Nursing Assessment and Process: A Case Study

ANCP CASE STUDY

Table of Contents
INTRODUCTION...........................................................................................................................3
MAIB BODY...................................................................................................................................4
CASE 1........................................................................................................................................4
CASE 2........................................................................................................................................6
CONCLUSION................................................................................................................................9
REFERENCES..............................................................................................................................11

INTRODUCTION
Nursing assessment refers to the gathering of information which is related to patients
sociology, physiology, a psychological and spiritual status which is generally assessed by
licensed registered nurse. Nursing assessment is one of the first steps in the nursing process.
Nursing assessment is done by certified nurses' aides. Nursing assessment is generally used to
identify the reason for the ill health of any patient. It incorporates recognize the difference
between normal and abnormal physiology function of the body. This, the assignment has a focus
on a reason for the nursing assessment and nursing process. It is needed to understand the
importance of using nursing assessment tool for providing care to the patient. This report is
focused on two different patient with concentrating on their daily living activity and reason is
explained for the necessity of nursing assessment. Nursing assessment is highly essential for
determining the cause of ill health of any patient for providing better and effective care for health
improvement. Nursing assessment tool plays a vital role in providing correct treatment for
ensuring the patients future care (Jang, (2018)). Different stages needed to follow the nursing
staff for providing better healthcare. Patient health nursing process also considered the caring
process for providing better Health and Care to patient. There are four type of nursing process
which includes assessment, planning, implementation and evaluation. Nursing assessment
provide nursing staff experience for providing better care to the patient which has been learned
through last experience. First step for the nursing processes assessment which is able to provide
relevant information of the patient based on past medical history of observation. Different
symptoms which can create better understanding for the nursing staff for delivery better health
care services and treatment assessment. There is gathering of objective and subjective data which
is collected and then integrated getting information related with patient health for delivering
better treatment and healthcare services for improved health. This is the information through
which planning is done planning is generally refers to making a strategy for delivering of
treatment. Care plan that can lead to create positive impact on patient health and implementing
this plan can provide health improvement to patient. Recording of the self assessment allows
nursing staff member to take decision accordingly (Rizzo, (2017)). There is also need to monitor
patient symptom which can help and allows nursing staff for delivery improve healthcare
treatment and services for better health of patient.

MAIB BODY
CASE 1
First case is discussed about Tommy Clarke. He is a 10 day old baby. Due to infant, there
is no no any previous medical history of this patient. He was born at 39 weeks and 3 days.
Delivery of Tommy was good and normal. Due to normal delivery and having good APGRE
score, there was no any requirement for any intervention. Tommy is breastfeed baby and was
feeding well until last 24 hours. There was no any health related problem during identification of
health related concern. Health visitors visit for assessment of baby through which there was no
any identification or discussion about any type of health related issues. But Tommy’s mother
found that there is something not good with the baby and this makes anxious regarding health of
her baby Tommy. Tommy has not yet regain his birth weight and initial observation by health
visitor reported that there is increased respiratory rate of Tommy and elevation in body
temperature and having decreased urine output (Pandya, (2020)). Due to increased temperature
of Tommy, there is use an activity for decreasing and maintaining the body temperature which
was needed to be discussed. homeostasis is a state which includes physical, chemical and internal
condition of living system. This also includes different variables like fluid balance and body
temperature which is needed to kept in set limit. This is able to provide the control of
temperature of any human. This also includes the message which is delivered for the body
system for any changes which can be normal or abnormal and should be needed to control for
better health of Tommy.
Hypothalamus is control Centre for the body temperature. It can be observed that there is
rise in temperature in the anterior and in posterior, there is a decrease in temperature.
Hypothalamus works to create response within autonomic nervous system that is able to support
body temperature to stay within appropriate range which is known by Thermoregulation. There
are different chemicals and hormones which are able to control the body temperature and allow
internal and external factor. This can create an impact on the body temperature of patient heat
within body which is measured as an temperature. In newborn baby, hypothalamus are engaging
and autonomic nervous system that altered due to lack of severe availability. Due to this, it is
unable to regulate body temperature (Hassan (2020)).
There is a normal range of body temperature from 36 to 37.5°C and for children. There
are no any other specified normal body temperature and can vary and depending on illness and