Clinical Reflection

  1. Briefly discuss what, how, and why you created/tad the assessment approach you utilized.

I started my assessment by providing privacy in order to make the patients comfortable during the assessment process, and to induce them into telling me as much detail as possible. As I set the room, I engaged the client and observed them in a wise manner to establish their general condition. This helped me to know whether they needed any urgent attention before carrying out the assessment. I then took the history of the client taking note of where a focused health assessment may be required. I followed this with physical assessment through the systems approach and the SPICES model. Through SPICES, I was able to access for sleep disorders, challenges with eating disorders, confusion, evidence, of falls and skin breakdown. My patient, a mister Kelvin Jones, 76, is stable, apart from some pain that is being treated through painkillers.

  1. Areas undertook well in carrying out the assignments

I ensured a foundation of good nurse-patient relationship by first creating a rapport with my patient. After that, I introduced myself and explained the purpose of the health assessment I was to undertake. I then asked Mr. Kelvin some general questions about the current admission. This assisted me to know more about his social history, family history, and the events that led to his admission to the hospital. This is important because it relates to patient and family centered care. I thus asked Mr. Kelvin about his family, and sought to understand whether his family is supportive. This helped me establish about psychosocial-state of my patient. While talking to Kelvin about his family, I also wanted to understand whether the family might have a big impact to his illness. I was also able to establish whether Mr. Kelvin was comfortable with the achievements he had made in life or he was disturbing him. By using SPICES, I was able to assess my patient using my understanding of the general health determinants for old people. SPICES directed me to assess the sleep disorder, problems with feeding or eating, incontinence, confusion, evidence of falls and skin breakdown. I realized that the rapport I created and the conversational manner of interviewing that I used had a great impact in assisting m get valuable information.

While taking history ad doing the physical assessment, I used open-ended questions as they have an advantage of a smooth flow of information, and they are patient-centered. As old people like to talk o ouch and give a lot of irrelevant details, l led the conversation with questions that were relevant to the health assessment. Through this, I ensured that the patient did not deviate from the topic.

eventually improved the credibility of the results. I was thus able to systematically do the neurological assessment, psychosocial, cardiovascular, genitourinary, digestive and respiratory. After this, I documented all my results. This will help communicate the other members of the health care team.

  1. The areas I need to improve

One strategy that Ihis support system, I realized later that had cut him a short while he wanted to explain about his friends. This would have helped me establish his complete system of support. Another strategy I need to employ I my future assessments are to garner enough confidence ad to prepare adequately. My phone, for example, rang as I was taking blood pressure and the process was started. I had to wait for some time in order to take the correct readings. However, I continued with the other aspects of the assessments as I waited.

On reflection, I also realized I did not use the best strategy while assessing the digestive system. In the mouth, I did not realize that the patient had dentures. Also, while assessing the abdomen, I used the wrong sequence, as I would have started with an inspection and auscultation before doing percussion and palpation. This would have prevented interruption f bowel sounds in order to get the correct impression o auscultation. Finally, I forgot to wash my hands after the assessment. It is a hygienic practice that helps prevent infection, that one should wash hands before and after a procedure.


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