Assessing The Patient With An Aspect of Care Essay

Lily was a 65 year old lady with stage 5 CKD, she had recently begun hemodialysis treatment three times a week as an inpatient and had been responding well to treatment. During dialysis treatment on the morning of the first day, Lily’s observations showed that she was: tachycardic, hypotensive, tachypnoeaic, had an oxygen saturation level of 88% and was becoming confused and drowsy. It became apparent that Lily had become hypovolaemic. The hypovolaemic shock seen in this patient was of a particular critical nature due to the fact that her dialysis treatment had moved her rapidly through the first two stages of shock with her compensatory mechanisms failing very quickly (Tait, 2012).Assessing The Patient With An Aspect of Care Essay

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Lily had only recently began dialysis treatment, and her unwillingness to proceed with treatment would have resulted in her care becoming palliative, something the healthcare professional did not think was suitable at this point in her illness trajectory. Tait (2012) points out that a critically ill patient experiences not only physiological trauma, but also psychological trauma. This psychological trauma that can be experienced after critical care has been addressed by the National Outreach Forum (2003) who suggested that services should be developed to address the implications of critical illness. Samuelson (2011) suggests that any negative emotions associated with critical care can be counterbalanced with memories that reinforce safety, control and trust. This is a useful point to consider in Lily case, who fortunately had the time to talk through her worries concerning continual dialysis treatment with the staff on the ward, who were able to convince her she was in the safest possible hands and that continuing her dialysis treatment would be the best option. The psychosocial impact of this event and its repercussions surrounding Lily unwillingness to continue her dialysis treatment is a key aspect to consider when looking at involving Lily in the decision making process. The DOH document “No decision about me, without me” (2012)Assessing The Patient With An Aspect of Care Essay

The goal for nursing practice has always been to heal the whole person in body, mind and spirit. The focus on the wellness and interrelationship of people and the environment dates back to the practices of Florence Nightingale, a 19th century nurse who is considered the founder of holistic nursing. Yet it wasn’t until 2006 that the American Nursing Association (ANA) recognized holistic nursing as a specialty.Assessing The Patient With An Aspect of Care Essay

The incorporation of a holistic, person-centered approach to patient care continues to gain importance, especially with the ongoing changes in healthcare reform. The practice of viewing the individual, family and community as an interconnected system can help with disease prevention. It encourages patients to become more involved in self-care to work on their long-term health and wellness goals. Lamar University recognizes the importance of a comprehensive holistic health assessment and includes this course within its online RN to BSN curriculum.

What Is a Holistic Health Assessment?
A holistic health assessment goes beyond focusing solely on physical health. It also addresses emotional, mental and spiritual health. The whole condition of the patient is taken into consideration for ongoing wellness across the lifespan. The development of a relationship with the patient begins with open, therapeutic communication. This supportive, non-judgmental method of assessment recognizes that the patient’s stress levels, diet and relationship issues can often exacerbate many ailments.Assessing The Patient With An Aspect of Care Essay

A holistic health assessment allows the nurse to gain information essential for diagnosis, planning and implementation. It shows respect for the patient’s preferences and preserves the patient’s dignity. The six aspects of a holistic assessment include:

Physiological: Complete a physical assessment.
Psychological: Review potential stressors that might exacerbate the ailment.
Sociological: Discuss family networks and who can help at home.
Developmental: Consider how psychosocial and cognitive development may affect the patient’s response to the health issue.
Spiritual: Respectfully ask about religious and spiritual practices and determine if nursing care will need to be altered.
Cultural: Discuss special diet, values or culture-specific requests.
Integrating the six aspects of a holistic assessment into the nursing assessment can help identify an underlying cause of the illness or whether other factors are delaying recovery. Nurses can use this approach to glean information regarding the patient’s family dynamics, values, beliefs and other factors that would inform the care delivered and the patient’s healing. This can result in more effective treatment and optimal health. Lamar University offers an online comprehensive holistic health assessment course in its RN to BSN program that can help nurses build upon existing assessment skills.Assessing The Patient With An Aspect of Care Essay

What Does It Really Mean for Nurses?
The practice of holistic health nursing is based on the premise that self-care is necessary to effectively care for others. Nurses who practice holistic nursing incorporate a philosophy of responsibility to the self and a commitment to integrate self-care into their personal life. They strive to increase their awareness of their connection to the environment and remove barriers to the healing process. This allows them to provide more comprehensive care.

Holistic nurses combine mainstream and complementary, or alternative healing modalities (CAM). Some of these modalities include meditation, massage, deep breathing, natural products, yoga or music. Offering more treatment options suitable for different lifestyles provides patients a greater healing potential.Assessing The Patient With An Aspect of Care Essay

Why Is Holistic Health Nursing Important?
More hospitals recognize and utilize integrative health services. Unlike other specialties that are defined by a client group or a disease category, holistic nursing can be practiced in almost every area of care and in all settings. This patient-centered, practical and sustainable approach to well-being can be beneficial to patients of any age. The authentic, real relationships developed by utilizing the practices of holistic nursing can be beneficial to the patient and rewarding for the nurse.

Patient assessment quiz one

Function of the medical record
1. Written record of important patient information
2. Basis for health care decisions
3. Serves as a legal document Assessing The Patient With An Aspect of Care Essay

Components of the medical record
1. Medical office administrative documents – 3 parts to it. o Patient Registration Record – Demographic info -Billing info o Notice of Privacy Practices (NPP) o Correspondence

2. Medical office clinical documents – 6 parts to it. o Health Hx Report o Physical Exam Report o Progrss Notes o Medication Record
– Prescriptions/OTC
– Medication Administration Record (MAR) o Consaltation Report o Home Health Report

HIPAA o Provides patients with better control over the use and disclosure of their personal health information. o Health care providers, health plans, health care clearinghouses (billing services) must all comply o Federal law Assessing The Patient With An Aspect of Care Essay

Different types of Documents

Lab documents – Reports of analysis of exam of body specimens to assist physician in diagnosing and treating disease. o Ex) Hematology, urinalysis, Microbiology, cytology, histology

Diagnostic procedure documents- procedures performed to assist in the diagnosis, management or treatment of patient. o Ex) ECG/EKG, Holter monitor report, colonoscopy report, Spirometry Report, Radiology Report Assessing The Patient With An Aspect of Care Essay

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Therapeutic services Documents- Documents the assessments and treatments designed to help restore a patient’s function. o EX) Physical therapy, Occupational therapy, Speech therapy

Hospital Documents- Dictated by a physician and transcribed at the hospital and a copy is sent to the patient’s regular attending (primary) physician. o EX) H&P report, Operative report, Discharge summary report, Pathology report, emergency department report.

Consent Documents- legal documents required to perform certain procedures or to release info contained in the patient’s medical record.
 PHYSCIANS responsibility to INFORM patient of risks, benefits, and prognosis of procedures being performed.
 Signature must be WITNESSED when the patient signs, to verify that the correct patient has signed. – the MA does this
 Is it your responsibility to explain prognosis/risks/benefits?
No, only to witness the signature.Assessing The Patient With An Aspect of Care Essay

This piece of work will be based on the pre-assessment process that patients go through on arrival to an endoscopy unit in which I was placed in during my second year studying Adult diploma Nursing. I will explore one patient’s holistic needs, identifying the priorities of care that the patient requires; I will then highlight a particular priority and give a rational behind this. During an admission I completed under the supervision of my mentor I was pre-assessing a 37 year old lady who had arrived to the unit for an upper gastrointestinal endoscopy. During the pre-assessment it was important that a holistic assessment is performed as every patient is an individual with unique care needs as the patient outline in this piece of work has learning disabilities it was imperative to identify any barriers with communication (Nursing standards 2006).Assessing The Patient With An Aspect of Care Essay

There were a number of nursing priorities identified, the patient also has hypertension. The key priority for nursing care with this patient is her learning disabilities and the potential communication barriers that may occur. The patient’s hypertension is well controlled with medication for these reasons I will focus this assignment around communication barriers with people with learning disabilities, the importance of good communication between the multi-disciplinary team within the unit. I will also explore any issues with consenting to the procedure as it is imperative that the patient is fully aware of the procedure and understands the possible risks and complications.Assessing The Patient With An Aspect of Care Essay

I introduced myself to the patient stating that I was a student nurse and gained verbal consent to carry on with the assessment, as a student nurse you must respect patients wishes at all times, if t…

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…ully aware of what the procedure involves and the possible risks and complications. I feel that the pre-assessment form used within the unit to be far to fundamental, If elements of the roper et al activities of daily living were to be incorporated this would help in achieving a much more in-depth holistic nursing assessment enabling for the best quality and level of care to be given to all patients arriving in the unit. Whilst I feel a full nursing assessment not to be fully necessary for a day case unit, as previously stated I feel that the communication element to be an excellent way of ensuring a better holistic approach is achieved, it will also help to achieve better documentation and communication between all staff members. Good documentation remains in line with the NMC code of professional conduct 2008 and to promote better communication (NMC 2008) Assessing The Patient With An Aspect of Care Essay