Nursing Assessment For Infants, Medication Chart And Communication Process

Undertaking the Nursing Assessment

In order to handle the communication process, several aspects like friendliness, open-mindedness, empathy, attentiveness and compassion will be used by me. In order to effectively handle my communication, while listening to the queries of the patients and revealing information related to their illness, I will ensure more concern and patience.

The confidentiality of the patients will be strictly maintained by me and I will promote a good relationship with them so that they feel comfortable while sharing personal information with me. In order to ensure that the patient and his/her family can effectively discuss and understand about the issues of the patient, I will use a certain language with which the patient and his family are comfortable. Face to face and verbal communication will be preferred by me as this type of communication will ensure better interpretation of the patient’s concern and  feeling. Apart from that, clear documentation an emotional support will be provided by me.

A nurse is entitled to prepare and handover a report summary to the patient during the discharge. Details like the time of next check up, prescribed meal and drugs are explained to the family members or the caretaker by the nurse. Part from allowing the patients to leave, discharge pass is important for referrals.

Question 2B

Apart from discussing about the current illness or injury of the infant, relevant past histories, medications, immunization status and social and family history will be discussed by me. Overseas travel recently done also needs to be documented. When it comes to infants and neonates, I will consider antenatal and maternal history, Apgar score, Delivery complications and type, whether resuscitation was required during delivery or not and finally, Newborn screening tests.

After the patients are admitted to the hospital, assessment of physical, psychological and behavioral state of the patient will be performed as long the patients stay in the hospital. Considerations will be drawn after assessing the external appearance of the patients.

• Infant and Neonate

1. Infant patent, parent infant interaction
2. Spontaneous movement and position and body symmetry
3. Facisl features positioning and symmetry
4. Bursting cry

• Toddlers

1. Child parent, parent child interaction
2. Fine and gross motor skills
3. Affect and mood
4. Developmental milestones
5. Appropriation in speech

• Adolescents

1. Communication
2. Personal hygiene
3. Affect and mood

My assessment after admission of the Infant will include baseline observations and review of VICTOR Graph every two hours in order to observe vital signs of the patients for clinical decision making.

In order to asses any respiratory distress, respiratory breath for 1 full minute will be calculated.

Temperature:

For infants of age greater than 6 months, tympanic temperatures need to be used.

For infants younger than 6 months, digital thermometer per axilla should be used.

Actions for Prn Medication on Medication Chart

Heart Rate:

For Infants, Femoral pulse or Palpate brachial pulse will be considered, while for children, radial pulse will be taken under consideration. The pulse rate will be counted for 1 full minute for ensuring accuracy.

Pain:

Pain assessment tools should be used in accordance to the age group. PICU and NICU areas require special pain assessment for sedated and intubated patients.

Oxygen saturation:

Along with monitoring, oxygen requirement and delivery mode will be noted.

While initial assessment will be documented in the patient care plan, further changes will be documented in the progress notes. General appearance of the patient will be considered to assess the condition of the patient.

• Breathing: Breathing assessment include assessment of bilateral air entry and movement, sound of the breath of the patient,  rhythm of the breath, respiratory rate and whether the breathing of the patient is spontaneous, labored, supported or ventilator dependent, requirement of oxygen and finally the delivery mode.
• Airway: I will assess the noises, cough, secretions and if the patient uses any artifice airways or not.
• Circulation: In order to assess circulation, assessment of pulses that include location, rhythm, strength and rate of the heart beat, central or peripheral temperature, skin color and moisture along with skin tugor will be performed by me. Apart from that, I will also assess the capillary refill time, the color of lips, oral mucosa and skin along with the color of the nail bed. Rate and rhythm of ECG will also be monitored.
• Observation of vital signs including pain: In order to assess this factor, usage of  FLACC along with usage of numeric scale, Comfort B scale and Neonatal Pain assessment tool kipping in mind the age group of the patient will be performed. Current medication for pain will be reviewed.
• Disability: In order to assess disability assessment tools like Alert Voice Pain Unconscious score (AVPU) , Gross Motor Function Classification System (GMFCS) and University Michigan Sedation Score (UMSS) can be used. I will also identify any abnormal gaits and aids required by the patients that includes mobility aids, spectacles, hearing aids, transfer requirements and requirement of orthotics.
• Skin: I will assess skin color, turgor, bruising, wounds, lesions and injuries.
• Nutrition/Hydration: I will check the feeding type of the patient that include oral, gastrostomy, jenujunal, breastfed, nasgastric or fasting. Apart from that, I will alao asses the type of diet and fluid intake followed by the patient.
• Output: I will access bladder and bowel routine of the patient along with his incontinence management urine output. Apart from that, I will also review the blood sugar level and fluid balance activity of the patient.
• Focused Assessment: I will assess the current issues along with other identified problems like respiratory, cardiovascular, eye and renal issues.
• Risk assessment: In order to assess risk pressure injury risk assessment, ID bands and falls risk assessment will be performed.
• Psychological assessments: considering the fact that during the adolescent period, the emotional, social and physical wellbeing of the patient is connected, it is really crucial to access the psychological condition of the patient.
• Wellbeing: Assessment of the mood of the patient, his sleeping habits, coping strategies, emotional state, support network, comfort objects, psychological assessments and reaction to admission will be performed. With the help of HEADSS which is a psychological screening tool, I will prepare a report by gathering information about the patient’s family, school, friends and his inner feelings and thoughts. After that, I will evaluate the report to find out whether there are any risk areas that need intervention, medication and prevention.

Question 2C

I will discuss the findings with the relevant allied health team, medical team and the ANUM. Patients who are under RCH care needs to assess daily and the assessment should be documented on a regular basis.

Question 3C

Prolonged illness resulting in hospitalization imposes a highly negative impact on the growth of development of children. Since the children surfing from long term diseases, need to spent a prolonged period in hospital, there cognitive development suffers. Since in hospital a child cant fin peer, his social environment development suffers. Besides that a child spending a majority of his time in hospital seems to develop a sad mood and thus lack emotional development.

Infertility imposes an n adverse impact on the social and spiritual state of mind of the patients. Social stigma about infertility makes the patient feel shy and isolated from the rest of the society which any fault of their own. Spiritually they feel betrayed by the creator. Emotionally they suffers from depression and become non interactive over time.

Question 6

Active interaction with children does impose a highly positive impact in the health of the patients. Interaction with children is found to have reduced health complications and negative habits of the patients. Individuals, who live in an unhealthy environment where excessive smoking or consumption of foods takes place, are found to have health issues like obesity or addiction. Genes are also responsible for health issues of an individual. For example, an individual having a family background of anemia is bound to sufferer from anemia. Hence, bith factor are responsible for affecting the health outcomes of people.

Question 7

1. Respect and dignity should be maintained by the nurse as well as by the patient and his/her family member with the help of usage of proper words during verbal communication.
2. The patient as well as his family should report any changes in order to help the nurse to indentify the next step.

Considering the fact that women are found to have better immunity system when compared to men, women can fight off viral infections better than men.

Impact of Long-Term Illnesses and Infertility

Due to the higher level of testosterone, men are found to be more susceptible to parasitic infection when compared to women. Testosterone enhances breeding rates of parasites.

In order to assess whether the condition of a patient has deteriorated or not, the observance of the improvement of the patient should be noticed from the time of his or her admission. If it is detected that the condition has got worse, it will be understood that deterioration has taken place and the patient is not giving positive response to the current medication.

In order to detect consciousness, whether the patient is in the wake state, awareness or alertness needs to be determined. Consciousness of an patient can be determined by assessing his or her voice tone and active rate. After consciousness is detected, the same must be documented for future use.

Being a nurse, my role will be to analyze the positive or negative development of a patient. In cases, where deterioration of the health condition of the patient is noticed, I am entitled to inform the health care professional urgently so that he can either change the medication or implement ideal attention by transferring the patient to an intensive care unit. After recognizing deterioration, I am entitled to provide necessary assistance in an emergency basis that include seeking help from healthcare professionals and officers.

This can be done by guiding practitioners so that they can maintain evidence based standards and contemporary practices. This include the usage of person centered goals for the patients, better clarity of the purpose of the service provided, shared understanding of good practices and strong therapeutic relationships.

• In order to ensure better health, an individual should intake a proper amount of nutrients in the form of food and fluids that will not only provide enough energy but also will also ensure proper growth and development.
• It is really crucial for an individual seeking proper health that he possess a digestive system that works effectively.
• Healthy body system is a necessity since it assure proper transportation and absorption of nutrients which are to be used by the body.

The wellness model is advanced than the recovery model by one step. According to the wellness model,

1. Each and every human by birth has the right to get recover and lead a healthy lifestyle.
2. Each human being has the right to express and enjoy his recovery in his life without suffering from preventable diseases and premature death.
3. Every individual must believe in the truth that he is able to enjoy his life which is infused by quality and characterized by longevity.
4. Each and every individual have the ability and right to make choices for their own life when it comes to greater health, well being and safety.

Infants can be defined as newly born children. If we go through global reports of the pat 50 years, we will be able to notice a spectacular change in infant and child health. It can be expected that similar change will be noticed in the following years. Or instance, in 1995, among 1000 babies, approximately 210 babies have died before the age of 5. Each year, about 20.6 million babies are reported dead in 1995. This graph has found to be fallen abruptly since 1995, and currently per 1000 babies 78 babies are reported to have died before their 5^th birthday. It is expected that by 2025, the number of babies reported to be dead, per 1000 babies will get declined to 37. The total death of babies per year will be 5.1 million approximately.