seemed very anxious and worried during the interview. The pain assessment was carried out with the help of the pain chart and she scored 2, which indicated a moderate level of pain. Yvonne and Liza (2013) states that, pain is an unfavourable experience and each individual perceives and reacts to the pain differently. Moreover, according to RCN (2016) the activities of daily living should be evaluated, as it is a vital element in the holistic approach. Anne lives alone at home. As she was experiencing pain in the last two weeks, her nutritional and hygiene needs were difficult to manage.
The objective data is the measurable and observable information, which can be obtained by the physiological observations (DeLaune and Ladner, 2002). The physiological observations reveal the function of the whole system of the body (DeLaune and Ladner, 2002).In the process of observations Anne’s vital signs were checked and recorded that pulse 78 beats per minute, temperature- 36 degree Celsius, oxygen saturation 98 percentages and blood pressure 120/70. She was alert and all the observations were recorded on the News chart (RCP,