All of the instructions will be given to you in a document. One document is the guidelines and the other is a sample to help guide you (and to make it a little more easier). For the background information summary, the section titled Significant assessment findings during days of care can be placed in a table. Also the medications can be placed in a table as well. I will also attach a NANDA Nursing Diagnosis to help for the “Risk for”.

Title: Assessing and Identifying Significant Assessment Findings and Nursing Diagnoses in a Clinical Setting

Introduction:

The process of assessing patients and identifying significant assessment findings in a clinical setting is a critical aspect of nursing practice. Nurses play a key role in collecting and analyzing patient data to identify actual or potential health problems. This process helps to guide the nursing care provided to patients and assist in the formulation of nursing diagnoses. This paper explores the assessment findings during days of care and the use of NANDA nursing diagnoses to address potential risks.

Significant Assessment Findings during Days of Care:

During the course of a patient’s hospital stay, numerous assessments are conducted to gather essential information about the patient’s health status. These assessments encompass various domains such as physiological, psychological, sociocultural, and spiritual aspects. Significant assessment findings during days of care can be summarized and organized in a table format for clarity and ease of reference. This table provides a concise overview of the patient’s condition, facilitating quick access to pertinent information for effective clinical decision-making.

By grouping assessment findings in a table, nurses can easily identify patterns or trends in the patient’s health status. For instance, vital signs, laboratory results, and physical examination findings can be summarized in separate columns, allowing nurses to compare and contrast variations over time. Organizing assessment findings in such a manner also aids in detecting any worsening or improvement in the patient’s condition, which can inform subsequent nursing interventions.

Medication Documentation:

The administration of medications is an integral part of nursing care. It is imperative that proper documentation of medications be maintained to ensure patient safety and continuity of care. Creating a dedicated table for medication documentation serves as a useful tool for nurses to record the medications given to patients during their stay.

In the medication table, essential details such as the medication name, dosage, route of administration, frequency, and any specific instructions or precautions can be documented. Additionally, the table can include columns for documenting the patient’s response to medication, adverse reactions or side effects observed, and any necessary follow-up actions. This structured approach to medication documentation helps to minimize errors, enhances communication between healthcare providers, and facilitates interdisciplinary collaboration.

Utilizing NANDA Nursing Diagnoses:

NANDA (North American Nursing Diagnosis Association) nursing diagnoses are standardized clinical judgments and statements used to describe actual or potential health problems identified by nurses. These diagnoses provide a framework for nurses to organize and communicate patient care needs effectively. By using NANDA nursing diagnoses, nurses can address potential risks for patients and facilitate evidence-based nursing interventions.

In the context of risk assessment, nurses can utilize NANDA nursing diagnoses such as “Risk for…” followed by a specific health problem or potential complication. These diagnoses assist nurses in identifying patients who are at risk of developing certain conditions or experiencing adverse events. For example, “Risk for falls related to impaired mobility” or “Risk for infection related to compromised immune system.” By recognizing these risks, nurses can implement appropriate preventive measures and interventions to minimize the likelihood of adverse outcomes.

Conclusion:

Assessing and identifying significant assessment findings in a clinical setting is crucial for providing high-quality and individualized nursing care. By organizing assessment findings and medication documentation in tables, nurses can easily access and analyze patient data, allowing for more informed decision-making. Furthermore, using NANDA nursing diagnoses aids in identifying potential risks and guiding nursing interventions to promote patient safety and well-being. Overall, these practices contribute to improved patient outcomes and enhanced nursing practice.