Please Submit Your Post Work To Canvas Within 24 Hours ✓ Solved

Please Submit Your Post Work To Canvas Within 24 Hours Of The Completi

Please submit your post work to Canvas within 24 hours of the completion of your VCBC Experience. Please refer to the Experiential Learning Orientation for further questions and a reminder on how to ensure your assignment is properly saved. Please complete the Concept Notebook (Map) for the concept of Assessment linked to your clients for the day.

Concept Notebook Template.docx download

Concept Notebook Rubric V2.docx download

Sample Paper For Above instruction

Title: The Role of Assessment in Client-Centered Nursing Practice

The concept of assessment is central to effective nursing practice, serving as a foundation for patient care planning and interventions. Accurate and comprehensive assessment enables nurses to identify patient needs, detect potential complications, and formulate appropriate care strategies. This paper explores the critical concepts related to assessment, exemplars illustrating its application, relevant assessments and diagnostic tests, nursing interventions, medications, potential complications, and the importance of collaborative care.

Related Concepts

Two key concepts related to assessment are 'data collection' and 'clinical judgment.' Data collection involves gathering comprehensive information about the patient’s health status, including physical, psychological, and social factors. Clinical judgment refers to the nurse’s ability to interpret assessment data, recognize patterns, and make informed decisions regarding patient care (Benner et al., 2010). Effective assessment relies heavily on these concepts, as they impact the accuracy and completeness of the information obtained. For example, thorough data collection allows for more precise clinical judgments, leading to tailored care plans. Incorrect or incomplete data can result in misdiagnosis or delayed interventions, adversely affecting patient outcomes.

Exemplars

Three exemplars related to assessment include: 1) Monitoring vital signs in a postoperative patient to detect early signs of hemorrhage; 2) Evaluating neurological status in a stroke patient to assess the extent of impairment; 3) Conducting nutritional assessments in patients with chronic illnesses to identify malnutrition. Each exemplar demonstrates how assessment informs the clinical decision-making process. Accurate vital sign monitoring can lead to prompt interventions, such as fluid resuscitation; neurological assessments help determine the progression or improvement of stroke symptoms; nutritional assessments guide dietary interventions to improve recovery.

Assessments

Assessment tools such as the Braden Scale for pressure injury risk, the Glasgow Coma Scale for neurological function, and the Confusion Assessment Method (CAM) for delirium are vital for comprehensive evaluation. These assessments help identify specific alterations, guiding further diagnostic testing. For example, in a patient with altered mental status, the Glasgow Coma Scale provides a quantifiable measure of neurological function, prompting additional tests like head imaging if necessary. Such assessments are essential for establishing baseline data and monitoring changes over time.

Diagnostic Tests and Labs

Laboratory tests such as complete blood count (CBC), blood glucose levels, and coagulation profiles assist in ruling out potential causes of changes observed during assessment. Diagnostic imaging, including X-rays and MRI, may be used to detect structural abnormalities or bleeding. For example, an elevated INR level indicates increased bleeding risk, prompting clinicians to adjust anticoagulant therapy accordingly. These tests are integral in confirming or excluding suspected diagnoses based on assessment data.

Nursing Interventions

Interventions include administering prescribed medications like antihypertensives for blood pressure control, providing wound care for pressure injuries, and implementing fall prevention strategies. Detailed interventions such as repositioning immobile patients, encouraging ambulation, and educating patients about medication adherence are based on assessment findings. For example, if risk of pressure injury is identified, repositioning every two hours can prevent ulcer formation. These interventions directly address identified alterations, promoting optimal recovery.

Medications

Medications such as anticoagulants (e.g., warfarin), antibiotics, and pain management drugs are used in response to assessment findings. For instance, a patient with atrial fibrillation may require warfarin to prevent stroke; antibiotics may be prescribed for infections identified during assessment; and analgesics are used to manage pain related to surgical procedures. Proper administration and monitoring of these medications are crucial to prevent adverse effects, such as bleeding with anticoagulants.

Potential Complications

If alterations identified during assessment are not addressed, potential complications include respiratory failure, sepsis, or deep vein thrombosis. For example, neglecting early signs of blood loss may lead to hypovolemic shock; untreated pressure injuries can develop into infections; and unrecognized neurological deficits may result in decreased mobility and further decline. Recognizing and intervening early can mitigate these risks and improve patient outcomes.

Collaborative Care

Effective management often requires collaboration with interdisciplinary teams such as physical therapists, dietitians, social workers, and physicians. For example, a physical therapist can assist with mobility exercises in patients at risk for falls; dietitians can provide nutrition plans for malnourished patients; social workers help address psychosocial issues impacting recovery. This collaborative approach ensures comprehensive care tailored to the patient’s needs.

Conclusion

In summary, assessment is a fundamental nursing concept that influences every aspect of patient care. Understanding related concepts, utilizing exemplars, and applying appropriate assessments and diagnostic tools are essential for identifying patient alterations. Implementing targeted interventions and medications can prevent complications, especially when supported by collaborative care. Maintaining meticulous documentation and adhering to clinical guidelines enhance the quality of care delivered, ultimately leading to better patient outcomes.

References

• Benner, P., Hughes, F., & Sutphen, M. (2010). Clinical judgement and decision making in nursing. Springer Publishing.
• Gordon, M. (2017). Manual of Nursing Diagnosis. Jones & Bartlett Learning.
• Luce, J. M., & Rose, L. (2019). Diagnostic Tests in Critical Care. Chest, 155(2), 365-372.
• Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2017). Fundamentals of Nursing. Elsevier.
• Stuart, G. W. (2019). Principles & Practice of Psychiatric Nursing. Elsevier.
• Orem, D. (2001). Nursing: Concepts of practice (6th ed.). Mosby.
• Gulanick, M., & Myers, J. L. (2018). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier.
• Hockenberry, M. J., & Wilson, D. (2019). Wong’s Nursing Care of Infants and Children. Elsevier.
• Carpenito, L. J. (2018). Nursing diagnosis: Application to clinical practice. Lippincott Williams & Wilkins.
• Dunn, A. M. (2020). Clinical assessment: A guide to the physical examination. Wiley-Blackwell.