Fundamental Approaches in Nursing: Assessment and Care Plan

This report delves into the fundamental approaches in nursing, focusing on the assessment phase of the nursing process and its role in planning patient care. It examines holistic assessment characteristics, including effective listening, trust development, and providing proper information to patients. The report presents a case scenario of a 55-year-old woman with knee pain, detailing the prescribed medication (Clexane injection with enoxaparin) and its purpose. The study also explores the importance of care planning, the nursing process (identification of needs, setting goals, implementation, and evaluation), and the role of nurses in medication administration and patient monitoring. The report also discusses the use of corticosteroids, hyaluronic acid injections, and other medications for pain management, along with the significance of exercise and physical support devices. Overall, the report emphasizes the development of therapeutic relationships and the delivery of optimal patient care.

FUNDAMENTAL APPROACHES IN NURSING
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INTRODUCTION
The present assignment has been conducted with an aim to showcase the assessment
phase of nursing process that develops while planning care for the patients. Along with this,
researcher also discussed one specific prescribed medication that is useful to treat the problems
of patients. Further, the role of nurses in different spheres have been discussed in the present
research work. It is crucial for the nurses to develop therapeutic relationship with the patients so
that prominent services could be delivered to the clients (Fairman and et. al., 2011). It is crucial
to have clear assessment of patient as proper scrutiny can only assist the practitioner to deal with
the patients effectively.
Suitable assessment can assist the practitioner to plan appropriate care services for the
patient (Mary) and this can also assist in adopting person – centred approach. Nursing
assessment is regarded as a process of gathering information about a patient’s physiological,
psychological, sociological and spiritual status (Townsend, 2014). It is also crucial to conduct at
the initial stage because without having it, medical services cannot be given to the patients.
Nursing assessment is very much broad in scope and it also focuses on one body system or
mental health. For the present case, the process incorporates the recognition of normal versus
abnormal body physiology.
Care plan is always developed after diagnosing the health issue of the patient and that can
be done through adopting person- centred counselling approach. Adopting of the approach is
useful since it deals with the ways in which individuals perceive themselves as a counsellor to
interpret thoughts and ideas in the best possible manner. In health care context, client care is
broad term that refers to interacting and treating the patients effectively (Potter and et. al., 2016).
While having any client, it is crucial to give optimum care so that the problems of patients can be
overcome accordingly. According to University of Cumbria, several guidelines have been stated
that needs to be followed so that the interest of patient could be maintained. It is crucial for the
practitioners to maintain confidentiality about the services of the patients as this is also crucial
under ethical standards.
In the research study, theoretical aspects will be linked to practical examples so that the
actual application of care plan and assessment could be identified. In order to conclude the
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assignment, researcher will be focusing on major findings. Further, researcher will also
emphasize on future aspects that will be considered at the time of doing similar studies.
CASE SCENARIO
Mary is a 55 years old woman working in a supermarket and she is engaged in delivering
direct services to the customers. From past 10 years, she has been working with the same super
market. Her basic job role includes direct assistance to the customers; thus for that she has to
stand nearby all the shelves. Due to her job, she had a problem in her knee and as a result, she
had to replace her knee. Currently, she is having chronic pain in her knee and considering the
same nurse had given her Clexane injection because she is having excessive bleeding. The
injection has been given to Mary as it contains the active ingredient enoxaparin which is a type
of medicine called a low molecular weight heparin. It is also used for the purpose of stopping
blood clots that forms within the blood vessels.
LO 1 ASSESSMENT AND CARE PLANNING
Characteristics of Holistic assessment:
Holistic assessment can be determined as process through which a condition is defined
with the help of presence and theory. Further, this type of assessment is used in order to make the
healing of patient in more natural way (Matney, Brewster and Staggers, 2011). There are
different type of characteristics that are included in Holistic assessment. In this below given are
the following:
Effective listening: There are different set of issues that are faced by people and when
they share their problems, then it is important to make sure that they are head properly. When
they share their issues, then there are cases which different set of issues are identified. Further, as
per the case, 55 years old Mary is facing issues with respect to her knees. The issues can be
identified when the problems that are faced by them are conveyed by them (Yarbro, Wujcik and
Gobel, 2010). As a result, it can be stated that for holistic assessment, it important to have proper
listening skills.
Developing trust: The mental state of a patient is not effectively when they have to visit a
care home or to concern a doctor. With this respect, it is important to make sure that nurses
develop trust and confidence among mind of patients. In order to do that in an effective manner,
it is possible when there is healthy interaction. This is helpful enough to understanding the
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mental state of the patient and it also enables to develop healthy relationship with patients.
Further, there are cases in which patient so not share their problems and one of the reason is due
to improper communication. However, when there is strong relationship, then it becomes helpful
enough to understand the issues or problems and in developing strong relationship (Dowling and
Cooney, 2012). As per the case, it is important for care providers to develop confidence within
Mary as it will help to make the knee problem heal quickly.
Providing proper information: There are different type of issues that are faced by people
and for each of the problem there diverse set of ways though which problems can be solved. In
accordance with the given case, it is essential to make sure that all the relevant information is
provided to Mary. When patient know the procedure and the consequences that can be followed
by them, then it helps to make up their mind to face any type of problems (Speziale, Streubert
and Carpenter, 2011). This is effective characteristics for holistic assessment.
Allowing patient to make decision: In order to over the problem or the issues that are
faced by patients, there are different set of strategies that are developed. In this context, all the
alternative ways should be conveyed by care provider and this will be helpful enough to make
sure that confidence that what type of procedure will be preferred by patient (Hoe and
Thompson, 2010). When the ways to overcome are determined by patient themselves, then it is
helpful enough to overcome the problems that are faced by them. In accordance with the case,
Mary has knee issue and for this purpose, she should be conveyed about the ways through which
it can be operated.
To come up with an appropriate outcome for the problem, then it is essential to make
proper assessment. For this purpose, there are different type of methods that can be used. These
methods are helpful enough to make sure that proper information is collected about the patient.
With this respect, below given are the some of the methods:
Interview: This can be determined as type of method, in which care provider will ask
different type of questions with the help of which they will get to know the issues or problems
that are faced by patient. This is an effective method as care provider get the opportunity to have
direct interaction with client (Kokkonen, Cheston and Smart, 2014). This help to understand the
problems and accordingly proper steps and meditation can be provided with the help of which
issue can be solved. In accordance with the case, so as to know the problems that are faced by
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Mary, care providers can make use of interview as it will help to know the issues that are faced
by them.
History taking: There are cases in healthy and social care in which most of the diseases or
problems are developed due to genetics. Diseases are transferred from generation to generation.
This is a helpful method that enable to identify most of the issues that are faced by patients. With
this respect, the issues that are not conveyed by the patient can be identified (Timmins, Neill and
Sheaf, 2015). This way proper steps can be taken to overcome the problems or effective
strategies can be developed to overcome the barriers. As per the case, the knee problem that is
faced by Mary is because of the work that she performs.
Observation: As per this type of method, care providers will make observation of the
physical issues that are faced by the patient. This is possible when the observation is made by
people who are professional and know the areas in which improvement is required to be made.
However, there are cases in which observation does not provide proper information and there are
also changes that the meditation given may go wrong (Forbes, 2010).
As per the nursing process, there are various ways that are helpful enough to make sure
that they identify the needs, set goals, implement and evaluate the issues that are faced by the
client. In this context, below given are nursing process developed for Mary:
Identification of needs: As per the type of profession that is played by Mary, she is
always standing and after the 10 years of work at same profession has affected her knees. The
need is identified due to the problem that she is not able stand on her legs and this can raised the
need of knee replacement (Mooney, Timmins and Corroon, 2011). This is because she was
having chronic pain and this raised bleeding.
Setting goals: Main aim of nurses is to make sure that Mary can walk again. Setting up
goal is essential as it enables to develop path on which proper services and meditation can be
provided. This is helpful enough to make sure that Mary can walk effectively and efficiently.
Implementation: In order to overcome the issue that is faced by Mary, it is important to
make sure that steps should be taken to reduce the problem of bleeding. Then proper steps should
be taken with the help of which the knee can be replaced (Giger, 2016).
Evaluation: When proper steps are followed, then evaluation can be made with the help
of determining the rate of improvement that Mary has made. This way they will be able to make
sure that Mary can walk again.
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LO 4 AND 5 PHARMACOLOGY AND A&P
Prescribed medication that affects the client’s psychological or physiological needs
Since, Mary is having pain in her knee; therefore for immediate relief, Corticosteroid and
Hyaluronic acid injections will be given to her (Dossey and et. al., 2012). This will assist her to
get relief from the pain for a short period of time. Furthermore, acetaminophen (Tylenol),
ibuprofen (Advil, Motrin), or naproxen sodium medicines will be given to Mary so that she
could get some relief to manage her daily activities. Along with the medicine, Mary would also
be provided with BodyVine Ultra Think Knee Stabilizer so that she may not find any problem in
walking and standing.
This is also crucial in terms of reducing the impact of chronic pain in her knee. Suitable
mediation will also assist Mary to fulfil her psychological and physiological needs as she will be
able to manage her requirements (Townsend, 2014). Proper exercise chart will be given to Mary
so that she could follow the same and can get recovered as early as possible. Although, she
would be directed not to engage herself in lifting weights as that might hamper her capability and
physical strength.
Role of nurses
It is crucial for the nurses to administer the practices so that the areas of improvements
can be identified. Nurses are also required to conduct the process of monitoring so that they can
undertake safe and secure measures at the workplace. Safe administration is imperative since that
protects the patients from all risks and uncertainties (Fairman and et. al., 2011). Further, nurses
must also monitor therapeutic effects which develops within clients and practitioners. Nurses are
required to develop direct interaction so that they can get to know the requirements of patients;
thus in the present case as well, nurses must ensure that they are communicating suitably with
Mary. This is also essential in terms of providing specific care to the patient. Further, nurses
should also analyse the side effects of the medicines in terms of patient’s safety (25 Treatments
for Hip and Knee Arthritis Pain. 2014).
Prior providing any medication to Mary, nurses must ensure that suitable dosage is being
given to the patient for prominent health and safety. At the same time, Mary will also be
provided non drug treatment because natural therapies are more effective as compared to
medicines. Since, Mary is having the problem of blood clotting; therefore Balenotherapy will be
given to her which is a most effective treatment (Potter and et. al., 2016). It involves soaking in
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warn mineral springs. It is also found to be an appropriate therapy for Mary as she is having
multi- joint OA and co-existing conditions. Most of the doctors treat arthritis with anti-
inflammatory mediations and pain killers; however some medications cause side effects and a
natural approach that gives reliefs from the pain (Natural Relief From Arthritis Pain. 2014).
Impact of drug on physiology of the person
Arthritis is a painful and degenerative condition which cases stiffness and pain in the
joints and the problem gets worse with age. Using such medicine would be helpful for Mary as
that reduce her pain level and can assist her to manage her routine activities. Acetaminophen
(Tylenol) will be significant for Mary as it is a first line treatment of mild- to- moderate pain
from knee and hip (Alligood, 2013). However, limited dosage should be given to Mary so that
she may not have any side effects of the specific medicine. The medicine will not only reduce the
pain level; but also it will improve the functioning of knee. Further, these medicines (Aspirin,
Ibuprofen, Naproxen sodium) will be another option for Mary to get relief from the pain.
However, on the other hand, the risk of GI side effects is also higher with NSAIDs as
compared to Acetaminophen (Butts and Rich, 2013). The defined medicines are also associated
with cardiovascular risk and kidney damage. However, along with this, a stomach protective
drug will also be given to Mary so that she may not have any side effect from NSAIDs. Thus, in
terms of conclusion it can be said that providing such medicines would assist Mary to get back to
her work as early as possible. However, she needs to carry out her exercise schedule in
appropriate manner for physical fitness. She is engaged in standing job; therefore for immediate
improvement, it is crucial for her to focus on her diet. Along with the same, she must take all the
medicines in suitable time period for her health aspects. The drugs are useful to reduce the
intensity of pain; however Mary needs to carry out all the activities as specified by the
practitioner (Ball and et. al., 2011).
LO 2 AND 3 COMMUNICATION
Therapeutic relationship with client facilitate effective assessment and care planning
There are different aspects that has to be considered by care providers. Among which
communication can be determined as an effective source that is helpful enough to make sure that
strong relationship can be developed (Vaismoradi, Turunen and Bondas, 2013). In this context,
patient share about their issues more closely. There are cases in which people do not convey
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about their problems when they do not feel comfortable. In order to make people comfortable, it
is essential to have strong communication or interaction as it help to develop trust and
confidence among patient and they share their problems. Below given are the benefits of
developing Therapeutic relationship with client as per the case:
Understanding: With effective communication, clients will understand the problems that
they are facing. Further, they will also get to know about the seriousness of the problem (Yarbro,
Wujcik and Gobel, 2010). Further, in accordance with the case, Mary will be able to develop
confidence in the treatment and the suggestion that will be provided by care provider. When
there is effective communication, it is also important to have proper listening skills for care
providers as it is helpful enough to know the problems that are faced by clients and this is also
helpful enough to develop trust and to build up strong Therapeutic relationship.
Taking decision: Professionals are the one who know better about the condition that is
faced by client. They know what type of treatment they should follows in order to overcome the
problem. With this respect, when there is healthy relationship between client and care providers,
then the suggestions that are provided by them will be helpful for patient to take appropriate
decision that will enable to them to overcome the problem (Speziale, Streubert and Carpenter,
2011). In accordance with the case, Mary needs to have knee replaced and for this process it is
important to have proper communication so that she will be able to make up her mind for
replacement and the problem that she is facing can be solved.
After understanding the issues being faced by Mary and developing an effective care plan
for her, I decided to interact with her in the most cordial and empathetic manner. Every action
undertaken by me was in consonance with maintaining her dignity, along with assuring her
safety and security. I understand the fact that I am under a professional duty to fulfil the needs
and demands of the patient and respect their dignity. I make every effort to reflect a caring
behavior, which matches the standard quality to be maintained (George, 2011).
Moreover, I have also assured that I stay informed about all the conditions which Mary is
undergoing, and the manner in which it shall be handled if no specialized care is available. At
every step I encourage Mary to be a part of the processes and treatments which she is
undergoing. At the same time, an effective communication is also maintained with the family
members of Mary. In consequence to which they have instilled confidence in me for taking good
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care of Mary, and believe in my techniques of nursing. Furthermore, I have taken care of the fact
that all the prescribed medicines and treatment to Mary is not posing side effects of her health.
In accordance to the care plan all the medicines are given to her in a timely pattern and in
suitable amounts (McCormack and McCance, 2011). In addition, I have also derived various
natural methods which can specifically treat blood clotting and other conditions of Mary, in
addition to the medicines and treatments being prescribed. Moreover, I assure that the
surroundings of Mary is always filled with negative energy, and in pursuance to the same I often
interact with the family members in respect to the drastic improvements in the condition of
Mary. After analyzing the improvement of various parameters of Mary, the doctor and other
authorities of hospital completely rely on my way of working as well as manner of tackling the
patients.
While dealing with the clients, it is crucial for the nurses and health care practitioners to
consider the importance of communication skills as that is the key term that can make things or
that can hamper everything (Parahoo, 2014). Effective assessment is crucial since that aids the
nurses to identify what needs to be done now to treat the patient effectively. Further, there must
be proper listening so that they practitioners and nurses can identify the type of medicine that is
to be given to the patient. Relating it to the present case, nurses must focus on suitable and
prominent communication so that Mary could discuss her health needs with the practitioners
CONCLUSION
Concluding the entire research work, it can be said that prior providing medical treatment
to the patients, the entire process of nursing assessment should be carried. This is essential in
terms of meeting all the requirements of the clients. Furthermore, it is also analysed that there
must be suitable relationships among clients and nurses. This will assist in maintaining direct
communication with the patients and as a result better amenities could be delivered to Mary. It is
also identified that care plan should always be made according to the identified needs and
requirements of patients through nursing assessment procedure.
While I was working on this module, I came to know about the medicines and services
available for joint pain; hence this has increased my knowledge and learning level on higher
extent. The study seems to be beneficial for my career as I came in contact with different nursing
terms which I would have never learned from any other sources. As per this study, I now know
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that physical and psychological both the treatment are essential for the person suffering from
different health problems. Thus, concluding I can say that the study has enhanced my learning
ability and I can also work on such studies in future as well.
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