Discuss the process you undertook to gather your data (both subjective and objective). Consider the concepts that we discussed in each lecture regarding consent and what did you do to prepare the patient for the assessment.

Professional experience essay – Patient with Tracheostomy

In this section you need to introduce your essay. You might like to introduce the nursing process here and provide the reader with an understanding of what you plan to discuss in your essay.

Introduction to the Patient

This is where you introduce your patient: this includes who they are, what brought them into hospital, their clinical course while in hospital as well as their past history and social history. Make sure to include information regarding support services they may have in place. You should also address any Advanced Care Directives as well as their resuscitation status here. If your patient has a very long list of medications, you can present the complete list as an appendix, but please refer to any specific medications linked to the patient and their presentation in this section

Head-to-toe Assessment of Patient

You need to discuss the process you undertook to gather your data (both subjective and objective). Consider the concepts that we discussed in each lecture regarding consent and what did you do to prepare the patient for the assessment. Make sure that you don’t simply omit something because it was within the normal range, and don’t simply state that it is within the normal range. You need to provide detail of the data. Students are also asked to include all data, even if on your ward they don’t routinely undertake a specific test/assessment, you are asked to still undertake the assessment and report on it.

General Assessment

This is where you can provide general patient information and well as your overall impression of the patient including their general appearance

Central Nervous System (CNS)

Here you provide the subjective and objective data that you have accumulated from your patient in regard to this particular body system.  Think here about what we learnt in lectures and labs about how we assess neurological function and report on it.

Cardiovascular System (CVS)

Here you provide the subjective and objective data that you have accumulated from your patient in regard to this particular body system.  Think here about what we learnt in lectures and labs about how you assess cardiovascular function and report on it. Remember to consider all aspects of CVS assessment.

Respiratory System

Again, provide the subjective and objective data that you have accumulated from your patient in regard to this particular body system.  Think here about what we learnt in lectures and labs about how you assess respiratory function and report on it.

Gastrointestinal System (GIT)

Again, subjective and objective data that you have accumulated from your patient in regard to this particular body system should be presented here. This about what the GIT system is and try and relate this to your particular patient. You may have been allocated to a surgical unit, your patient may have had a period of Nil by mount, alternatively they may have swallowing difficulties, these all need to be reported.  Again, think here about what we learnt in lectures and labs about how you assess GIT function and report on it.

Renal System

Present again subjective and objective data that you have accumulated from your patient in regard to this particular body system.  Think here about what we learnt in lectures and labs about how you assess renal function and report on it. Remember to consider all aspects of renal including how the patient voids as well as their fluid status.

Musculoskeletal System

How does the patient mobilize, here you should consider risk assessment are they a falls risk and what kind of assistance do they need?

Integumentary System

Think about the condition of the patient’s skin. Again, use the information from your risk assessment here. Are there any areas of concern, wounds, cuts pressure injuries, are these new?

Psychosocial Wellbeing

Consider the psychological state of your patient. Do they have any concerns in this domain?

Metabolic System

Metabolic refers to whether or not the patient is diabetic. If so you need to discuss again your subjective and objective data.

Additional systems

You can include additional headings referring to other body systems that are relevant to your patient such as haematology.