ASSESSMENT PROCESS OF A PATIENT

Assessment Process of a Patient



Assessment Process of a Patient

Introduction

The purpose of this essay is to reflect on a systematic nursing assessment I carried out during my placement. I will first define what assessment is all about, followed by the patient profile; I will then describe and analyze the assessment I carried out, comment on my learning regarding this experience and conclude by summarizing the main point of my essay. For confidentiality reasons, I changed the name of my patient and, I will not quote the name of my placement area (NMC 2008).

In the Clinical Nursing Procedure by Doherty and Lister (2008), a nursing assessment is the action of identifying needs and collecting information about a patient regarding his/her physiological, psychological, sociological and psychological status; it is the first part of the nursing process. Thus, this nursing procedural guideline can be intended to be followed by nurses involved in caring for the highly dependent or critically ill infant or child requiring body temperature monitoring within the Paediatric Intensive Care and High Dependency Units at R.H.S.C. Yorkhill (Blows, 2001).

The case

Patient profile:

Anna is a 95 years old woman admitted on the ward with multiple health problems, such as dementia, chest pain, respiratory disorder (Asthma) and High blood pressure. Anna arrived in the ward with her career, I introduced myself and orientated her to her bed; I gave her privacy then returned with my mentor. I later came back to Anna's bed and asked some security question; which she gave her consent (NMC 2008). I first asked to confirm her identity, date of birth and all the personnel details. After checking that the details are correct, I started my physical assessment, Anna was not sure of her height and weight because she can be confused because of her dementia.

I took her height, weight and baseline observation, like temperature, blood pressure, respiration, pulse and oxygen saturation, I recorded every data accurately on the chart and signed. Record and sign chart is essential and very important; failing to record and signed, each data can lead a nurse can be removed from the NMC register (NMC hearings 2011).

The Main Body

Dementia:

Dementia is defined as memory loss and the symptoms are confusion, and mood changes. When discussing Anne, in my view she is a demented patient as she forgets everything after a certain time. Anne has problems with thinking or reasoning and she finds it difficult to follow conversations, it was also observed that she also have communication problems like finding right words for things when describing something. Anne seems to be withdrawn, sad, frightened or angry, as she only sleeps in the morning by day she is always wording all over the places, always saying she want to go home to see her children but she can't remember how many children she had likewise their names. As Anne is under my care it is, my responsibility to make sure that she is assisted with washing, dressing, and toileting, and to take care of the ...