The First Assessment I Performed For My Patient

Undecided, initially, because of her age the possibility of an inaccurate diagnosis, the differences of both the reliability and validity which may occur because of the difference in age, race, gender as well as socioeconomic status. However, in Clara’s case, it may just be a phase like many toddlers and adolescents go through. On the contrary, it can also be something a little more severe because of the fact that she is adopted,

I wrote up an assessment on a therapy session with a 74 year old female as she played Rummickub. This was the first documentation experience I had during my fieldwork. An example of my first write up was: “Pt initiated 30 min session in TR clinic working on cognition, UE strength, fine motor skills, scanning, sequencing, math skills, social skills, activity tolerance, memory and direction following while participating in a table top activity. Pt required min. cues for concentration. Pt demonstrated willingness to participate in activity initiated conversation. Pt tolerated session well. Cont. POC.” This Pt was a stroke patient with symptoms of overall weakness.

This patient arrived on time for her scheduled appointment with this writer. This writer introduces herself as the patient assigned counselor, at which the patient was pleased to be assigned to a counselor. This writer discussed with the patient UDS and the patient's prescribed medication. According to the patient, she provided information of her current medical concerns such as the seven blockage with her heart, her chronic back pain- the patient reports that she needs to replace 2 or 3 discs, and her foot surgery. The surgery for the patient's heart and foot are pending at this time. The patient reports she is scheduled to conduct a sleep apena on 03/03/2016 and is aware that she must provide an update to Nursing at the clinic. The patient praised about having a excellent Cardiologist, who is currently monitoring her heart. the patient was emotional discussing the many loss of her family who suffers from congestive heart failure. The patient reports, " I believe there is a GOD and he is

Plan your initial assessment so that you can use the position change and turning time with an assistant or auscultate the posterior chest with someone to help you turn and hold the immobile patient. Auscultate left lateral when the patient is lying on his or her right side, and vice versa. Document the findings based on the lung fields; do not describe the lobes because

I did assessment on my daughter. I walk into the room and my first assessment was her safety and the environment she is surrounded by. I washed my hand and introduce myself and what I will be doing to the patient, and ask the patient for her name and date of birth. I gave a privacy and started to check for vital signs.

Critical Thinking: During the first scenario, the patient was a 39-year-old female admitted to a med-surg unit following an abdominal hysterectomy. She had no known allergies and had a Foley catheter in place. Also the physician’s orders included, sequential compression devices and pain medication. While receiving report about my patient, I was beginning to think, as a nurse what my priority would be when first entering the patient’s room, which would be performing an assessment, monitoring vitals, assessing pain and inspecting the surgical site and dressing for signs and symptoms of infection, and assessing for potential post-op complications such as respiratory and cardiac problems; however, that didn’t go as planned. I was too focused on being reactive and thinking about what I was going to do next instead of being proactive, that I forgot simple steps such as introducing myself to the patient. Moreover, in the second scenario, my colleagues and I were placed in the emergency department to care for a 34-year-old patient with complaints of difficulty breathing due to asthma. In this scenario, the physician’s order consisted of administering oxygen via nasal cannula as needed in addition to administering albuterol via the nebulizer. Once again, before entering the patient’s room, I knew my first priority was going to be to assess the patient’s respiratory status by auscultating breath sounds, examining the quality and rate of respirations, the shape and configuration of the

Respiratory rate is a greater predictor of a deteriorating patient, and a predictor foe adverse patient outcomes. There is much discussion within the literature around the importance of accurate measurement of respiratory rate, registered nurses perception of respiratory rate compared to other vital signs and adverse patient outcomes and implications associated with respiratory dysfunction. This discussion is undertaken to gain a further understanding of the role of the Registered Nurse in assessing patients respiratory rate.

The patient manifested signs of respiratory distress precipitated by a pneumonia and bronchiolitis infection. A.D was on 0.5 liters of oxygen via nasal prongs with an oxygen saturation reading of 94%. On prior days without the supplemental oxygen, she was desaturating to below 92%, “ high flow rates generate continuous positive pressure in the airways that could help reduce the work of breathing in bronchiolitis and decrease the need for more invasive respiratory support” (Casey, 2015, p. 24). The patient had a respiratory rate of 42 breaths per minute and the normal respiratory rate for a 13month old as stated in Perry et al. (2013) ranges between 20-40 breaths per minute. Also, the patient had a heart rate of 158 beats per minute and the

Through this diagnostic assessment process I have been afforded the opportunity to practice critical steps in discovering what my focus child knows or understands about addition and subtraction. Prior to this I did not understand the value in employing diagnostic techniques to uncover student thinking before teaching a concept. I would simply go in to the classroom teaching as though students had no experience with a concept. I now understand the importance of determining an appropriate starting point. The diagnostic assessment task, delivered through the Mathematics Online Test has helped me quantify and uncover how much of the addition and subtraction concept, my focus child had mastered and any misconceptions she holds. Understanding this has been vital for effective

The patient was in the same condition. The interim assessment was occurred before the treatment. Homecare performed was the same by stretching the hamstrings and partial sit ups. Massage was followed the same and homecare was changed to a squat position to encourage strengthening of the hamstrings.

The second nursing concern is impaired gas exchange for patient with COPD, this may be related to; alter oxygen supply, alveoli destruction and alveolar capillary membrane changes. The nursing intervention of this would be, to elevate the head of the bed up to help the patient breathe easier, to assess the skin and the membrane for color changes and to encourage the patient to cough to help clear secretion, as well as, to monitor the level of consciousness and mental status. The expected outcomes would be that the patient shows improvement of ventilation and oxygenation of their tissues and by assessing the ABGs and to be free of respiratory distress (Vera, 2013).

My client is a full time night shift nurse. Her nursing diagnosis during visit 3 was having a disturbed sleep pattern. She states inconsistent sleep patterns with an average of less than 5 hours of sleep per night. Our long term goal was for her to be able to sleep for 8 hours within a 24-hour period and out short term goal was for her to develop a sleep routine, track her sleep cycles and quality of her sleep.

Even if the provider lacks the necessary financial means to continue patient care, they are still responsible for finding a suitable referral physician for the patient. The physician is instructed with the task of monitoring the health of the patient either directly through patient exams or indirectly through patient charts sent over from the referral physician. Continuously tracking the patient’s current health condition is a critical aspect to providing exceptional care. In some cases, a referral may be unbeneficial for the patient because medical fees are higher in some facilities. Any initial efforts of maintaining patient health would be futile if the patient declines further care to avoid potential accumulation of medical debt. The

What was going through my head was to make sure I follow procedure in fluid motion and relate any information that was notably outside of the norm. Throughout the respiratory assessment, I was trying to interact with the volunteer as to relax myself and keep a genuine interaction as possible; even as a simulation. Though this attempt at interaction may have affected my assessment as I did not note the volunteer had exceptionally healthy lungs for their age.

Listening to his lungs went well, I heard crackles from one of his lungs, but my heart was pounding when his vital monitor started to beep on him as I put the oximeter on his finger to check his O2 sat. The screen was red and blinking, and then the number I got was 78 %. Although his O2 sat number went up 92~93%, the machine was still beeping, along with that my heart was pounding. As I was startled by monitor’s beeping, the respiratory therapist told me “Don’t look at the number; look at your patient and listen to him,” then I took my breath and pondered what I missed there. My patient was confused a little but he didn’t show neither cyanosis nor pallor on his skin, and his capillary refill was less than 3 seconds. Most of all, he was talking to me about his breakfast. I was deceived by machine, ignoring my assessment findings, resulting in almost getting wrong data. I did see and hear my patient, but neither look at nor listen to him carefully. I couldn’t use my intuition which I thought I was good