Free Essay Example with the Patient Assessment

Q1.What Went Well in Your Assessment

I was able to gather all the information about the patient's spiritual, sociological, psychological and physiological needs. Nonetheless, I managed to sort, analyze, organize and communicate the data collected from the patient. Also, I was able to recognize normal and abnormal physiology of the patient that would assist to prioritize care and intervention of the patient. Lastly, I managed to introduce myself as well as establishing a rapport with the patient.

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Q2.What Went Wrong and the Intended Change for the Next Assessment

In the course of the interview with the patient, I noticed the use of medical phrases resulted in a communication barrier. Furthermore, a wrong structuring of the question yielded no information from the patient. In the next assessment, I intend to use more focused and well-structured questions.

Q3.The Findings

Subjective Data

The patient is a 78-year old Korean female. She has constant pain in her lower belly as well as difficulties going to the bathroom; the dull crampy feeling is 6 out of 10 on Pain Scale. Five days ago, she had a gradual bloating. Resting helps her, but there is no relief once she sips water as suggested by one of her friends. The patient has never tried any medication aggravated by eating. About physical activity, the patient reports low energy levels. Bowel movement noted a few days ago was diarrhea, and the patient denies any history of constipation.

Further, the patient reported having diarrhea about 2 to 3 days ago; she describes it lose and watery. She reports darker urine than usual and decreased urination frequency as a result of reduced water intake. Nevertheless, the patient reported cholecystectomy at the age of 42, a C-section at the age of 40, and no post-operation complications were noted. Also, the patient denies any history of liver disease, stomach cancer, appendicitis, heartburn or ulcers, gerd, and any GI history disorders. Lastly, the patient denies blood in her urine, and the last past man noted about ten years ago.

Objective Data

Vital Signs

Temperature is 37, blood pressure is 110/83, heart rate is 70, and the respiratory rate is 16

Head and General Face Inspection/ Observation

.Head and face light flushing of the cheeks, nose dry appearance, mouth and throat dry appearance.

Abdomen Inspection

Abdominal scarring noted approximately 6 inches in a scar to the right upper quadrant and about 10 cm scar at the middle line super pubic region.

Cardiovascular Inspection

There is no edema noted bilaterally in the lower extremities. Heart sounds S1 and S2 audible with no extra sounds and breath sounds are present in all areas with no adventitious sounds.

Gastrointestinal Inspection/ Palpation/Auscultation

There is no bruit in the abdominal aorta, abdominal arteries as well as in the bilateral renal, iliac or femoral. Also, there are no friction rubs noted over the spleen and liver. However, dullness is noted to the left lower quadrant and tympanic in all the other quadrants.

Additionally, the percuss spleen tympanum is noted and percuss liver approximately 7cm in the midclavicular line. Right lower quadrant with light pressure reported no tenderness, no guarding or distention and no masses. On the other hand, palpated left lower quadrant with light force reported tenderness, palpable guarding and distension but no masses. Palpated left upper quadrant with light pressure reported no masses, guarding or distension. Palpated right upper quadrant with light pressure reported no tenderness, masses, guarding or distension.

Deep Abdominal Palpation

Palpated right quadrant with deep pressure reported no masses, palpated left upper quadrant with deep pressure reported no masses, and palpated right lower quadrant with deep pressure reported no masses. However, palpated lower left quadrant with deep pressure reported firm elongated mass 2x 4 cm.

Aortic Palpation

The width is 2cm, and there is no lateral pulsation.

Liver Palpation

The liver is palpable 1 cm below right costal margin.

Spleen Palpation

Not palpable.

Bladder Palpation

Not palpable, no distension or tenderness.

Kidney Palpation

Bilateral kidneys palpated; not palpable.

Palpation of the Skin

Turgor, warm, dry, and no tenting.Pelvic Examination

There is no inflammation or irritation of the vulvar. Also, there was no abnormal discharge or bleeding and no mass growth of tenderness upon palpation.

Rectal Examination

There were no hemorrhoids, fissures or ulceration. Fecal mass was detected in the rectal vault as well as a strong sphincter tone.

Urinalysis

The urine was clear, dark yellow with a typical odor and no presence of nitrates, BC, RBC, or ketones detected; pH 6.5 and SG 1.017.

Q4. Questions that Yielded More Information and the Reason Behind their Effectiveness

Open-ended questions seemed to yield more information. This is because the patient felt free and was not limited to answering a specific issue; hence she can provide all the relevant information about the question.

Q5. Diagnostic Tests

The diagnostic tests would include a CBC test; this would assess for elevated white blood cells that may be related to diverticulitis. The second test would be a CT scan; this would establish any instance of obstruction. The third test would be an electrolyte profile; this would assist in evaluating electrolyte and fluid status.

Q6. Differential Diagnosis

Currently, I would consider fecal impaction, Irritable Bowel Syndrome (IBS), Constipation and rectal cancer as a differential diagnosis.

Q7. Medication

If Mrs. Park is diagnosed with diverticulitis, one would recommend and bowel rest IV fluids. On the other hand, if it is discovered that she has a bowel obstruction, NPO and IV fluids would be the best as well as a general surgical consult. In case she has constipation then there would be a need to increase fluids, fiber, and activity as tolerated.

Q8. Patient Teaching

I was able to complete patient teaching on numerous areas, for instance, sexual education, especially the importance of intercourse in a relationship, drugs, and substance abuse education, healthy living, for example, taking six to eight glasses of water every day as well as taking food rich in fiber. Also, I managed to educate the patient on bowel movement, medical advice, for instance, never to skip a dose and the importance of having three meals a day. The additional teaching would be over the counter medicines, how to manage blood pressure as well as how to manage allergic reactions.

Q9. How My Assessment was Able to Demonstrate Sound Critical Thinking and Clinical Decision Making and Changes to Making it Better

My assessment confirmed a sound critical thinking and clinical decision making in that I was able to actively and skillfully analyze, synthesis and evaluated the collected information from the patient through observation and efficient communication. However, to improve further, I intend to utilize the experience of the nurses around me as well as making valid conclusions; this can be achieved through an understanding of how other nurses arrive at their findings.

References

Kelly, K. N., Iannuzzi, J. C., Rickles, A. S., Garimella, V., Monson, J. R., & Fleming, F. J. (2014). Lapatotomy for small-bowel obstruction: first choice or last resort for adhesiolysis? A laparoscopic approach for small-bowel obstruction reduces 30-day complications. Surgical Endoscopy, 65-73.

Mounsey, A., Raleigh, M., & Wilson, A. (2015). Management of constipation in older adults. American Family Physician, 500-504.

National Institutes of Health Clinical Center. (2015). Understanding your complete blood count (CBC) and common blood deficiencies. NIH Clinical Center Patient Education Materials, 1-5.

Pedersen, C. A., Schneider, P. J., & Scheckelhoff, D. J. (2016). ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education-2015. American Journal of Health-System Pharmacy, 489-512.