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Patient Assessment Assignment Sample

Q1: History Taking

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Applying a model and framework to consultation or history taking is consideredimportant (for example SOLER, Calgary Cambridge, SOCRATES, DEADSWAMP).(Critically appraise/discuss) the use of a model or framework relevant to your field ofpractice. Please use literature to support your arguments.

Ans:When the healthcare professional is focusing on the adult patients assessment in all the different filed of practice, it is essential to apply better models and framework which can help them in providing better consultation. Stickley (2011) had mentioned that SOLER is a useful model which can be implemented by the healthcare service provider, and it is widely used in the field of medical care. This model mentions that the healthcare professional should focus on sitting squarely, with an open posture, lean towards the other, eye contact and relax. According to this model, these things plays an essential role in making the professional an effective listener and also helps them in being effective at non-verbal communication and develop these skills.

Calgary Cambridge is an effective model which can be used in healthcare practices and can help the practitioners in having effective communication with the patients when they are providing them consultation. According to this model, there are five important steps which are required to be taken into consideration by the healthcare service provider while having conversations with the patients. These five different steps are initiating the session, gathering information, physical examination, explanation and planning and closing the session. In the view of Awinda, et al. (2020) if the professional is ineffective at applying the relevant models in an effective manner, then they will not be able to provide better consultation to the adult patients.


Books and Journals

Awinda, D., Syakurah, R. &Fadilah, M., (2020). Assessment of Doctor-Patient Communication Among Residents in Internal Medicine Polyclinic At RSUP Dr. Mohammad Hoesin Palembang 2014 Using Simplified Checklist of Calgary Cambridge Guide. Medicinus7(6). pp.184-194.


Stickley, T. (2011). From SOLER to SURETY for effective non-verbal communication [Online]. Available through: <https://pubmed.ncbi.nlm.nih.gov/21489877/>. [Accessed on 18th Dec 2020].

Q2: Patient assessment and understanding assessment findings

NEWS2/PEWS/ICD11 are examples of tools or diagnostic frameworks used to aidclinicians to understand illness severity. Select a tool or framework relevant to yourarea of practice and (debate/discuss) its strengths and weaknesses (you maychoose one of the frameworks listed above).

Ans: For understanding the illness severity of the adults patients in an effective manner and in detail it is important to apply relevant tools or the diagnostic framework which can help the healthcare service providers in analysing that how severe the disease is. It is important to analysing the severity of illness and then classify them into minor, moderate, major and extreme as well. While treating the patients, the healthcare professionals can apply the ABCDE model, which can help them in better assessment and also will help in understanding the severity of illness. According to this model, the practitioners should focus on airway, breathing, circulation, disability and exposure while diagnosing the patient. One of the advantages of using this model is that it can be applied to all the adult patients and for all the diseases as well(Soltan& Kim, 2016).

Some of the laboratory tests are also important diagnosis techniques which are helpful for the healthcare service providers as it helps them in analysing the severity of the illness among adults in an effective manner. Different diagnosis techniques can be applied to the patients on the basis of the diseases they are having. Some of the most common diagnostic methods which are being performed by the patients include the measurement of blood pressure, body temperature, pulse, biopsy, CT scans and other laboratory tests but this all varies from disease to disease and patient to patient(Kraljic, et. al. 2017).


Books and Journals

Kraljic, S., Zuvic, M., Desa, K., Blagaic, A., Sotosek, V., Antoncic, D. &Likic, R., (2017). Evaluation of nurses' workload in intensive care unit of a tertiary care university hospital in relation to the patients' severity of illness: A prospective study. International journal of nursing studies. 76. pp.100-105.

Soltan, M. & Kim, M., (2016). The ABCDE approach explained. BMJ. 355.

Q3: Priorities of care

Holistic care is of upmost importance and it is necessary to optimise physical and

mental health. Select one of the four cases and, drawing on the research evidence,

(critically reflect/ reflect) on priorities of care in that case.

Ans:When the care is given to the patient it is important that the healthcare service provider should aim at providing the holistic care to the patient which focuses on all the different factors such as social, economic, spiritual, physical and emotional needs of the person. In one of the cases, 33 years old women had a complaint of severe daily headache for the past three weeks. The healthcare professional had focused on better physical examination and had gathered all the information related to the past history of the diseases which are being faced by the patients. While communicating and consulting the patient, the doctor gets to know that she is having multiple diseases and medical issues which are continuously affecting her and leading to several issues for her(Jasemi et al. 2017).

After examining all the things, she had been referred to the neurosurgeon who had suggested the surgery. After surgery, she had completely cured the disease effectively. It can be said that for successful outcomes of healthcare, it is important that effective holistic care should be given to the patients, which is more appropriate and helps in better assistance and treatment. Through this case I have understood that the healthcare service provider should prioritise the care and should try to provide holistic care which is important for better assessment of physical and mental health of the patient(Naka & Hirokawa, 2020).


Books and Journals

Jasemi, M., Valizadeh, L., Zamanzadeh, V. and Keogh, B., 2017. A concept analysis of holistic care by hybrid model. Indian journal of palliative care, 23(1), p.71.

Naka, R. and Hirokawa, A., 2020. What is Holistic Care in Nursing?. Journal of International Society of Life Information Science. 38(1). p.57.

Q4: Patient advice and medication

Medications can support health and well-being. Drawing on evidence-basedguidelines, select one of the medications prescribed in one of your case studies.Provide a rationale, (critically discuss), why this medication has been prescribed andhow adherence can be optimised.

Ans:The medication which is being provided to the patient plays a major role in his treatment so it is important that the practitioners should focus on giving best medication which can help the patient in fast recovering. In one of the cases, 78 years old women were referred to the dentist as she is having a history of oral ulceration after using the antidepressant pills. In the diagnostic, the doctor came to know that this is not a case of oral cancer it a nonspecific inflammatory reaction. Improper medication is a major issue in the oral mucosa, and a number of cases are being found in this context(World Health Organization. 2016).

The physician had evaluated the medication, and after that, sertraline was replaced by 75mg venlafaxine and exfoliative cytology was also performed. The practitioner had mentioned that there are different medicines such as captopril, piroxicam, phenobarbital and niflumic acid,which leads to ulcer in the majority of the cases. In this case, with the continuation of the medication, the ulcer had disappeared. From this case, it can be said that proper medication is very crucial for the health and well-being of the patients so the practitioners should focus on providing correct medication to their patients(Donaldson et al. 2017).


Books and Journals

World Health Organization. (2016). Medication errors. World Health Organization.

Donaldson, L. J., Kelley, E. T., Dhingra-Kumar, N., Kieny, M. P., & Sheikh, A. (2017). Medication without harm: WHO's third global patient safety challenge. The Lancet389(10080), 1680-1681.

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