Assignment on a comprehensive assessment on a patient

The following assignment was undertaken to identify a patient during clinical placement and using the preferred Roper-Logan-Tierney model of nursing, carrying out a comprehensive assessment on this patient using the model’s 12 activities of daily living. Both the patient and the hospital’s true identities will be protected for the purposes of anonymity, in accordance with the Nursing and Midwifery Council’s Code for Nurses and Midwives (NMC 2015) and the Data Protection Act 1998, and the patient will be referred to as Alice for the purposes of this assignment.

It was during my second placement of year one adult nursing, that I had the privilege of meeting and providing nursing care for Alice. Alice was a 56-year-old divorced mother of three, who was already an inpatient on the acute medical respiratory ward that I was assigned to. It was Alice’s inspiring and positive attitude to her progressing illness that drew me to ask for her willingness and consent to involve her as the subject of my writing. Alice was an extremely friendly and outgoing person and had no inhibitions in sharing intimate details of her unfortunate failing health with me. As Alice was also situated in a private sideward, this enhanced the environment for our personal conversations, thus upholding the Nursing and Midwifery Council Code 2015 of prioritising people, by treating them as individuals and upholding their dignity, whilst also promoting professionalism and trust.

Prior to my assessment, the following medical information was made available to me from Alice’s medical notes, for which I sought her consent and approval for use in my writings. Alice initially presented in the Emergency Department with a rapid onset of acute pain in her right shoulder and back, coupled with shortness of breath and wheezing. Alice had a primary lung cancer and new metastases to her liver and bones. From Alice’s past medical history, I noted she suffered from scleroderma, a chronic condition caused by the immune system attacking the connective tissue, leading to thickening of the skin and sometimes damage to the internal organs and blood vessels (medical reference book). She also suffered from oesophageal reflux, a common complaint whereby hydrochloric acid from the stomach travels up in to the oesophagus and throat, causing pain, nausea and discomfort (medical reference book). The assessment of any patient is the first part of a 5-stage nursing process, which itself is a systematic problem-solving rationale that generates evidence-based nursing strategies used to create an individual care plan for a patient.

The five stages of the nursing process are assessment, diagnosis, planning, implementation and evaluation (ADPIE), therefore stage one, assessment, is crucial to the laying of foundations for the eventual care plan of a patient. Accurate assessment of the patient from the outset will lead to a holistic, systematic method of problem solving and identifying the needs of a patient for their future management of their condition. Assessment should lead to diagnosis, which in turn will set in motion planning of interventions and treatment, subsequent implementation of the aforementioned, and final evaluation of the outcome. A thorough examination of a patient’s activities of daily living should be at the core of good health assessment.

For a nursing process to get underway, a model of assessment must be engaged, and this model need to be holistic in approach and to all aspects of patients’ needs. To obtain solutions that identify and define a patient’s problems, while implementing them in a manner agreeable to the patient, an assessment derived from information collected about an individual’s health state must be obtained. A complete and accurate assessment is important in providing the building blocks for important decision making, both holistic and clinical, with regards to a patient’s future wellbeing and treatment regime. This requires a nurse’s judgement and accuracy. The World Health Organisation sees health as not only being the absence of disease or infirmity, but also being a state of physical, mental and social well-being.