Reference no: EM133187101

Assessment Task: Professional Experience Practice Analysis Essay

Assessment Outline: The Nursing Process is a sequence of problem-solving steps used to identify and manage the health problems of patients. This assessment requires you to use the nursing process as a framework to discuss the nursing management of a patient that you have cared for whilst on PEP. Some elements (supervised head-to-toe assessment and identification of priority problems) will be completed during your PEP experience, whilst writing up and presenting your patient assessment is to be completed both during and after your PEP experience.

Step One- whilst on PEP
In collaboration with your Clinical Nurse Educator (CNE) or clinical preceptor, students are to identify an appropriate patient to perform a full and comprehensive systematic physical and psycho-social nursing assessment. Please ensure that you use the head-to-toe assessment guide (appendix E) when performing your assessment. Your Clinical Nurse Educator/preceptor is to witness the head-to-toe assessment and sign off the paperwork set out in appendix E, which will then be submitted as an appendix as part of your PEPAE submission. The psych-social assessment does not need to be witnessed but is essential to complete with your patient. This assessment will include past medical history, family history, current medications, social history, living arrangements and carer responsibilities.

Next, having completed the patient assessment, you are to sit with your CNE/preceptor and identify all priority problems for your patient and document these on appendix F. This is to be submitted as an appendix as part of your PEPAE submission. Please note that these appendices do not count towards your overall word count for this assessment.

Step Two - writing up your head-to-toe assessment:
The final part of this assessment requires students to write up the results of the head-to-toe assessment and develop a plan of care to address the needs of the patient. Students are to provide an overall introduction to the essay, an introduction to the patient and a written summary of the head-to-toe assessment.

Introduction to the patient:
• Medical diagnosis
• Past medical and surgical history
• Social history
• Relevant family medical history
• Allergies and adverse reactions to medications
• Current medications (You must link all medications to your patient I.e. explain clinical indication correctly. This can be presented in table format in the assignment andpresented as an Appendix),
• Summary of clinical course whilst in hospital

Summary of head-to-toe Assessment:
Discuss the objective (signs) and subjective (symptoms) data collated from the nursing assessment of the patient
• This account is to utilise a head to toe system analysis/framework.
• Normal and abnormal assessment data is to be outlined.

Then, using the template presented in appendix H,offer two (2) priority problems, along with their associated NANDA nursing diagnosis statement, SMART goals, evidence-based intervention and rationale, and an evidence-based outcome statement for each priority problem/NANDA diagnosis.

Diagnosis:
Identify one (1) actual and one (1) potential healthcare problems that the nurse is accountable and responsible to treat. The problems identified in this discussion are to directly link to the patient's abnormal assessment findings outlined in the assessment data. Actual and/or potential healthcare problem MUST be written using NANDA taxonomy.

Planning:
Patient goals are directly related to the patient's problem as stated in the nursing diagnosis. In clinical practice, nurses established patient goals utilising a SMART (specific, measurable, achievable, realistic and timely) approach
• Provide a description of the expected benefit &/or intended outcomes within a timeframe of the plan of care that is to be implemented by the nurse, this needs to be supported by literature
• One (1) SMART goal is to be outline for each nursing diagnosis.

Implementation:
A nursing intervention is defined as any treatment based on clinical judgement and knowledge that a nurse performs to enhance a patient's health care status.
• A description of one (1) independent nursing intervention and one (1) collaborative/dependent intervention to address the patient's actual problem and one (1) collaborative nursing intervention to avert the patient's potential problem is to be discussed and supported by literature. (*collaborative nursing interventions requiring a medical order may be discussed e.g. administration of medications, IV fluids etc)
• The nursing interventions discussed are to be within the scope of practice of a second year first semester entry-to-practice nursing student
• Evidenced based rationales with reference to the current literature is to be provided for each nursing intervention

Evaluation/Expected Outcomes:
In clinical practice, nurses evaluate the appropriateness of their nursing interventions i.e. have the patient's nursing care goals been met.
• This section will describe the expected patient's subjective and objective data after nursing actions have been implemented i.e. it will outline the observed patient response to nursing care in line with the established objectives
• When writing outcomes, the nurse should ensure that the outcome statement is written in measurable behavioural terms. A useful mnemonic here is RUMBA i.e. the outcome statement should be realistic, unambiguous, measurable, behavioural and achievable. The outcome statement should be written sequentially, and with timeframes

Conclusion:
A conclusion to the essay is also needed. This will summarise the major points covered in your submission.

Assessment E-portfolio Part B: Problem sheet template for PEPAE
Using the data gathered from your head-to-toe assessment, students together with their CNE/preceptor, are to identify all priority problems for the patient and document these on the appendix F document. These priority problems should be ordered by priority and identify whether it is an actual or potential problem.

Priority Problem Template
Use this template to present your priority problem, NANDA nursing diagnosis statements, interventions, rationale RUMBA statements and supportive evidence. Please ensure that you present this as part of your PEPAE submission along with your introduction to essay, introduction to your patient, a written summary of your head-to toe assessment, summary of all pharmacology for your patient (can be presented as a table) and ensuring that you link all medications to your patient I.e. explain clinical indication correctly, and finally an overall essay conclusion. You must also present a complete reference list using APA 7th ed.

Attachment:- Professional Experience Practice Analysis Essay.rar