Advanced Health Assessment & Clinical Diagnosis In Primary Care Essay Paper

Importance Of Effective Communication Skills

A registered nurse need to perform her or his professional duties by following Australian competency standards (NMBA, 2017 P, 3). Nurse should be competent enough to make self-decisions. Nurse need to think critically and analyse the data collected for the 41 years old male patient admitted to the Queen Elizabeth Hospital(QEH) ED referred by GP noted him tachycardic. This can be helpful for the nurse to achieve the correct outcome. For example, it is important to collect maximum of both subjective and objective data from other healthcare professionals, patient and family members. Also, nurse needs to check and collect information from Enterprise Patient Administration System’ (EPAS) if the patient has a pervious history on the system related to his current visit (NMBA, 2017, P, 4-5).

During initial assessment, Nurse should perform head to toe assessment to analyses and assesses patient’s current health condition. Also, nurse should be capable of identifying abnormality at patient’ vital signs and take action accordingly (Rose & Clarke, 2010, P, 11).  In this case, abnormal pulse rate was identified, 142 beats/min. Nurse should be able to interpret the abnormal heart rate and rhythm, and should take corrective measures following local early warning score (EWS) escalation protocols (Plante, 2018). Under supervision of RN, 12 ECG leads was performed to determine the cause and the rhythm of tachycardia as it is considered as first signs of deterioration of the patient (Drzewiecki & John, 2012, pp. 57-58). Along with cardiac signs, nurse needs to monitor periphery of the patient because in tachycardia patient’s periphery becomes cool and pale. Hence, this patient was exhibiting intermittent chills and rigor.

Nurse needs to use clinical reasoning cycle to find out what other possible physiological signs like pain, anxiety, dehydration, infection and pyrexia can cause tachycardia (Dains et al., 2012, pp. 88-89). Based on respiratory assessment, patient’s airway was cleared, and he was speaking full sentences. However, respiration rate was abnormal, 29 breaths/min. Two weeks’ history of cough was also noted.  Chest auscultation was performed and found crackles on left lower lobe. Vital signs also need to be monitored on the regular basis. Nurse needs to work in collaboration with other healthcare professionals like doctors, pharmacist, radiologist and diagnostic lab technician to provide safe and effective care to the patient (Bridges et al., 2011, p. 3402). Nurse needs to establish effective verbal and written communication to inform the adverse events observed during the assessment of the patient. It can be helpful in proper analysis of the data and acquiring knowledge and skills from the senior nurses and doctors. Along with this direct observation of the patient, knowledge acquired through discussions can be helpful in improving competency of nursing student (Papathanasiou et al., 2014, pp. 283-284). To help identifying the proper diagnosis, x-ray has been ordered and blood has been taken and sent to the lab; therefore, more accurate treatment was initiated.  Nurse needs to make sure that patient lie-down flat because he was experiencing light-headedness. within the scope of the nursing student and supervision of RN, intravenous therapy, sodium chloride 0.9% infusion 1000 mL over two hours, was administered to ensured optimum circulating fluid in the patient body (Drzewiecki & John, 2012, pp. 105-016).  Advanced Health Assessment & Clinical Diagnosis In Primary Care Essay Paper

Nurse Competency In Critical Decision Making

Nursing documentation is the principal source of clinical information and it should meet legal and professional requirements (Tuinman et al., 2017, pp. 580-581). Nursing documentation should comprise of information related to the admission, assessment, nursing care plan, progress report and discharge plan. Nurse can maintain documents both in the form of paper-based and electronic based nursing documentation. Quality of nursing documentation is based on the structure and format of documents, documentation process and documentation content. Documentation need to be completed on daily basis and it should be done based on the hospital policy and guidelines. Accurate documentation can be helpful in the effective communication and decision making (Tuinman et al., 2017, pp. 580-581).

Improvement in the nursing practice can be achieved by working in the facilities equipped with all the required resources. Nurses need to research and visit different facilities of different Emergency department and implement new technologies in the department. Nurses need to be updated with the recent developments in tachycardia care and same should be implemented for the patient. Nurse need to communicate with experts to take advise for providing tachycardia care. Nurses need to spend enough time with the patient, hence patient can feel more comfort level with the nurse and nurse can built trust on the patient. Nurse need to identify his or her requirements for providing nursing intervention to tachycardia patient. It can be helpful in the improving learning of the patient and professional activities (Coyne & Needham, 2012, pp. 99-014).

Nurse need to be engaged in the therapeutic and professional relationship and it can be achieved through professional communication (NMBA, 2017, p. 6). Nurses need to maintain both professional and personal relationships among different people involved in the care of the patient. Professional relationship need to be maintained with other healthcare professionals. Personal and professional relationship need to be maintained with patient and family members. However, nurse need to establish demarcation between personal and professional relationship. Nurse need to communicate effectively with patient by considering patient’s dignity, culture, rights and values. It can be helpful in the establishing professional communication between the nurse and patient. Both verbal and non-verbal communication need to be used for communicating with patient and other healthcare professionals. ISBAR handover and nursing progress note can be helpful in communicating patient information to the other healthcare professionals (Malekzadeh et al., 2013, 179-180). Nurse need to maintain proper documentation and its effective retrieval procedure should be established. Through effective communication, patients and their family members can be incorporated in decision making. Needs and requirements of the patient and family members can be enquired through proper communication. Needs and requirements of the family members can play prominent role in the decision making because these are based on their experiences in life (Casey & Wallis, 2013, p. 36).

Assessment And Analysis Of Cardiovascular Function

Patient and family members communication can be helpful in providing medication education to the patient. It can be helpful in improved adherence of the patients for the medication consumption and patient satisfaction can be improved. Nurse should explain care plan to the patient in professional manner and explain the patient how it can be helpful in fulfilling their needs and requirements. Professional communication with the patient should always be for the benefit and for improved outcome of the patient. Professional communication with the patient should be in such a way that patient should understand therapeutic communication (Kourkouta & Papathanasiou, 2014, p. 66). If it is difficult for the patient to understand therapeutic communication, nurse need to approve translator and interpreter for the patient. Translator and interpreter can be helpful in the avoiding barriers for communication between nurse and patient. Mutual and professional respect among different healthcare professionals can be maintained through professional relationship and professional communication. It can be helpful in the productive discussions among different healthcare professionals and exchange and sharing of ideas for patient care. Hence, there is importance for therapeutic communication and professional relationship in national competency standards in the Australian health system (NMBA, 2017).

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Nurse are the central point for communication in the healthcare organisation because nurses play important role in the assessment, recording and reporting on patient’s treatment and care. Moreover, nurses need to communicate with the all the healthcare professionals like doctors, pharmacist and diagnostic lab technician. In the process of communication, nurse should uphold patient’s rights. Confidentiality and privacy of patients and their disease condition need to maintained be during communication. Nurse should not answer to enquiries about patient’s health status without patient’s approval (Wright, 2012, p. 2012).

Nurse should cross professional boundaries in providing care to the patient. If nurse wish to provide care for specific patient beyond the scheduled hours, it should be authorised, effectively communicated and properly documented. Nurse act and behaviour should be according to code of ethics and nurse should follow hospital policies and professional standards (Hassmiller & Bilazarian, pp. 186-187) .

Nurse should communicate with other nurse and healthcare professionals in common language which was taught to them during their nursing education. It can be helpful in better interpretation of the patient health condition. Language used by nurse should be aligned with different nursing resources and it should explain practical aspects of nursing. This language should comprise of different medical terminologies and abbreviations (Meuter et al., 2015, pp. 2-3).

Collaborative Work Culture And Interpersonal Communication

Nurse need to identify different health care professionals for providing care for different conditions. Nurse should communicate professionally to cardiologist for cardiac disease, nutritionist and dietician for nutrition and diet.  Communication and discussion among these different healthcare professionals can be helpful in improving quality of care for the patient. This collaborative work culture and interpersonal communication among different healthcare professionals can be helpful in the facilitating professional and therapeutic learning, exchanging necessary information, correcting knowledge, acquiring new professional and nursing skills and improving patient care (Bridges et al. 2011, p. 3402). Effective communication is the important tool for avoiding human errors in the provision of care to the patients. Nurse’s communication with the doctors can be helpful in providing information related to actual condition of the patient. Hence, doctor can provide accurate care to the patient, hence human error can be avoided effectively to improve patient’s health and safety.

With reference to NMBA (2016, pp.4-5), nurses are bound to provide safe and appropriate care to the patients to achieve desired health goals for the patients. Nurse need to collect all the necessary information related to the patient for providing safe care to the patient. Nurse should use this information to provide accurate care to the patient. Nurse need to work within the scope of professional practice and expertise. Hence, safe and accurate delivery of the nursing care can be ensured. If nurse requires guidance from the senior nurse for providing care to the patient, nurse should approach in a professional way to the senior nurse and seek help. Otherwise, it can lead to human error and provision of unsafe nursing care to the patient. Authorisation and monitoring from the senior nurse is required for providing safe care to the patient. Nurse should follow hospital guidelines and policies for providing standard comprehensive and quality care to the patient. Documentation and communication plays important role in providing safe care to the patient. Documentation for a specific patient should comprise of information like admission, assessment, care plan and progress of health condition. Maintenance of all this information throughout the care be helpful in providing safe care to the patient. Chances of wrong medication administration can be effectively reduced with proper documentation because nursing charts are accessible to all the healthcare professionals.  During shift change, this documentation can be more useful (Kargul et al., 2013, pp. 27-28). In the Emergency department, there is no existence of poor practice because proper documentation is maintained for each patient. Improvement in this documentation process can be made by implementing archiving process of the patient’s documents by giving specific identification coding. This type of archiving can be helpful in retrieving data in the latter case. There should be provision for reporting of errors, hence medication errors can be prevented effectively. Risk assessment tool need to be implemented to identify potential risks of medication errors. Early identification of errors can be helpful in implementing corrective strategy to prevent medication errors (Cebeci et a., 2015, pp. 459-460).

Nursing Documentation Standards

In the Emergency department it is the responsibility of the nurse to maintain documentation of the of the patient. Separate file need to be maintained for each patient and information provided in these files need to be reviewed on the regular basis to ensure correct entry of patient information which can be helpful in avoiding professional errors. Hence, accurate care can be provided to the patient. Nurses can play significant role in avoiding medication error and promoting patient safety. Nurse need to administer medication under the guidance of senior nurse and should follow the ten rights of drug administration. Ten rights of medication administration include right medication, right dose, right time, right route, right client, right documentation, right client education, right to refusal, right assessment and right evaluation (Pirinen et al., 2015, pp. 3-4).

NMBA also states that nurses need to follow standards and regulations for providing safe care to the patient. In this patient, nurse followed Queen Elizabeth Hospital(QEH) policy in ED to monitor vital signs every hour and recorded in the patient chart. It helped in understanding accurate health condition of the patient and alterations of the medications accordingly. It can be helpful giving optimum dose of medication, hence medication adverse effects can be reduced. Patients is being administered with different mediations like amoxicillin – clavulanic acid injection, azithromycin injection and paracetamol. All these medications are associated with adverse effects. Nurse need to monitor adverse effects of the medications to provide safe care and to improve quality of care (Seidi et al., 2017, pp. 6065-6066). After administration of these medications, nurse need to monitor signs and symptoms of patient’s condition to assess effectiveness of administered medication. Nurse need to check blood samples for the presence of community acquired pneumonia. Further spread of infection can be prevented by confirming absence of microorganism in the blood sample of the patient. Nurse need to research the effect of administered medications on each other. If one medication is exaggerating other condition, it can result in unsafe medication administration (Seidi et al., 2017, pp. 6065-6066).

Nurse has called CRT because provided data indicate that his vital signs like respiratory rate, blood pressure and heart are getting deviated from the normal values. According to QEH policy must be called when when the HR above 140 , BP above 200 and RR less than 8. By involving CRT in care of patient, further complications can be avoided and deterioration of the patient can be prevented (Rose & Clarke, 2010, p, 11).

Professional Relationship And Therapeutic Communication

NMBA states that nurses need to evaluate the progress of patient outcome and it should be effectively communicated to other healthcare professionals and patient (NMBA, 2017). Assessment and evaluation of the patient outcome can effectively assess effectiveness of nursing intervention and its course of action. Hence, it can be helpful in the justification of the implemented nursing interventions, its alternative strategies and its potential outcome (Brennan et al., 2013, pp. 765-766). Nurse need to perform blood tests, ECG, chest X-ray and urine analysis. In blood test 6.1 glucose level was observed. It indicates diabetic condition. In ECG, cardiac rhythm is found to be normal. During chest X ray examination, small area of opacification over left base was observed in the patient. It indicates that patient is associated infection. However, nurse was not sure about type of infection. Hence, nurse went back and did further research. Nurse studied few same type of cases. From this research, nurse noted down important points and prepared summary of these observations. After this nurse, concluded that detailed investigation need to be carried out to identify type of infection. After discussion with doctor, further investigation was carried out and it was observed that patient was having community acquired pneumonia.  Urine analysis indicates negative results for type of infection. It can be helpful in assessing effectiveness of provided intervention and evaluation of influence of other factors on the outcome of nursing care. If nurse couldn’t find expected outcome to meet the goals of care, nurse can amend the nursing intervention. It can be helpful in providing appropriate care to the patient to improve outcome (Bigbee & Issel, 2012). During assessment of the patient, nurse observed that there are abnormal alterations in the vital signs like heart rate, respiratory rate and blood pressure of the patient. Hence, nurse took immediate decision to call for CRT. If this assessment and evaluation would not have been done in frequent intervals, there would have been delay for call to CRT. It would have resulted in further deterioration of patient. Patient is feeling better with IVT and IV abx. Improvement has been observed in the Heart Rate (90) and Resp Rate (22). Moreover patient is tolerating PO fluids.

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It is accountability of nurse to determine and document nursing prioritise, its course of action and its outcome. In this case, nurse need to maintain cardiovascular parameters in the normal range. Hence, nurse need to administer antihypertensive drug to the patient. Diuretics can be used as antihypertensive drug. Hence, it cannot be used in this case because in this patient loss of fluid need to be avoided. Hence, diuretic sparing antihypertensive drugs are administered in this patient. Moreover, IVT saline is administered in the patient to keep him hydrating. ECG monitoring of the patient can give accurate condition of the patient in terms of heart rate. Hence, this continuous monitoring can be helpful in taking action. It can be helpful in improving overall outcome of the patient. Based on the continuous monitoring, alternative strategies can be implemented in the patient. Heart rate can be manually determined in this patient. However, ECG is also implemented in this patient as alternative strategy for accurate evaluation of heart rhythm (Drzewiecki & John, 2012, pp. 88-89).

Crossing Professional Boundaries In Patient Care

Nurse allowed to reflect on the nursing activity performed in the Emergency department. It helped in assessing nurse competency in nursing care. It helped in improving confidence of the nurse. Reflection also helped in the sharing and exchanging knowledge with senior healthcare professionals. National competency standards of NMBA states that reflection can be helpful in providing high quality nursing care to meet patient’s needs (NMBA, 2017). Advanced Health Assessment & Clinical Diagnosis In Primary Care Essay Paper

Patient discharge plan should include Discharge home on PO abx like  Amoxicillin 500mg TDS for 5 days and Doxycycline 100mg BD for 5 days. Nurse need to educate patient about the risk of infection and precautions need to be taken for the prevention of risk of infection. Nurse need to educate patient about the adherence to the medication consumption because full course of antibiotic consumption need to be completed to achieve better effectiveness of antibiotics (Weiand et al. 285-86).

Patient’s outcomes can be effectively improved by performing accurate patient assessment. It can be helpful in identifying patient’s needs and prioritise nursing actions with respect to patient’s needs. Nurse’s nursing knowledge and resources need to be effectively used for improving patient outcome. Nurse need to collect the data accurately, analyse it, interpret it and discuss with senior nurse to provide quality care and improve its outcome (Jones, 2016). Nurse’s goals should be realistic and achievable; also, these should be within the hospital’s policies, guidelines and framework of care. Student nurse need to provide care under the guidance and monitoring of senior nurse. Patient consent need to be taken and patient need to be educated for care to be provided to the patient. Nurse need to implement flexible and measurable nursing care plan for improving the continuity of care. Nurse need to inform senior nurse about the improvement in the patient condition and modify nursing care plan after discussion with senior nurse (Dubois et al., 2013, pp. 3-4).

Reference List

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Pirinen, H, Kauhanen, L, Danielsson-Ojala, R, Lilius, J, Tuominen, I, Díaz, RN et al. 2015,   ‘Registered Nurses’ Experiences with the Medication Administration Process’, Advances in Nursing, vol. 2015, pp. 1-10.  Advanced Health Assessment & Clinical Diagnosis In Primary Care Essay Paper