The Importance Of Individualised Patient Assessment

Refection on Competency Standard 4: Comprehensively conducts assessments An individualised patient assessment involves purpose, goal-orientated critical thinking and structure (Estes, Calleja, Theobald, & Harvey, 2013). This orderly approach to patient assessment provides a structure for clinicians practice and guides decision-making to prioritise essential care which subsequently enhances patient outcomes (Munroe, Curtis, Murphy, Strachan, & Buckley, 2015). A comprehensive assessment starts with a primary investigation of airway, breathing circulation and disability to identify and treat life threatening conditions (Munroe et al., 2015). Clinical information is gathered and interpreted during the physical head-to-toe examination, directed

Kong, Qin, Zhou, Mou and Gao (2014) support this suggestion and adds that effective communication is a vital component of nursing practice contributing to wise decision-making and effective patient management. A holistic assessment which is culturally sensitive, ensures that healthcare is concordant to a patient’s values and beliefs (Tucker, Roncoroni & Sanchez, 2015). Cultural competence in nursing, requires health professionals to have an understanding of the diversity of cultures among patient groups and in doing so, to provide care which is respectful and culturally-centred (Tucker et al., 2015). Using the reflective model of situation, task, action and response (STAR) below, I was able to recall a clinical experience and review my practice in nursing (Swinburne University,

This process enabled me to work in an efficient, rational way to problem solve and meet my patient’s needs (Munroe et al., 2015). On reflection, individualised safe nursing care was implemented when I was allocated to look after a patient in Joondulap Health Campus’s Emergency Department (JHC ED) who presented with central chest discomfort. On handover of an ISOBAR by the triage nurse, I promptly conducted observations using the ABCDE structure. The patient presented as a category 2, electrocardiograph information was attained and given to the assigned doctor for analysis. Following a diagnosis of non-life threatening ventricular tachycardia, the Doctor discussed the cardioversion treatment risks with the patient, consent was given and I was assigned to provide one-to-one nursing care. During the 2-hour waiting period, I familiarised myself with the JHC ED cardioversion protocol, ensured close monitoring of the patient and reported any changes to my supervising RN. I also utilised this time to establish a therapeutic