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Nursing Assesment

In: Social Issues

Submitted By sally6464
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Assessment
Assessment is the most important part of care planning and delivery. It includes areas such as health and health needs, daily living skills, activity programmes, mobility, mental health, risks to the client, finance, respite, social events/outings, support requirements, spiritual needs and, possibly, accommodation issues (Department of Health, 2000b;Sox, 2004a). As a start, a background check is needed to be able to assess the situation of the patient. Our patient is conscious but was not able to respond properly because of her condition. So we need someone close to the patient or a relative to answer questions needed for the care plan. Data such as previous hospitalization, medication taken and others related to the patient condition is important.

Diagnosis
The patient was brought in the hospital because of diarrhoea and vomiting. The initial diagnosis is that the patient is dehydrated base on the physical appearance of the patient. Diarrhoea usually gets better on their own, often without treatment. If the diarrhoea continue within several days it is best to check patient’s medical history and physical exam.
Planning
In planning, the nurse plays an important role in the recovery and stay of the patient in the hospital. The patient upon admission was given attention on the main complain which is diarrhoea and vomiting. However further diagnosis and assessment of the medical team discovered that the patient is suffering from malnutrition. Our plan focuses on malnutrition; the reasons why the patient is having this kind of condition, and the treatment and the protocol that the nurses should follow for the welfare of the patient.

Implementation
Implementation of a care plan is the most challenging part of the nursing process. The patient is pale and has lost a lot of weight. The patient also lacks proper hygiene as a result of her appearance upon…...

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