...Running head: PATIENT EDUCATION ASSESMENT 1 September 30, 2013 PATIENT EDUCATION ASSESMENT 2 Patient Education Assessment Document : Discharge Instructions For Care is used at our geriatric rehabilitation and long term care facility. This document is used when discharging residents. The instructional document has seven sections, all of which have areas that have blanks that require information in the fields that pertain to the resident individually. The document begins by asking for basic information like name, room number, medical record number, date, and place being discharged to. The first section asks for follow-up physician care, which includes the who, when, and where regarding the appointment. The next section is for medications which asks for the name of the medication, directions involved with taking the medication, comment/quantity, and whether a written prescription has been given or if they have been called in to a pharmacy. The next section asks if there are any treatments. The fourth section informs the resident about the diet. Section five describes what physical limitations the resident is supposed to follow. After that, there is a short area for referrals. Lastly, there has been provided an area for additional instructions, a drawn skin issues man, and a signature area. SMOG Score After the...
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...THE HERITAGE ASSESSMENT TOOL: A CULTURAL VIEW OF THE PATIENT The Heritage Assessment Tool: A Cultural View of the Patient Grand Canyon University: 439v March 11, 2012 The Heritage Assessment Tool: A Cultural View of the Patient The Heritage Assessment Tool is a series of 29 questions designed to determine a patient’s ethnic, cultural, and religious background. The tool gives nurses an understanding of the patient’s traditional health and illness beliefs and practices so that culturally appropriate interventions can be initiated (Flowers, D.L., 2005). The following paper summarizes the assessment results of three culturally different families, and uses those results to show how the nurse would proceed with health promotion based on the differences in health traditions between the three cultures. Health Maintenance The value a patient places on family values and their perceived support system can greatly influence their overall health maintenance. With two of the families interviewed, one with a Hispanic ethnic background and the other from an American Indian background, both families placed great value in their family relationships. Both families were able to express knowledge of an extended family network and were active participants of that social system. The family unit is the most important support system to both cultural groups. Askim-Lovseth & Aldana (2009) explains that in an extended family network all “family members are expected...
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...UNIVERSITY OF THE WEST OF SCOTLAND NURSE PRESCRIBING V150 CASE STUDY COURSE: NURS09125 BANNER NUMBER: B00113677 DATE OF SUBMISSION 13/12/10 COURSE LEADER FRANCES DOWNER WORD COUNT: 3745 CONTENTS PAGE 1. INTRODUCTION & GENERAL OVERVIEW, Pgs3-4. 2. ASSESSMENT PROCESS, Pgs 5-8 3. TREATMENT OPTIONS, Pgs 9-12. 4. EVALUATION, Pgs 13-16 5. CONCLUSION. Pg 17 6. COPY OF PRESCRIPTION, Pg 18 7. REFERENCE SECTION, Pgs 19-23 8. BIBLIOGRAPHY, Pg 24. INTRODUCTION In the following case study, the author will discuss the issues surrounding a seventy-year-old female with a chronic neuropathic ulcer on the sole of her right foot and the rationale and implications of prescribing in the community setting. The author a (trainee nurse prescriber) will display the need for a robust assessment, exploring all areas of health and well-being in order to achieve a safe outcome. The author will further follow current guidelines and be mentored by a senior nurse prescriber throughout the process. The aim of the case study is to display the implications involved in issuing a nurse prescription if deemed appropriate. With regard to writing a prescription as a qualified practioner, the author will adhere to the guidance within the Nursing and Midwifery Council (NMC 2006a) standards for safe prescribing. To protect this patient’s identity and maintain confidentiality, she will be referred to as Mrs X throughout the...
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...Journal Article Review # 1 Sherry Moore Chamberlain College of Nursing NR 305 Health Assessment Professor Kettley November 10, 2013 Introduction “A guide to taking a patient’s history” is an article which was written by Hiliary Lloyd and Stephen Craig, published in volume 22, issue 13, of Nursing Standard in December 2007. Lloyd and Craig describe the process of taking a health history and explain how environment and other factors affect the accuracy of the health history obtained. This article provides different methods to taking a comprehensive history and the order in which to do so. Summary of the Article Taking a patient’s health history is an integral of patient assessment and it is important that nurses hone their assessment skills while expanding their role as a nurse. Before a health assessment is taking the nurse must first have informed consent from the patient. While taking a health history it is important to choose the right environment, free from distractions if possible and safe for the patient and nurse. The nurse should convey respect for the patient as a person and maintain a level of privacy and dignity. Good communication skills are essential; the nurse must introduce herself to the patient, develop a rapport with the client by being professional, friendly and show interest by actively listening to the patient, the patient should not feel rushed or hurried. Nurses should refrain from using medical jargon when possible and utilize verbal and non-verbal...
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...Directions: Enter the patient’s room. Observe the patient, family, and environment for up to 60 seconds, while reviewing the following questions in your mind: Assess Airway Breathing Circulation (ABCs) without touching the patient * What data lead you to believe there is a problem with airway, breathing or circulation? * Is the problem urgent or nonurgent? * What clinical data would indicate that the situation needs immediate action and why? * Who needs to be contacted and do you have any suggestions or recommendations? Assess Tubes and Lines * Does the patient have any tubes or an IV? * Is the IV solution the correct one at the correct rate? * Does the patient need those tubes? If so, why? * Do you note any complications? * What further assessments need to be done? Assess Respiratory Equipment * If the patient is using an oxygen delivery device, what do you need to continue to monitor to ensure safe and effective use of the system? Patient Safety Survey * What are your safety concerns with this patient? * Do you need to report this problem and to whom? Environmental Survey * What in the environment could lead to a problem for the patient? * How would you manage the problem? Sensory Assessment * What are your senses telling you? * Do you hear, smell, see or feel something that needs to be explored? * Does the patient’s situation seem “right”? Additional Assessment * What additional information would be...
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...Organizations HCS/587 Virginia Weatherston July 16, 2014 Organizational Change Plan - Part II Patient satisfaction scores related to pain management continues to be a struggle at Banner Hospital, so it is important that a new pain management process becomes implemented. If nurses become better educated on pain management and how to asses it, if pain goals are discussed and written on the whiteboards, and if pain assessments are included in hourly rounding, pain would be better controlled and patient satisfaction scores would increase. Change, however, is never easy to implement. Once change begins, monitoring the implementation process is important to evaluate the effectiveness, the quality of the change, and how it will affect staffing. Communication also plays a vital role in the implementing process, as keeping everyone informed and empowered is important in order for change to be successful. The proposed solution to help implement the change would be to hold educational programs about pain management and assessments that each and every medical-surgical unit nurse would need to attend. The educational program will be held three times per week for each shift to complete. The program will be mandatory and each week a certain nursing unit will be assigned until all units/nurses have attended the educational program. The educational program for pain management and assessment will teach nurses about the pain process, how to assess it visually and through communication, and...
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...during their practice based learning, and how this experience may affect my future practice. Throughout the account, in order to protect the identities of people, trust and clinical setting involved confidentiality will be maintained via the use of pseudonyms or omission of names (Nursing and Midwifery Council (NMC), 2008a). The function of practice based learning is to provide experience, serving an important role in developing the skills of the student in interacting with patients and their families assisting in technical, psychomotor, interpersonal and communication skills (Ali and Panther, 2008). Practice based learning provides an opportunity to link theory and practice, and promotes professional identity development (Fishel and Johnson, 1981). Practice based learning is also crucial in the profession of nursing due to the vocational nature of the work, and necessity of assessing clinical competency and safeguarding the public (Rutowski, 2007). By ensuring specific standards are met with assessment in practice, it effectively ensures that students are fit for practice at point of registration (NMC, 2004). My demonstration of demonstrating my eligibility to supervise and assess students in a...
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...clinical setting, whether medical or psychological, diagnosing patients is a major part of the job. This sounds like a daunting task. The clinician is taking full responsibility for the welfare of the patient. Labeling a patient can change how they are treated. Although diagnosing needs to be done, I think that a clinician should still treat the patient and not the disease. There are multiple models of diagnosing. Some of which I think I would like more than others. In my own medical experience, diagnosing usually follows a SOAP model. SOAP stands for subjective, objective, assessment, plan. Although this was not mentioned in lecture or the book, all of the assessments fall into this model. Subjective diagnosing would be clinical interviews and projective tests. I think this type of testing would be the hardest to diagnose. You must use your own discretion and it is not as valid or reliable. The patient could also be making up symptoms or have ulterior motives. In a clinical setting, I don’t think I would use much subjective diagnostics. The way that I diagnosed someone could differ from how another clinician would diagnose the same patient. My general impression of the patient would be important but in order to diagnose. However, I would want to use more objective tests because they are more standardized and . The more objective methods for testing that we learned about were objective assessments, psychophysiological test, neurological test, and neuropsycological...
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...The Process of Clinical Assessment helps the provider understand how problems persist and how they can be modified. It also helps the provider understand the nature of the problems, symptoms, complaints or dilemmas presented in the patient population (Messer & Gurman, ). The process of clinical assessment is especially useful for my field placement because I conduct assessments, diagnose patients, and determine potential levels of care while providing one-on-one therapy. The unique element is that my placement is located at a correctional facility. Patients are often not compliant with treatment in the community and incarceration is often their first contact with mental health providers. Patients with documented histories often have an...
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...NUR 111 Physical Assessment ID Patient:Verify name on band | Patient in 304 identified and identity confirmed. | Orientation:Name, Date, Place | Patient is A&O x0 | Vital Signs:Temp, pulse, resp, blood pressure, saturation, pain level | Temp: 98.1P: 79RR: 17BP: 147/106 – Nurse and instructor were both notifiedSAT: 96 on 2L of oxygen via nasal cannula Pain: unable to determine since patient was A & O x0 and non verbal | Head:Mental status (calm, cooperative) eyes, (pupil response), mouth, tubes (oxygen) | Calm, allowed me to complete assessment. Pupils were PERRLA. Mouth was dry and pink with clear mucous. On 2L of oxygen via nasal cannula | Neck:JVD, masses, swollen lymph nodes | JVD non visible, not distended. No masses or swollen lymph nodes. | Arms:Radial pulses, symmetry of grip, cap refill, temp, color, IV site check | Radial pulses are +2 and equal bilaterally.Strength was 3/5 and equal bilaterally. Capillary refill was 3 seconds.Skin temperature was warm to the touch and appropriate for race. IV site was clean, no inflammation, infection or drainage. | Chest:Resp status, breath sounds (anterior, posterior, bases) | Patient had trouble breathing, coughing with each breath.Breathing treatment was administered. Breath sounds were raspy with auditory wheezing. | Heart:Sounds, rhythm, Apical rate, telemetry | Heart tones were clear, no murmurs noted with an even rhythm.Apical pulse: 79Telemetry: not able to obtain reading. | Back:Curvature, edema...
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...PL3236 - Abnormal Unit 3 Notes – Assessment and Diagnosis Term | Info | Intro | * Clinical Assessment - the process of gathering information about a person and his or her environment to make decisions about the nature, status, and treatment of psychological problems * Typically begins with a set of Referral Questions developed in response to a request for help * Determine the goals of the assessment and select appropriate psych tests or measures | Goals of Assessment | * What procedures and instruments to use – age, med condition, and symptoms influence tools – psychologist’s theoretical perspective also affects scope. * Integrate findings to develop preliminary answers – shares this – process sometimes has therapeutic effect – feedback | Screening | * Screening - an assessment process that attempts to identify psychological problems or predict the risk of future problems among people who are not referred for clinical assessment * All members of group are given a brief measure for which some identified cutoff score indicates the possibility of significant problems, e.g. Centre for Epidemiological Studies-D (CES-D) – possibility of depression. * General Health Questionnaire (GHQ) – broad-based – indicates if more thorough evaluation is needed. * AUDIT test – 10-item screen to identify substance abuse * To evaluate usefulness of screening, they must have: * Sensitivity – ability of the screener/instrument to identify a problem that actually exists...
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...practice, professional readiness, and clinical evaluation. Others include screening, assessment, treatment planning, referral, case management/service coordination, implementing the treatment plan, consulting assessment and treatment planning. Possible assessments evaluation instruments are: substance use history, family dynamics, work history, psychological concerns, physical and mental status. Also, educational and life skills, current legal status, use of community resources, and more. Core elements for individual counseling are rapport, empathy, genuineness, attentiveness, respect, immediacy, concreteness, and warmth. Counselor skills go together with the elements of counseling and guide the counselor in the therapy process. Listening, reflecting, questioning, confronting, self-disclosing, interpreting, and clarifying are among these skills. Documentation is the recording of the screening and intake process and the assessment and treatment plan as well as the preparation of written reports, clinical progress notes, discharge summaries and other clinical-related data. Successful charts should be notable for the thorough and accurate charting of all pertinent aspects of patient contact. Responsibility to find a good supervisor, meeting their training needs, is up to the counseling student. They should be monitored with record keeping, counseling activity, referral, assessment and diagnosis, ethics and professional issues, presentations, evaluations and issues of...
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...Systematic Approach to Patient Assessment Examiner : 2nd officer: Concept Area and description of performance criteria Approach to scene The student should describe to the examiner the use of PPE, standard precautions and safety equipment. Focus points Explains the use of standard or additional precautions Describes the use of the following gloves; glasses; clothing helmet reflective vest Explains the type of information being sought in the following areas and provides professional inferences on patient condition number of patients exact location time of day weather time to scene / time to hospital partner & qualifications back-up (level & time away) access and egress enquires about nearest appropriate hospital TO TAL /6 Pre brief The student should describe to the examiner the concepts of a systematic pre brief. /10 Concept Area and description of performance criteria Primary survey The student should discuss and demonstrate the primary survey with the examiner and explain their actions. Focus points Explains the type of information being sought in the following areas and provides professional inferences on Danger Verbalise (Assessment of hazards to self; partner patient; bystander and other emergency services) Introduce self and partner Takes time to observe and comment on patient’s overall presentation ( including obvious haemorrhage; patient general appearance; colour; position; immediate patient environment) Asses response...
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...is undertaken by assessment against the following statements: These statements are designed to indicate competence to use this device. Responsibility for use remains with the user, so if you are in any doubt regarding your competence to use the device, you should seek education to bring about improvement. Various methods including, self directed learning, coaching and formal training may be initiated. You must be able to answer “yes” to all the questions before considering yourself to be competent. If you are not competent, instigate learning and then repeat assessment. If you have never used the device before or have not used the device for over a year, then you are required to be assessed by an approved assessor for the named device. Self assessment must occur for all staff. Please circle: assessor assessment / no assessor assessment Can you correctly answer the following questions? Self Assessor Assessed Assessed Pre-operational inspection and correct set-up of the device: 1. Ensure that the electrosurgical generator is connected to the electricity supply and Yes / No Yes / No switched on, is visibly clean and free from dust 2. Ensure that the electrosurgical generator performs and passes the start up self test Yes / No Yes / No cycle Ability to operate the device safely: 3. Securely apply a patient return electrode (where necessary), in an appropriate position avoiding metal prostheses, damaged skin and skin prep solutions 4. 5. 6. 7. 8. 9. Ensure the patient is not in...
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...module supervision I believe some students are having difficulty finding the assignment guidelines, these are on webCT in the module handbook, however, to make them more explicit I have also copied the guidelines below. Hopefully you have been able to choose a patient and are making progress with your assignment, remember to use your module supervisor as you develop your piece of work. If your module supervisor in on leave for more than 1 week you may approach ONE other team member for help during your supervisor’s absence. Should you choose this option then you have a responsibility to inform your temporary supervisor of what guidance you have previously been given. Once your original supervisor returns they immediately resume their supervisory role and you should inform them of what advice you have received in their absence. all the best with your assignment Graham 10/6/10 CASE STUDY GUIDELINES FOR NU2285 This assignment should provide evidence of theoretical understanding underpinning practice. It is a summative assessment that requires you to write a 3000 word case study on an adult patient you are currently nursing. The patient must have a condition that is covered in the module content i.e. a patient who has a neurological, cardiac, respiratory, metabolic or neoplastic disorder. What is a CASE study? It is NOT a study of nursing care alone, and hence this is not a nursing care study. Case reflects all aspects of “care” provision including medical treatment...
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