Discuss the objective (signs) and subjective (symptoms) data collated from the nursing assessment of the patient.
Word Count: 2200 words
References: 15-20 references – No older than 5 years old
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 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 – 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:
Past medical and surgical 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 evidencebased outcome statement for each priority problem/NANDA diagnosis.