Michaela P. Capulong
NU 333-01: Physical Assessment for the Nursing Professional
June 1, 2015
Journal 3 A good assessment technique is a strong foundation in our nursing career. Gathering an accurate history is vital in determining the etiology of a patient's problem. Also, having excellent communication skills will help nurses to collect data accurately. The ability of the nurse to listen and ask questions could enable her/him to obtain good patient health history. Performing a detailed assessment may help nurses identify, solve, and treat potential adverse events. First, I would do the one to one interview with the patient to develop trust. Second, I would perform the thorough head-to-toe exam. Then I would document my findings.
Gathering objective and subjective data could help the health care team in …show more content…
I also look for the patient’s lab and imaging results, and recent vital signs to obtain objective data. I will obtain the subjective data by asking the patient his/her chief complaint, symptoms, current health status, past medical health history, current medications, allergies, family and social history. Before I will enter the patient’s room, I ensure to wash my hands or use the hand sanitizer gel to prevent the spread of infection. I start my assessment my introducing myself to the patient. The room must be free of any distractions and the curtain should be completely closed for privacy. I would check the patient’s arm band, check the room for clutters, upper side rails up x2, and the call light and belongings within patient’s reach. I would use an open-ended questions communication technique and to avoid medical terminology words. As mentioned by Jarvis (2012, p.33), “This question encourages the person to respond in paragraphs and to give a spontaneous account in any order chosen.” Using open-ended
NU 333-01: Physical Assessment for the Nursing Professional
June 1, 2015
Journal 3 A good assessment technique is a strong foundation in our nursing career. Gathering an accurate history is vital in determining the etiology of a patient's problem. Also, having excellent communication skills will help nurses to collect data accurately. The ability of the nurse to listen and ask questions could enable her/him to obtain good patient health history. Performing a detailed assessment may help nurses identify, solve, and treat potential adverse events. First, I would do the one to one interview with the patient to develop trust. Second, I would perform the thorough head-to-toe exam. Then I would document my findings.
Gathering objective and subjective data could help the health care team in …show more content…
I also look for the patient’s lab and imaging results, and recent vital signs to obtain objective data. I will obtain the subjective data by asking the patient his/her chief complaint, symptoms, current health status, past medical health history, current medications, allergies, family and social history. Before I will enter the patient’s room, I ensure to wash my hands or use the hand sanitizer gel to prevent the spread of infection. I start my assessment my introducing myself to the patient. The room must be free of any distractions and the curtain should be completely closed for privacy. I would check the patient’s arm band, check the room for clutters, upper side rails up x2, and the call light and belongings within patient’s reach. I would use an open-ended questions communication technique and to avoid medical terminology words. As mentioned by Jarvis (2012, p.33), “This question encourages the person to respond in paragraphs and to give a spontaneous account in any order chosen.” Using open-ended