Reflection On Head-To-Toe Assessments

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This week, my shift at KLH was intense, but at the same time informative. I was able to successfully meet my goal from last week of becoming more fluent with head to toe assessments. I have been finding that regardless of each patient’s acuity, it is becoming much easier to conduct a full assessment without looking at my cheat sheet. Although I was not able to meet my goal of incorporating complimentary and alternative medicine (CAM) into my practice, I was given the opportunity later on during charting to recognize where I could have utilized them. Specifically, my client was experiencing decreased lung sounds on expiration and crackles to her right lower lobe (RLL). In hindsight, I recognize that I could have taken the opportunity to educate on deep breathing or coughing techniques to clear her…show more content…
During one of my interactions, my patient rated her pain a 7/10 and I could tell that she was in discomfort by her facial expressions and lack of conversation. By recognizing this I was able to have a conversation with the RN around what could be given to alleviate her pain. The RN was appreciative that I relayed the information and she happily gave her an analgesic. About an hour later, while checking in on my patient, I recognized that she was much more at ease. I could also tell that she was happy with my care as she quickly thanked me for my help and explained that the pain was now tolerable at a 4/10. Throughout this experience I realized how quickly a patient’s health can change. The importance of doing hourly rounds was evident as had I not gone in to check on my patients level of pain again, I would not have known that it had increased in such a short amount of time. This was a positive experience for me as I felt that I was more involved with my client’s care and was able to really make a difference in her health and
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