Clinical Health Assessment in Nursing

 

 

 

Describe a new ESRD patient who may be referred to you for assessment, care planning and ongoing management and explain your current approach to client assessment and needs to commence haemodialysis. In this discussion, you should

Describe your model of/approach to clinical health assessment

Justify why you use this model/approach for your client group

Critically reflect on and critique your model/approach with reference to the models/frameworks .

2. Discuss how your model/approach to assessment would change with authorisation as a nurse practitioner including the advanced/extended skills that you would need to develop with reference Standard 1 of the NMBA Nurse Practitioner Standards for Practice (NMBA 2014). In this discussion, you should describe the knowledge and skills you will need to competently perform a comprehensive client assessment so as to effectively plan and manage the health needs of your clients as a nurse practitioner. 

3. Identify those aspects of your client assessment that are unique to your role as the nurse practitioner, making clear and justifying the difference between the role and scope of practice of a nurse practitioner and a registered nurse. 

 

Introduction

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Nursing professionals, being a crucial part of the care teams, are contributing in the wellbeing of the patients. However, the roles and responsibilities of different nursing professionals differ significantly according to their expertise and experience, in order to ensure that service users are getting the highest level of care. Each nursing professionals with different designation have some role boundaries, which they need to maintain, while dealing with service users, in order to meet the NMBA standards. For instance, there is a significant role difference among the nursing practitioner, registered nurse and assistant nurse practitioner. In this following assignment, the role of a nurse practitioner would be demonstrated, while dealing with an end-stage renal disease (ESRD) patient (Birks et al. 2016). ESRD is a chronic kidney disease, which has led to an advanced state after gradual loss of kidney function. When kidneys fail to filter wastes and excess fluids from the blood stream through gradual loss in its filtering capabilities, a dangerous level of fluid, electrolytes and wastes usually build up in the body. The end-stage renal disease often need dialysis or kidney transplant, in order to retain normal renal function of the kidney. The following assignment would focus upon the clinical assessment of the new ESRD patient as well as the role of a nurse practitioner in regards to the approach of care. 

 


1. Discussion of patient assessment with Comprehensive Multidisciplinary Patient Assessment (CMPA)

 


A 63 years old new male ESRD patient has been referred to the emergency department, after experiencing episodes of breathing shortness, chest pain and nausea. When the patient was brought to the emergency department, he was unconscious. His son reported that the patient was experiencing some other symptoms since last 2-3 days including loss of appetite, sleep problems, itching and muscle cramps. Initially, the patient was diagnosed for his condition, which is followed by the development of his care planning and further treatment schedule. The patient was diagnosed with chronic kidney disease in last year, which has been progressed with decreased filtering capabilities of the patient’s kidney. Prior developing a proper care plan based on the patient’s holistic needs, a thorough clinical assessment is needed, which would include initial as well as advanced stage of diagnosis. 
In order to assess the patient, the Comprehensive Multidisciplinary Patient Assessment (CMPA) has been selected to be used here (Council of Nephrology Social Workers, 2008). According to this model, initially, the patient is demographic and communication information is collected. The following step includes evaluation of patients’ medical history. In the case of current patient, he has a history of type 2 diabetes and hypertension, diagnosed 2 years ago and he was undergoing medication and required diet for dealing with the issue. In addition, the renal diagnosis shown high level of sodium and potassium, compared to the standard level of electrolytes in blood, which indicated renal dysfunction. His BP was 150/100 mmHg during last week, before his hospital admission, but after hospital admission, his blood pressure was 90/70 mmHg, indicating interrupted or slow blood flow in the body (Cashin et al. 2015). The patient has a history of frequent alcohol consumption since last 30 years. He is also a chain smoker, smoking 20 cigarettes a day. Now, according to the CMPA approach, the next level of assessment is assessing his vital signs. In this context, it has been revealed that his body temperature was 102º F; his face showed pale, swelling noticed in arms and legs. At the time of admission, the patient was unconscious. His respiration rate was 10 and pulse rate was 45 per minute; oxygen saturation was 71 % SpO2. All of these vital signs indicated potential chance of fluid build-up in heart. It has also been assessed that the patient’s urination was limited since the week. Based on the above diagnosis, the next step of ESRD assessment was done, which is laboratory diagnosis of patient’s blood and urine sample, in order to assess the concentration of excretes in the blood or urine. 
In this context, ‘blood urea nitrogen test’ was done, which showed 60 mg/dl. The Urea reduction ration was low. The blood test revealed level of potassium was 6, higher than normal level and albumin was 2.5 g/dL, lower than normal level. Calcium concentration was 11.5 mg/dL, which is higher than normal level; the serum creatinine level was 5 mg/dL and the glomerular filtration rate (GFR) was 10 ml/min, which indicated the urgency for starting dialysis. Patient’s fluid balance and hydration level were altered. All of these data were justifying the need for immediate haemodialysis. Haemodialysis is referred in order to retain normal fluid and electrolyte balance in the blood and filter the metabolic waste in blood, which built up in the body for impairment of kidney’s filtration ability. Finally, Kt/V was calculated prior planning his dialysis schedule. Haemodialysis was recommended for the patient due to the high creatinine and urea level in blood, which indicated that haemodialysis is the best modality (Fisher, 2017). After scheduling his diagnosis sessions, patients’ physical status, ability and participation in the haemodialysis was assessed, followed by the assessment of available patient and family support. As the assessment follows a holistic model, the psychological and spiritual wellbeing of the patient were also assessed and it was revealed that the patient is anxious about the therapeutic fate of dialysis. 
There are three methods for gaining access to the blood, for dialysis, which include “an intravenous catheter, an arteriovenous fistula (AV) and a synthetic graft”. Initially, for the current patient, intravenous catheter would be used, which has been suggested by the nephrologist, upon analysing the condition of his vasculature. Based on his current condition, the patient has been suggested to undergo three dialysis courses a week. 
The current clinical assessment approach has been selected in the context of current ESRD patient, for several reasons. For instance, the current approach of health assessment is specific for the ESRD patients, which makes it a preferred option compared to the other health assessment approaches or frameworks. Moreover, the patient has already been diagnosed with kidney dysfunction; thus at the end-point care, he needed some advanced diagnosis, which was possible by using the above-mentioned assessment tool (Higgins, 2016). Further, it has also been revealed that the current assessment approach has facilitated a holistic approach of needs assessment, which would in one hand ensure that all the domain of patient wellbeing are addressed; on the other hand, would also ensure that maximum patient outcomes has been approached. Moreover, this approach also provides a systematic framework for conducting all the necessary steps in patient’s full diagnosis. These criteria also justify the selection of the above-mentioned assessment tool for clinical assessment of the ESRD patient. 

 


2. Discussion of patient assessment skills and advanced role for a nurse practitioner

 


While dealing with a dialysis patient, like the ESRD patient demonstrated in the scenario, the nursing professionals are responsible for some key practices, which are unique compared to the other patients, who are not undergoing dialysis. Thus, in order to perform such evidence-based practices according to the “nephrology nursing practice recommendations developed by Canadian Association of Nephrology and Technology (CANNT)”, the nursing professionals must possess some key skills and competencies. These skills and competencies would help the nursing professional to ensure that the patient’s maximum outcomes are achieved. The nursing professionals need to practice the following in order to take care of the dialysis patient. 
Hemodialysis Vascular Access: 
    • Assessing the fistula/graft/catheter and the subjected arm prior and after each dialysis or every shift
    • Assessing complication of central venous catheter including tip placement, exit site, complications and documentation
    • Educating the patient with appropriate cleaning of intravenous site and identifying signs of infection
Hemodialysis adequacy: 
    • Constant assessment for signs of inadequate dialysis and identifying the cause of inadequacy
    • Educating the patient about the importance of adequate dialysis (Peeters et al. 2014)
Hemodialysis treatment and complications: 
    • Performing full body physical assessment prior, during and after hemodialysis for checking complications and accessibility
    • Confirming and providing dialysis prescription based on updated laboratory diagnosis data
    • Addressing concerns and educating patients 
Medication management and infection control practice:
    • Engaging patient in medication regimen procedure
    • Following infection control guidelines according to unit protocol
The approach of assessment role would change with authorization as a nurse practitioner in case of the same ESRD patient. As a nurse practitioner, the assessment and patient care would focus on five themes, which has been identified from the evidence-based care perspectives and include “managing and coordinating”, “streamlining and alleviating”, “developing capability”, “supporting innovation and quality” and “ensuring patient satisfaction” (Stanley et al. 2015). According to NMBA standards for nurse practitioners, the following key skills required by the nurse practitioner, while taking care of a dialysis patient (Peipert and Hays, 2017).
    • Skills for checking patient’s vital signs
    • Expertise in kidney disease and holistic health assessment 
    • Skills for patient education 
    • Critical thinking skill for conducting comprehensive physical assessments of the patient and formulate care plans accordingly
    • Emotional intelligence skill for continuously empowering patient and developing a nurse-patient relationship
    • Excellent communication skill for communicating patient information to the other members of multidisciplinary team as well as the patient and his family members
    • Attention to detail, for clearly monitoring dialysis adequacy, infections at intravenous or grafting sites and patient’s comfort

 


3. Difference between role and scope of practice of a nurse practitioner and registered nurse regarding client assessment 

 


The role of a registered nurse and a nurse practitioner differ significantly in a clinical setting. It is because; the role boundaries of a registered nurse would limit some of the assessment practices, which are allowed for an expert nurse practitioner. Nurse practitioners are advanced level nurses, who have in-depth knowledge and expertise in a particular care domain. However, registered nurses usually perform overall care practises and seek permission from the physician or leader of the multidisciplinary care team, regarding any changes in the care plan, which might not be required for a nurse practitioner. A nurse practitioner has the responsibility to assess the patient condition and to inform clinical decision making with their rational thinking ability, in absence of a physician, which is prohibited for a registered nurse. In contrast to the role of a nurse practitioner, the registered nurse has different role in case of clinical assessment and care practices for a dialysis patient. Registered nurse working with a dialysis patient has got special education and training for dialysis and known as dialysis nurse (Stanley et al. 2015). The registered nurses are responsible for the following practices. 
    • Communicating with patient and empowering the patient constantly 
    • Checking and documenting patient’s vital signs
    • Educating the patient and help the patient to understand the treatment modalities, while addressing their concerns
    • Administering and overseeing medication and other treatment routines
    • Empowering the patient and ensuring that patient is receiving right medications at right time
    • Ensuring patient’s comfort
    • Supporting the patient and other members in the care team to ensure that the patient is having highest quality of care 
The key difference between the role boundaries of the registered nurse and nurse practitioner regarding the dialysis patient is that the nurse practitioner is able to take clinical decisions and make changes in patient’s care plan (Birks et al. 2016). However, according to NMBA standards, this practice is not allowed for registered nurse; rather they are responsible for informing the need for change to the leader of the care team or nurse practitioner. 
Conclusion
The role of a nursing professional is crucial for determining the patient’s safety, experiencing end-stage renal disease. Focusing upon the responsibilities and special requirements, appropriate clinical assessment approach needs to be selected, for identifying patient’s actual needs, based on which advanced care plan is developed. In this assignment, an ESRD patient’s case has been selected and his clinical assessment has also been discussed. In the following section, the role of a nurse practitioner in the patient’s assessment and care has been demonstrated, compared to a registered nurses’ role in the same context. 

 

Reference List

 


Birks, M., Davis, J., Smithson, J. and Cant, R., 2016. Registered nurse scope of practice in Australia: an integrative review of the literature. Contemporary nurse, 52(5), pp.522-543.
Cashin, A., Buckley, T., Donoghue, J., Heartfield, M., Bryce, J., Cox, D., Waters, D., Gosby, H., Kelly, J. and Dunn, S.V., 2015. Development of the nurse practitioner standards for practice Australia. Policy, Politics, & Nursing Practice, 16(1-2), pp.27-37.
Council of Nephrology Social Workers, 2008. Comprehensive Multidisciplinary Patient Assessment (CMPA) Example Questions Social Work-Focused Criteria. [online] kidney.org. Available at: [Accessed 5 Apr. 2018].
Fisher, M., 2017. Professional standards for nursing practice: How do they shape contemporary rehabilitation nursing practice?. Journal of the Australasian Rehabilitation Nurses Association, 20(1), p.4.
Higgins, C., 2016. Urea and creatinine concentration, the urea:creatinine ratio. [online] Acutecaretesting.org. Available at: [Accessed 5 Apr. 2018].
Peeters, M.J., van Zuilen, A.D., van den Brand, J.A., Bots, M.L., van Buren, M., Ten Dam, M.A., Kaasjager, K.A., Ligtenberg, G., Sijpkens, Y.W., Sluiter, H.E. and van de Ven, P.J., 2014. Nurse practitioner care improves renal outcome in patients with CKD. Journal of the American Society of Nephrology, 25(2), pp.390-398.
Peipert, J.D. and Hays, R.D., 2017. Methodological considerations in using patient reported measures in dialysis clinics. Journal of Patient-Reported Outcomes, 1(1), p.11.
Stanley, M., Worrall-Carter, L., Rahman, M.A., McEvedy, S. and Langham, R., 2015. Assessment of an established dialysis nurse practitioner model of care using mixed methods research. Contemporary nurse, 51(2-3), pp.148-162.

 

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