NUR 643E Health Assessment Topic Reflection 1 Paper

NUR 643E Health Assessment Topic Reflection 1 Paper

Taking patient histories and performing physical exams is fundamental to providing comprehensive care to all patients across the lifespan. A nurse must be thorough and efficient in taking history and performing physical exams with a wide range of patients, including healthy clients and patients with acute, chronic, and complex life-threatening illnesses (Flugelman, 2021). The optimal selection of lab tests, treatment interventions, and referrals relies on a well-developed patient history and physical exam. The purpose of this paper is to reflect on what I learned during the topic of History Taking and Physical Exams.

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Experience

In my previous organization working in a care home, I encountered a dementia female patient who developed an acute deterioration in cognition, behavior, and function. I noticed that the patient developed an acute change in consciousness and had difficulties focusing on what I told her during the patient interview. She also developed dysphasia, dysarthria, tremor, and psychomotor abnormalities. I suspected the patient was developing delirium, which led me to perform a thorough and complete physical examination, including a mental status examination and vital signs. I confirmed the impaired attention by using bedside tests requiring sustained attention, like telling the patient to recite the days of the week backward (Johansson et al., 2018). From the exam, I ascertained that the patient had fluctuating levels of consciousness and informed the physician, who diagnosed delirium.        

Potential Difficulties

Potential difficulties can occur when obtaining a history of a patient with delirium. Delirious patients are often confused and unable to give accurate information. Thus, the clinician can only get a detailed history from caregivers, family, or nursing staff (Johansson et al., 2018). In this case, the physician relied on my nursing notes to establish the patient’s fluctuating course. However, the information in the nursing notes might be inadequate to develop a timely delirium diagnosis.

Christian Worldview and Compassion

            The Christian worldview and compassion support the steps I took in assessing the patient since they helped make a timely diagnosis and take the necessary medical interventions. As a result, the patient’s fluctuating condition was addressed, leading to better outcomes and reduced suffering.

Conclusion

During this experience, I learned that the clinician should obtain, whenever necessary, supplemental patient information from other sources, like significant others or previous exams. I also learned that a physical examination should be performed logically, organized, respectfully, and thoroughly despite the patient’s health state. The examiner should focus on the client’s general appearance, vital signs, and pertinent body systems.        

References

Flugelman, M. Y. (2021). History-taking revisited: Simple techniques to foster patient collaboration, improve data attainment, and establish trust with the patient. GMS Journal for Medical Education, 38(6), Doc109. https://doi.org/10.3205/zma001505

 Johansson, Y. A., Bergh, I., Ericsson, I., & Sarenmalm, E. K. (2018). Delirium in older hospitalized patients-signs and actions: a retrospective patient record review. BMC Geriatrics, 18(1), 43. https://doi.org/10.1186/s12877-018-0731-5

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Complete a written reflection (250-350 words) on what you learned during this topic. Include the following in your reflection, considered through the lens of a nurse educator.
1. Think about an experience you have encountered when viewing or completing the particular assessment. Reflection Experience A description of the experience the student encountered when viewing the assessment is extremely thorough and includes substantial detail.

2. Describe the steps you took when completing this particular assessment.

3. Discuss difficulties that could potentially arise or specific questions related to completing this type of assessment. Difficulties A discussion of the specific difficulties or questions that student has pertaining to the specific part of the assessment is extremely thorough and includes substantial detail.

4. Include illustrative examples of potential strategies used to overcome the difficulties encountered when completing the particular assessment.

5. Describe how the Christian worldview and compassion for all play a role in this type of assessment. Christian Worldview A description of how the Christian worldview and compassion for all plays a role in this type of assessment is extremely thorough and includes substantial detail.