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Assessment Task: Professional Experience Practice Analysis

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 while 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. It includes 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 you to write up the results of the head-to-toe assessment and develop a plan of care to address the needs of the patient. You are to provide an overall introduction to the essay, an introduction to the patient and a written summary of the head-to-toe assessment, and a conclusion

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, and not presented 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 G, identify 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 problem 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
establish 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 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 are not to be discussed e.g. administration of medications, IV fluids etc)
• The nursing interventions discussed are to be within the scope of practice of a first year first semester entry-to-practice nursing student
• Evidenced-based rationales with reference to the current literature are to be provided for each nursing intervention

Evaluation/Expected Outcomes:

In clinical practice, nurses evaluate the appropriateness of their nursing interventions, i.e. whether the patient's
nursing care goals have been met.
• This section will describe whether 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.

Part B: Head-to-toe assessment guide for PEPAE
Students are required to complete a full head-to- toe assessment on a patient they have been caring for whilst on clinical placement. This assessment must be supervised by either a CNE or preceptor, must be signed once completed and then attached as an appendix as part of your PEPAE submission. Please note that this document (appendix E) does not count towards the overall wordcount for this assessment. Once you have completed your patient head-to-toe assessment students, should sit with their CNE/preceptor and identify the patient's priority problems, documenting these on appendix F.

Attachment:- Professional Experience Practice Analysis Essay.rar