a nurse is assessing a female patient who is taking diphenoxylate This is a topic that many people are looking for. bluevelvetrestaurant.com is a channel providing useful information about learning, life, digital marketing and online courses …. it will help you have an overview and solid multi-faceted knowledge . Today, bluevelvetrestaurant.com would like to introduce to you 4. Assessment. Following along are instructions in the video below:
In this video. Well look at assessment as part of the assessment planning. Implementation implementation and evaluation model as used in everyday clinical practice.
During the assessment station. You be asked to assess a patient played by an actor. You could be faced with a wide variety of scenarios in clinical practice.
This video will reinforce some of the key actions and behaviors that you should observe in all cases regardless of the type of scenario you may encounter. Remember to treat a station as though you are in practice. Use the mindset that this is a genuine patient to be treated at the start of any assessment.
Mentally check off the six cs that you will need to demonstrate in your practice care compassion communication commitment courage competence always unsure its safe for you to approach any clinical environment. I enter the room i check for the scene safety. I see that the room is safe to approach look for items such as trailing leads or foreign objects.
Which can create a trip. Hazard and take steps to address these check for the scene safety. The scene is not safe for me to brush and make the scene safe be aware of any additional hazards that might compromise the patient safety cigarettes and lighters for example should be moved so before i do all my observation.
I see theres a pack of cigarettes. You do smoke jam. Okay.
I want to tell you that this hospital is a smoke free zone and their oxygen runs all over the place. And you are using oxygen yourself. So is it okay.
If i take the packet of cigarette and move it around out from your sight check the medication left lying on tables. These should not be taken. Unless.
Prescribed glasses or jugs of water should be moved away. Depending on the patients clinical. Need you must demonstrate hand hygiene using the correct alif hand.
Washing technique you can save time by doing this as you introduce yourself. Hello iana. Hey.
Hey okay are you just a pest drowsy eye emergency and im gonna also be taking care of you today. Its worth repeating that effective communication with the patient is vitally important from the start introduce yourself early and start to establish a rapport hi good morning. My name is anthon am.
Your nice food today may annoy. Your full name my name is julie smith. So julie.
What brought you here in clinical practice. Its always important that you check the patients id against their id band and check the details of any allergies they may have can i check your id band okay okay your name is john white and your date of birth is first to 1st. 1960 and your hospital.
Number is oh all 100 1 2. 3. 4.
5. So do you have any allergies. The patient will not necessarily be wearing an allergy wristband.
All the details may be incorrect. So always check with the patient and rectify. Any mistakes so mark can you tell me do you have any allergies.
Oh. I prefer them ok. And what exactly happens.
When you take ibuprofen. Ok. Oh.
Gosh and i got a bit of a wheeze on my chest. Mm hmm. All right so ill make sure that i dont give you this drug.
Okay can i take a look at your allergy band. Yeah. I think thats on there all right.
So. It says. Mark brown 25th.
Of 9 1957. Alright. So the name of the drug is not written.
The drug that youre allergic to so i make sure that after 8. I am done with my observations. Ill come back with a new allergy bag.
Which indicates the name of the drug when conducting your assessments. Do not simply run through a list of questions. But bring the patient into a general conversation.
So julie. What do i do here. Ive had a hernia.
Im on the on the right hand side for a couple of years and ive come in to have that repaired so have you got any pain now no not today its not so bad when im lying still make sure you listen and respond to what they say by doing so youll build a more effective rapport with the patients how are you feeling are you again. I just just refresh every breathing feeling pressure okay just try to relax. Well just try to help you what brought you to the hospital last couple of days have harder to breathe a lot if asking them about any pain.
Make sure youre clear about the pain scoring tool. Youre using so mark can he tell me what exactly brought you to the hospital well. I felt i was cleaning me windows in the house and i was just using some ladders and i just slipped and fell off the ladders and i bangus adam ii had its really really sore.
So be honest all right so do you have pain. Now yeah. Its quite painful quite about headache so if you have to score it on a pain scale of all to ten.
Where zero is the least antennas the worst pain where would you score it for four do you think you were okay now or do you need any painkillers. Now. I think ill manage okay all right okay pay attention to the environments.
And where possible use any items that you see to help inform your assessment for example. If youre emptying a sample bottle. You could use this as an opportunity to ask the patient about passing urine look out for glasses and hearing aids.
Again. These provide an opportunity to discuss the patients needs and requirements. Oh.
I see that you got some glasses. Here. Do you usually use that or is that some reading glasses just mainly for reading.
Thats fine okay so i already thought that now yes. If the patient is classed as nil by mouth make sure they do not have food or fluids within their reach. Ive seen from the north side you got to search through.
Today. So you got to be a little by month and got a glass of water here so do you mind if i take it away no thats fine so we just left it there. But that had only in your is fasting thank you patients may also be wearing nail varnish or jewelry.
An appropriate advice should be given. Oh. I see that you got a nail polish.
And some jewelry. So can i tell you that before you going for this surgery. Youll have to take your salary.
And dont want that niall ornish is that okay yeah. Thats fine. My husbands going to take it home and then when it comes in a bit.
You should follow the normal routine as you would in practice. When recording the patients observations. The key difference is that you need to speak your thought bubbles and make your course of action.
Clear in the following examples. Well show how this might work during the exam talk to the patient consistently through the scenario and keep them informed about what youre doing before starting check that the patient is rested that they do not need the toilet and that their legs are on crust so before i start taking observations have you been taking rest for the last 20 minutes. Yes have you emptied your bladder.
Yes. Make sure that your legs. Are uncross.
Yeah. Okay. Thank.
You once youve checked that comfortable ensure that the patient is happy for you to proceed. So i just wanted to take a set of observations on you. Which.
Includes your blood. Pressure your temperature. Pulse.
And your oxygen saturation is it okay. For me to proceed make sure you state aloud that the equipment is clean and calibrated. I have calibrated the equipment to zero.
And have plenty if with me prior to use when taking their temperature check that the patient is not wearing a hearing aid and check the signs of inflammation in or around the ear so mark ill be checking your temperature now and for which i need to pop this inside your here okay so do you have a curing aid on no all right ill just check. If there is any sign of redness or inflammation. I see that its clear okay ill just put this in its always good practice before taking blood pressure to check with the patient that they have no cannulas or if theyve undergone any surgery in that arm.
So first im going to take your blood pressure. Which is on your left arm. So have you had any surgeries or limp anything before in the past.
No. No so i see that there the no lymphedema. No inflammation no signs of any infections.
So its safe for me to put the bp cuff round on when checking their respiratory rate. Do not explain what youre doing until after you have taken a reading to avoid affecting the result. So ive checked the respirations for complete one minute for the rhythm and effort of your breathing.
And i found that its 22. Okay so im just going to document. It okay before taking such a racial levels check that the patient is not wearing nail varnish or false nails measure the capillary refill time and state the results so now im going to put the probe on your right finger so before putting the probe.
I want the hand is not cold. Its not clammy and i check the capillary refill and i see that the capillary refill is good its less than two seconds. So its safe for me to put the probe on the arm and check your oxygen saturation okay for gcs observations check that theyre not wearing contact lenses and ask about eye surgery before measuring eye reaction so mark can you tell me do you have contact lens right now in your eyes contact lenses.
No no okay and did you ever have any surgery on your eye. No all right so ill be flashing this light on to your eye just to see the reaction of the pupils. Okay okay as part of a gcs assessment.
You will also need to assess limb movement and power mark. Did you ever have any surgeries on your back or on your neck or shoulder. No.
No so are you okay. Lifting your hand up. Oh yeah.
Okay. Now if i apply pressure over it. And if i resist against gravity will you be able to resist if i push this down.
I think so yeah. Thats good alright is it okay yeah. Thats fine all right so can you raise your left leg for me okay.
And if i apply a gentle pressure will you be able to resist that yeah okay. Thats fine now ill be checking the similar way on the other leg. Can you raise this leg for me okay have you playing gentle pressure.
Thats fine all right so we cover you back after completing the clinical observations state that the equipment will be cleaned and replaced so now im julie ive just finished my observations im gonna clean and replace the ecumene and do my documentation so ill be back to your song is that okay and can you explain to the patients that youre documenting the results in the observation chart and states. Any follow up actions you need to take so i have done the documentation and the gcs chorus come to 14 and so are the one finger patient every army since it is less than 15 documented the new score and the new score is zero. Its important that you familiarize yourself with the scoring system for both news and gcs for example any patient using oxygen must automatically be scored as at least a 2 on the news chart make sure you escalate appropriately.
If the score is outside of normal parameters. So ive documented the respiration saturation temperature blood pressure heart rate on the news chart. And i have found a total score of 4 2.
For the respirations and to foyer since youre using the oxygen mask. So i see that the new score is its quite high so im going to monitor the observations you jack every half an early as well as im going to consult with the doctor right now to see if any escalation of plan is required for you during ongoing conversation with the patients its essential that you continue to demonstrate effective communication skills socially im gonna ask you a couple of questions what does the job i doing yes our kara for an elderly gentleman okay. So were you working on to recently up until the end of last week.
Yes hats take some sick leave look for any opportunities to discuss health promotion for example. If you notice a packet of cigarettes. You can use the opportunity to mention available services to help quit smoking.
So mark. I see a pack of cigarettes. Here.
Do you smoke. Yeah. Yeah.
I do so can you tell me how many cigarettes do you smoke. Ten to fifty in a day really ten to fifteen a day. Yeah okay so how are you ever thought of quitting smoke.
No not yet. No i might do after this. Yeah.
Okay. Because weve got a smoking. Cessation team here in the hospital.
And you know im a bit concerned because the smoking might aggravate your condition yeah. So for now. Ill be keeping the cigarette back aside.
Ill be locking. It and ill be handing it to your relatives. When they come is that okay.
Other areas for concern might arise during the assessment for example diet. Or exercise all right really so what about your diet butter. What sort of diet do you take.
Normally. Its a bit erratic to be honest. Because i work really strange shifts and my husband works shifts as well and it we tend to kind of just eat you know ready meals and fast food.
Its not not a very good not very well balanced diet at all okay said giving a lot of bad problems. I am. Quite constipated.
But i do tend to only go to the loo two or three times a week. Anyway. I can see that your diet is not really healthy and would you like me to refer you to a dietician.
A dietician would probably give you more suggestions regarding your diet and could probably help with your constipation is that okay. Well sure ive trying right watches. A few times.
Thats not work so if anything else can help im open to suggestions particularly if itll help me recover after the operation where the patient has concerns or worries about their activities of daily living explain what you will do to address. These problem is ive got stress incontinence and my toilets up is downstairs. So at night.
And i know i struggle to get down the stairs and im worried after my operation. If i need to get opened down to the talut quite quickly in a night. If im drinking too much fluid during the day.
Im gonna have more problems thats whats worrying me really all right i can understand your problem. I can have a word with the physio and they can look into the rehabilitation plan and if necessary a commode can be arranged for you to use upstairs will that be okay during your assessments. Its really important that you pick up on any details about home life like family pets or children.
The patient may act as a carer for a relative for example. Ive got a son whos is 20. But yes learning disabilities and so jack we have got social services in our hospital.
So what do you want me to so im going to take the number and im gonna call. The social service person who will go back home and take care of your children. So you need not worry just relax.
And well just sort it out is that okay at the end of the assessments. Make sure you mentally review. What youve done remember to check the patient has everything they need in relation to the four ps position possessions personal care pain.
We wanted to position your problem laughter confidently remind the patient of your name. And have a final check of their needs. So mark.
Im done with your observations. Okay so ill be here around thank. Me.
And if you need anything ill just place. The buzzer in your hand or you just need to press. This and ill be here is there anything that you want to ask me no.
Thats great thank you all right i might come back again to ask some more questions is that okay yeah of course all right and ill also see if you do for any painkillers. And ill come back with it as part of the assessment process. You will need to consider what risk assessments need to be completed for the patients individual needs.
You should verbalize key risks at the end of the assessments. Ill make sure all the risk assessments. Including before us will be done before she goes in for the surgery.
Remember effective hand hygiene at the end of any interaction with patients is essential in summary effective assessment is not just about following the correct procedure. But demonstrating effective communication having knowledge of risk assessment processes and being able to develop follow up plans and actions. Remember to confirm the patients id and check this against the documentation.
Accurately complete all observations and documentation keep the patient in form throughout remember for measuring the respiratory rate. You should only mention this after taking the reading identify any health risks that arise during the assessment and refer. These appropriately this includes smoking and alcohol consumption.
There must be a clear match between the risk and the level of escalation. Consider any risks for the patient and ensure these are addressed this concludes our overview of the patient assessment station. The information.
Youve collected here will be used when planning patient care music you .
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