Instructions:
Word Count: 2200 words
References: 15-20 references – No older than 5 years old
Use NANDA
7 APA
EVERY STATEMENT NEEDS TO BE REFENCE (ie head-to-toe assessment, diagnosis, planning, implementation, ALL needs to be reference. Even as basic as the vital signs)
Professional Experience Practice Analysis Essay (PEPAE)
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 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.
Assessment Outline:
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
I. 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
II.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 evidencebased 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 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.