Examining Assessment and Decision Making in Patient care

The focus of this assessment is to assess a patient who was admitted onto a surgical ward and plan care based on their needs that were highlighted in the holistic assessment process. The assessment will include the initial assessment and the complete care plan as an appendix in which a model of nursing will be used as a framework. The model chosen was the Roper, Logan and Tierney activities of daily living (2000). This assessment will then discuss about how and why a student nurse made judgements and decisions about the patient needs, this will then be supported by relevant theory which underpins assessment and decision-making processes. The setting of the care was as follows the patient had been admitted through accident and emergency to a surgical ward, with acute abdominal pain. To act in accordance with the NMC code of conduct (2008) all names and places will remain confidential, and that consent was obtained from all involved in the delivery of care and the patient.

Patient’s previous medical history included irritable bowel syndrome (IBS) tonsillectomy (2009) and insulin controlled diabetes, and it was clear to the student nurse and the ward sister that the patient was in pain.

As previously mentioned a model of nursing was used to base a care plan on, the model that was used as Roper Logan and Tierney’s activities of daily living. This model was chosen as it was the preferred model of nursing, in which the student nurse was on placement as it covers a holistic care assessment. This therefore means that the model can be used to frame a care plan around patient which will take into consideration social, emotional, psychological and physical problems and needs. The model of nursing was also chosen because of the regimented daily living activities which clearly highlighted relevant needs for the patient. These are as follows; to allow the patient time to communicate their worries, to manage pain and to successfully manage the experience of nausea whilst providing reassurance through communication.

The holistic care plan that had been completed, prioritised nausea and pain control as the patient is needs. These aspects were identified as being priority after initial assessment had taken place (appendix 1). After the initial assessment and care plan compiled for the patient in which many decisions were made however only two of these will be discussed, these are as follows; to control the patients pain, and the decision to reassure the patient.

The decision of giving the patient reassurance was made before any initial assessment had occurred. This decision was made as it was clear to the student nurse that the patient was worried and the diagnosis was made because of past experiences with patients who have suffered similar pain with illnesses, according to Taylor (2005, p.46) nursing knowledge is a crucial part of the decision making process. As well is communicate with the patient to reassure them and give the patient knowledge about her possible reason for the current onset of pain information was also gained from the patient’s family member about normal behaviour which helped confirm why the patient is worried. Kaplow (2007) suggest family members can reassure worried patients. Mallik et al (2004) suggests that the communication is important in the decision-making process, this is evident from the care plan that could communication and data collection from both the patient and relative was gained.

Hilgard et al (1994) States that pain is controlled in many ways, and that levels of pain and depending on patient’s perceptions of pain. It was apparent that the patient was in pain as observation of body language and also through communication with the patient. Therefore analgesia was given as prescribed and administered by the nurse not the student. Help assess the pain levels of the patient a pain chart was used (appendix 2). The Use of the nursing process enabled a systematic approach to identify the patient’s problems and help with the care planning process after communicating with the patient diagnosis of pain was made and the student was able to make a decision to educate the patient with having relevant knowledge through literature of positions that may help relieve the patient’s pain.

It appears that the nursing process is a vast amount of making decisions for patient care. Knowledge of anatomy and physiology also play a part in the decision-making process and past experiences with previous patient’s with the same problem help make decisions. After much reading it is evident that there is much research on experienced nurses making decisions but only a limited amount on student nurse decision-making. Thompson et al (2004) talked about cognitive continuum theory; this explains how decisions are made by data collection and interpretation as well as intuition. Nurses have always had to make decisions in practice about patient’s care but now they are accountable for decisions that are making.

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