health assessment

Table of Contents

As a first-year student I was assigned to conduct a health assessment on a student colleague in the clinical labs at QUT while my colleague recorded it to undertake a simulated health assessment. Throughout the video, the undertaking of vital signs such as the blood pressure, temperature, pulse, respirations and oxygen saturation were being taken on a student patient and recorded on an observation chart. The video was also used to watch back and assess my skills and techniques taking vital signs. As the nurse, I had to ensure safe practices by carrying out good hand hygiene as well as cleaning the ear plugs of the stethoscope before use, therefore, I played on the clinical practices of protecting both patient and staff/myself from any cross contamination. Ensuring my patient was relaxed and comfortable, I took her pulse rate using my three middle fingertips to locate the pulse and luckily, I managed to find her pulse right away as that usually takes some time to find. For the next 30 seconds, I asked her if I could redo the same thing but over the chest so it would be easier for me to count her respirations without notifying her and I purposely didn’t inform her as informing could lead to feeling uneasy and increase respirations which would lead to inaccurate readings. Her pulse rate was 96 BPM and respirations were 15 breaths per minute which were both higher than the average adult rate with adult pulse rate ranging within 60-100 BPM and respiratory of 9-20 (Tollefson, 2010). After seeing results and comparing the parameters, I proceeded to ask whether she had anything to drink or do prior the check up and with the response being coffee, I made sure to let her know that it was most likely the coffee that have affected the results. Though these results were a little higher than usual, I reassured her they were still within the normal range. According to…. a fast pulse exceeding 100 bpm can be a sign of infection or dehydration (Reference). With that knowledge moving forward, I could have suggested one or two cups of water to get her back to her usual rate.In terms of technical skills, I was really stressed out about messing up the assessment of the blood pressure. As evident through the video, I was able to get readings on the first try although looking ack on the clip I’m disappointed with the minor technique issue of inflating the cuff as shown I had to redo it a couple times. Nonetheless, I must improve my skills in this area to let the assessment continue smoothly.With temperature, I lacked communication where I should have explained the process before taking an oral temperature but in this case, it was acceptable since she knew exactly what she had to do. Her temperature was 37.2 degrees and to which I evidently informed her it was great and within the normal range (Reference). In the learning process, I have learnt that reflection is really a big part of nursing as it guides us through everything, we as nurses do. For instance, if her temperature had been below 35 degrees, then I would need to reflect and take further action to counteract the results. On the other hand, if her temperature was too high that would result in a fever and would need medical attention immediately, although it could also mean a response to improvement of the function of the immune system (Thompson & Kagan, 2010). Under the critical thinking component, I could have planned my working area carefully. Instead, I was immediately involved in attending to the patient and completing the procedure within the time limit which should not have been the case. As a result, I had to move around quite a bit which could have been minimized with careful area planning.On the communication part of skills, I intended to try my best to re-assure, inform and address my patient of the normal and abnormal findings of the vitals. After analysing the video, I realised before taking the vitals I didn’t ask how she felt and went straight into assessing as that dialogue could have helped her relax and engage with confidence. I feel a little disappointed I was not able to communicate everything that was required and desired such as clearly explaining what might have caused her to obtain slightly altered results, give appropriate suggestions on how she could go back within her normal parameters and reassuring her to ensure she was well and comfortable and certainly doing just fine. Perhaps the pressure of being watched, filmed and timed might have slightly been a fraction of the reason that affected my lack of effective communication, hence why I believe the communication skills I portrayed in the video was done very poorly. Nevertheless, these skills can be improved in the future and in order to excel with effective communication I will continue to practice to appropriately provide information needed to be heard and make time to reassure my patients comfort because after any task is done the patient should be left comfortable and informed of results that have been documented. Lastly, I believe I had done a commendable job in relations to ethical practice and professionalism. I tried my best to keep my patient informed and comfortable. Through this assessment, the reflections and lessons learnt were to ensure a comfortable environment and to build confidence and bond with the patient to be able to make an accurate assessment for future resolutions.