SBAR is a nursing tool used to assess the situation, background, assessment findings and the recommendations to a patient. The Registered Nurse (RN) performing the assessment is wholly accredited to work in a health facility and provide healthcare services and care to patients. Health Care Professionals (HCP) regularly assess the patient’s condition depending on their current situation before any treatment recommendations. The video captures Jones as the RN. The patient being assessed is identified as Steven John, who is a male of 39 years. Steven has come to seek health care from the health facility, and Jones RN is assessing to know the right prescriptions critically. He says that he has a problem with his eyes as most of the time, they itch, and at times he is unable to see clearly. The current condition of Steven is that he can see but with a lot of difficulties.
The present complaint presented by Steven that he is unable to see started some years back. His condition started while he was still in high school. When there is excess light or inadequate lighting, he always found himself struggling to read and write with the condition. The condition persisted for long, and he decided to seek medical attention with his relatives. The HCP at that time was able to recommend and gave him eye drops, and it seemed to work out. Steven's family history shows that the eye problem is common as he reveals that most of the family and relatives have this condition. The condition of the eye brought about social and emotional situations as he was not able to perform tasks and other activities normally with ease. The condition led to him being mentally disturbed and thus sought to seek medical care.
To ascertain the eye condition that Steven had, an assessment process had to be undertaken. The findings of the report were given the right recommendations by the HCP or an RN. Various methods did the assessment, and the primary survey was one of them. The primary survey included the use of primary sources such as medical books that had the eye condition. The primary survey also included a study of other patients with the same conditions and how they were able to get treatment and how the condition was managed. The primary survey gives an overview of how other patients can recover or live with the same condition as Stevens.
The general survey included research and report of other patients with different conditions. The general survey does not necessarily look into those that have eye problems but look into the patients coming to seek health care services generally. Another process of the assessment is the patient interview. The patient interview involves an RN or any other HCP asking a question to a patient to try to find the accurate condition of the patient. The interview will lead to the right medical prescription depending on the response of the patient.
The assessment process also considers the vital signs of a patient. There are common signs that can be seen by an RN even without the primary survey or an interview. The symptoms may include body temperature, pulse rate, and respiration rate. All these assessment strategies are important in that it gives a conclusion to which is the right medication to prescribe. The assessment provides accurate results and the condition the patient is in. The condition identified with the right medication will lead to high chances of recovery to the patient.
The data collected from the case study and the normal parameters in the textbook shows a match of the condition with the prescribed medication. Abnormal data was found whereby data collected were not matching. The RN should ensure that appropriate action is taken, such as communicating the findings to the medical team and other HCP. Data from the initial assessment and focused assessment, and the patient situation shows that the patient’s condition has worsened. Steven’s eyes have turned red, the eyes are itching, and he is unable to see clearly. The clinical decisions that I suggest besides any other medication is that Steven should be able to wear the recommended eyeglasses that will help him along.
The patient’s family members had indicated that the people suffering from the condition were six, while another finding recorded four cases of the family members. The priority health problem experienced by the patient was the magnitude of the problem as he could not even sleep due to the irritation of the eye, especially at night. The recommendations for further assessment that were required by the nurse to fully understand the health status of the patient was for the nurse to determine if the condition was hereditary. The magnitude of the condition makes it a priority health problem as the eyes are the vital sense organs in the body (Zator Estes, 2013). Thus, it is significant for further assessment to ensure that the eye condition is dealt with in the right and recommended manner.
STARL is a nursing framework used to reflect on the situation, task, action, results and learning of a patient. The RN conducted the health assessment and interview in a health facility where the patient had come to seek medical care.
The RN was required to undertake the following tasks to the patient: The initial assessment whereby it is the first assessment to a patient to determine the nature of the problem and prepare the way for ensuing assessment stages. Time-Lapsed Assessment is also another task whereby it is conducted after the treatment has been implemented, and it ensures that the patient is recovering from his condition (Heilbrun, 2014). During the Time-Lapsed Assessment, the patient's current status is compared with the previous situation to ascertain whether there is an improvement. Emergency assessment is a task performed by an RN whereby the nurse, at this point, he identifies the root causes of concern for the patient and assessing the airway, breathing, and circulation. Emergency assessment may turn into initial or focused assessment, depending on the situation.
The RN assessed the body temperature and the pulse rate to perform the initial assessment. To perform the time-lapsed assessment, the RN recorded the condition of the patient after two weeks to determine if there was change. The emergency assessment was conducted by assessing the breathing rate and circulation rate. The communication skills used by the RN changed depending on the patient’s condition. The joining stage witnessed verbal communication accompanied by an active listening of the RN nurse to capture the details of the patient accurately. The working stage experienced non-verbal communication, whereby the RN used more of written communication. The termination stages entailed the combination of verbal communication with active listening. The RN assessed vital signs such as body temperature by the use of a thermometer. The RN also recorded the pulse rate and the rate of circulation.
The task's results indicated that the patient’s eye had a problem and the cornea in particular. The retina and the veins that support the eye were not well circulated with blood-based on the RNs assessment findings. The interview process entailed the joining, working, and terminating stages. The RN interviewed the person keenly and carefully to obtain relevant data to prescribe the right medication. The address and the contact for the person are what was missing. The RNs clinical skills techniques were professional according to the medic’s requirement. The focused assessment entailed collecting subjective data about the patient’s history of eye condition and his family’s history concerning the problem. The emotional and psychological impact of the condition made the findings more comprehensive. The vital signs assed include body temperature, pulse rate, and circulation rate. There were no recorded abnormalities.
A comprehensive examination and assessment of the patient allow the nurse to obtain a complete recommendation of the patient. Techniques used to gather information may include; observation, palpation, and auscultation. Clinical assessment frameworks would be beneficial in the future to help assess patients' conditions and their recommendations (Steadman, 2013).
Heilbrun, K., DeMatteo, D., Holliday, S. B., & LaDuke, C. (Eds.). (2014). Forensic mental health assessment: A casebook. Oxford University Press, USA.
Steadman, R., Myers, R. P., Leggett, L., Lorenzetti, D., Noseworthy, T., Rose, S., ... & Clement, F. (2013). A health technology assessment of transient elastography in adult liver disease. Canadian Journal of Gastroenterology and Hepatology, 27(3), 149-158.
Zator Estes, M. E., Calleja, P., Theobald, K., & Harvey, T. (2013). Health Assessment and Physical Examination: Australian and New Zealand edition.
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