Question 1
Introduction
A routine assessment of a client is a process through which a trained nurse conducts a health assessment on a patient through interviews, general observation, physical exam, vital signs and assessment of all the body systems (Robert, Morrow, Maben, Griffiths, & Callard, 2011). I conducted a health assessment on Mr. M who came to the hospital with complains of sudden onset of shaking chills, shortness of breath, night sweats, chest pain and cough. The patient was admitted to the medical ward with a diagnosis of community acquired pneumonia.
I conducted the health assessment on Mr. M while in his ward bed during my routine assessment. The patient appeared calm and sick looking after a quick survey. He was lying in bed in a supine position with bed rails in place to prevent any fall. I introduced myself to the patient and informed him that I am a nurse who will be taking care of him. I also informed him that I had come to conduct some assessment on him to determine how he was fairing. As a precaution for infection prevention, I washed my hands and donned gloves. I then handed the patient a clean gown and assisted him to sit in an upright position. While conducting the assessment the patient was coughing continuously, leaning forward with his left arm placed on his the chest. This was a clear indication that he was experiencing chest pain.
Vital signs appeared to be normal although blood pressure and temperature were deviating from the normal, Blood Pressure 134/90mmHg, Radial Pulse 90beats per minutes, respiratory rate 18 cycles per minute, temperature 37.6 degree Celsius and saturation of oxygen was at 98%.
On respiratory assessment the patient exhibited signs of tachypnea, use of accessory muscles when breathing, coughing and having purulent sputum. On percussion both lungs were resonant. On auscultation there were presence of crackles and bronchial breaths sounds. Both the percussion and the auscultation of the heart reveal no abnormality. On abdominal examination, the abdomen appears distended on auscultation there is normal bowel sounds. Skin is pink in color with no signs of dehydration. Review of the systems is very important especially in the management of patient (D'Amico & Barbarito, 2012).
On the cardiovascular assessment the patient had an apical pulse of 70 both heart sounds S1 and S2 were auscultated with no presence of heart murmurs. Extremities appeared pink with good capillary refill. I palpated the abdomen and it appeared distended on auscultation, bowel sounds being present. On the genital urinary assessment, I palpation the bladder and it appeared to be full. I provided a urinal and assisted the patient empty the bladder. He raised no complain with urination. The urine appeared clear with no foul smell.
Question 2
As a result of taking this course, I have been able to have a clear understanding on the role played by a professional nurse in health assessment. Initially I could not see the importance of conducting both the health assessment and physical assessment on the patient. According to Penz and Bassendowski (2006), health assessment and physical exam are very essential especially in coming up with a diagnosis for the patient.
In my current clinical rotation, the concepts of health assessment can be used effectively in coming up with a proper nursing care for the patient (Winsett & Cashion, 2007). I have been able to know how to use the data obtained from health history and that from physical exam in order to detect any particular disease that the patient might be suffering from even though the patient might not be aware. Through the health assessment, I have learnt on the important of having a collaborative assessment on the patient. In my nursing practice I plan to encourage on the importance of both collaborative assessment and management especially in primary nursing.
References
D'Amico, D., & Barbarito, C. (2012). Health & physical assessment in nursing (2nd ed.). Upper Saddle River, NJ: Prentice Hall
Penz, K. L., & Bassendowski, S. L. (2006). Evidence-based nursing in clinical practice: implications for nurse educators. Journal of Continuing Education in Nursing, 37, 251–4; quiz 255–6, 269.
Robert, G., Morrow, E., Maben, J., Griffiths, P., & Callard, L. (2011). The adoption, local implementation and assimilation into routine nursing practice of a national quality improvement programme: The Productive Ward in England. Journal of Clinical Nursing, 20, 1196–1207. doi:10.1111/j.1365-2702.2010.03480.x
Winsett, R. P., & Cashion, A. K. (2007). The nursing research process. Nephrology Nursing Journal : Journal of the American Nephrology Nurses’ Association, 34, 635–43.
