CU Nursing Adequate Development of Patient Care Discussion Response

I did better than expected during the simulation than I initially thought I would. I don’t do comprehensive/wellness assessments in my line of work, so being able to do well on it surprised me. I felt knowledgeable during the history and physical assessment because I could get the appropriate information needed from the patient. I asked questions related to the assessment, and a few key questions were missed. I remember during the week one orientation case, I had asked many questions that weren’t needed or related to the case. I do feel like this case was realistic. Many patients in my area come in for health assessments required by insurance. I know of members in my family who have yearly health assessments to keep their insurance, so I see the resemblance. UTIs are also very common, and education related to those is needed, along with the importance of having a PCP.

Since I don’t do many assessments of this type, I need to improve my SBAR communication. Nurse notes allow the physician to get an idea of what is going on with the patient; I was a little vague regarding the responses, so when thinking about the physician, I would need more info for the physician to make a clinical-based decision. I didn’t provide adequate background information for the physician to understand what could be happening to the patient. I also need to improve in picking out every little detail. For example, I noted every abnormal lab value. This isn’t bad, but it may not necessarily be a priority when caring for patients. In this case, I wasn’t surprised by the feedback I received; I thought it was a fair evaluation of my assessment.

From this case, learning how to give appropriate comprehensive health assessments and how to do a proper SBAR is something I could apply to nursing practice since it is something I don’t do often. Again, the SBAR is something that I found valuable and interesting to give information about the patient appropriately. This assessment reinforced why comprehensive health assessments are essential. They help differentiate abnormal and normal conditions and help develop a care plan. With time and experience from these simulations, I aim to improve my assessing skills and do nurse notes properly. I don’t have any questions related to this scenario.