Reference no: EM133144452

Comprehensive Client Profile

Q1- INTRODUCTION

a) i. Identify a potential participant for your Comprehensive Client Profile.
Explain how you introduced yourself,
how you informed the client of what the Comprehensive Client profile involved,
how you gained consent from the client to participate.

ii.Record your conversation with the client below to show evidence of your client's informed consent - Remember that client names should never be used as their details must remain confidential, so please replace name with Mr/Ms (letter).

b) i.What would you do if you were unable to communicate directly with the client due to language, cognitive or physical barriers? - you must include at least 1 culturally appropriate strategy.

ii. Explain who you used to assist you in communicating with your chosen client and why.

c) i.List the client's gender, age, and any cultural, spiritual or religious details.

ii.Why is it important to document EACH of these details?

d) i. Document the clinical measurements you obtained during the assessment of the client.
Temperature and how it was taken (e.g. Tympanic):
Respiratory Rate and characteristics:
Pulse and characteristics
Blood Pressure:
Oxygen Saturation:
Pain (scale, location and characteristics)
Developmental stage
ii. Why is it important to perform clinical measurements and assessments when
undertaking client assessment?

iii. What resources did you use to identify the client's developmental stage?

Q2- Collect Information:

a) After discussion with your client and referring to their current client file at your facility, document your chosen clients' lifestyle patterns, health history, current health practices, coping mechanisms, issues and needs below:

b) Discuss with the family member or carer of this client, any emotional or physical needs theyassist with to support this client. Document your findings below.

c) Use critical thinking to interpret objective and subjective data from your various assessments conducted and determine if the data is or is not within normal parameters of the client and of acceptable ranges (e.g. BP 120/80).

Indicate which data is subjective and which is objective.

Identify which of this data was not within acceptable ranges and possible reasons why.

d) Why is it important to communicate immediately all deterioration concerns about the client to the Registered Nurse?

(If any) what data did you relay to the nurse regarding this clients' assessments and how did you inform them?

e) From analysing your clients' health history and clinical assessment, what (if any) risks or impairments of their ability to participate in activities of daily living have you identified?
How might this influence the care they receive?

ASSESSMENT

• Below you are required to record all the data collected from your clinical assessment of your client
• You must record ALL findings; normal and abnormal
• You must record ALL acceptable ranges for all findings
• For findings outside acceptable ranges - how they are abnormal
• Possible causes

Vital signs (T, P, RR, BP)

Neurological Assessment (GCS...)

Physical Appearance

Mobility Status

Cardiovascular Assessment

Respiratory Assessment

Integumentary

Urogenital (Include continence care)

Gastrointestinal

Perform a Urinalysis (Full Ward Test) results and interpretation

Q4-CARE PLAN:

You are required to develop a care plan for your chosen client. This care plan will include 5 potential/ actual problems, goals and interventions that reflect your assessments and their current medical diagnoses.
Remember that the medical diagnoses will often alert you to actual and potential problems.
Client's Medical diagnosis:
Please record your clients full diagnoses - if using abbreviations, please also write the full diagnosis next to it.

Q5- Evaluate outcomes of care provided
a) Consult and collaborate with your multidisciplinary team (RNs, Physios, OT, dietician etc.), to identify and evaluate your own contributions to the person's care. - what did you do specifically that helped meet their care plan goals?

a) From reflecting on your clients' outcomes within their care plan, evaluate their progress and the effectiveness of the interventions used.

b) Document below the required changes to the clients nursing care plan in line with best practice in nursing.

Q6- Risk prevention strategies
In the sub sections below, document how you would assist in these areas.
what you would do?
what you would look for or assess?
what documentation/ tools/ resources you would source?

You MUST reference your answers to show evidence-based practice.

a) maintaining a safe environment
b) preventing falls and falls assessment
c) promoting active and passive exercises
d) promoting deep breathing and coughing exercises
e) maintaining skin integrity and pressure area care

Attachment:- Comprehensive Client Profile.rar