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Assessment and Care Planning for the Adult in Hospital. This essay will include a case study of a patient I have nursed in practice.

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Introduction

´╗┐Assessment and Care Planning for the Adult in Hospital Client Care Analysis Introduction According to the NHS Information Centre, Hospital Episode Statistics for England, (HES 2011) during the period of August 2010 to July 2011, over 14.8 million people were admitted to hospital and 5.3 million of these were emergency admissions. These statistics represent individual people who have their own needs, but share the common need for their healthcare professional to provide expert care to them during their time in hospital. Effective care planning and accurate, ongoing assessments of our patients and their needs is essential in achieving a positive experience for the patient and their continued recovery. This essay will include a case study of a patient I have nursed in practice. I will make a holistic assessment of my patient?s needs. I will identify two of these needs and discuss these with regard to the care given, also discussing psychosocial, biological and patho-physiology of these issues. I will reflect on my own skills with regard to the care planning and delivery process and refer to relevant literature and the evidence base concerning assessment, care planning and delivery of appropriate care. Main body Castledine (2004) tells us that all nurses should carry out a patient assessment automatically as this is the first stage in ascertaining the health of the patient. A past medical history should be obtained and a physical assessment made as the information gained will enable the nurse to provide evidence based care tailored to the patient?s individual needs, both immediate and long-term. The initial assessment interview with the patient not only allows the nurse to gather the required baseline information about the patient, but can also serve as the starting point for the establishment of a therapeutic relationship between the service user and their nurse (Crumbie, 2006). Assessment of a patient involves gathering as much information (data) as possible about the person and then using that information to form a plan of action with regard to the level of care, support and intervention that the patient will require (Hamilton & Price, 2007). ...read more.

Middle

These benefits include good post-operative analgesia, reduced blood loss during surgery and reduced incidence of post-operative deep vein thrombosis (DVT) and pulmonary embolism (PE). When Chris came back to the ward after the operation, he was monitored every half hour initially and all his routine observations were normal with a pain score of 0. Chris had been given Fentanyl as a peri-operative analgesia and approximately 3 hours after coming back from recovery, Chris reported that the feeling was coming back into his legs and he was aware of some discomfort in the operation site which he rated as a 3 on the NRS. I checked his drug chart and he had been prescribed Paracetamol and Diclofenac which were appropriate for his reported level of pain. My mentor and I administered this medication in line with the Nursing & Midwifery Council (NMC) Standards for Medicine Management (NMC, 2007). When Chris?s partner and step-sons came to see him that evening, his routine observations were mainly normal, although he had become slightly tachycardic, he appeared to be happy and coping well. However when his visitors had gone home, Chris rang the call bell for assistance and said he needed additional analgesia. I asked him what score the pain was and he said it was 8. Until then Chris had reported a score of 3 or below for pain, however when the pain increased his family were with him and he didn?t want to worry them so he said nothing about it. Peter and Watt-Watson (2002) tell us that nurses need to be aware that patient?s self reporting of pain can be influenced by many factors, including mood and medications and these can result in patients not reporting their pain accurately. Some patients do not report their pain as they are trying not to overburden already busy nurses. According to Apfelbaum et al (2003), many patients believe it is necessary to have pain after surgery and this is part of their experience. ...read more.

Conclusion

Once the drain was removed, the drain site was covered with a sterile dressing and secured. In order to maintain an accurate record of drainage from the wound and enable us to evaluate the wound, the contents of the drainage bottle were measured and recorded in Chris?s wound assessment in his file (NMC, 2009). We also changed the dressing on the main surgical wound as there was strikethrough evident. The wound was dry and not leaking blood or exudate upon the dressing change and therefore did not require cleaning before the new dressing was applied. If a wound is clean and with little exudate, repeated cleaning is contraindicated because it may result in new tissue being damaged (Doran-Williams et al, 2011). Blunt (2001) also believes that exudate contains nutrients and factors that may be beneficial to healing and so should not be removed from wounds routinely. One of my roles when caring for Chris was to liaise with other members of the multi-disciplinary team (MDT), such as the surgeon, the RMO, the out-patient?s department and the physiotherapy team. The surgeon wanted to see Chris again 4 weeks post-operatively to check on his progress and I had to ensure Chris was aware of this and assist with arranging his follow-up appointment as an out-patient. The RMO was responsible for prescribing analgesia for Chris while he was an in-patient, and they were also required to prescribe medication for Chris to take home. The physiotherapy team had to wait until the nursing team gave them approval to begin working with Chris after the surgery, and then they had to clear Chris as being fit for discharge before we could begin that process. In order for Chris to be cared for effectively and efficiently, it is vital that all relevant members of the MDT communicate clearly and quickly with each other. Chris needed us to communicate with the RMO with regard his analgesia, physiotherapist needed to communicate with us when they were happy for Chris to be discharged. Should the communication process fail, ultimately the patient suffers and this is unacceptable. ...read more.

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