Clinical Journal

Clinical Journal One

Milford Regional Medical Center

The nursing process is an assessment, diagnosis, plan, implementation and evaluation of our patients. As a practical nursing student this is something we are learning and improving on daily. Assessment is the most important part of the nursing process. This process is becoming clearer every day spent in the clinical setting.
The assessment part of the process is done with every interaction of our patients we are taught in school. I thought how could that be assessing something takes a considerable amount of time so assessing every patient, every interaction sounded absurd to me.
Currently my clinical setting is a post surgical unit. The nurses on this unit are registered nurses with varying amounts of experience. As I observe the nurses, I have noticed they actually do assess everyone, every time. I was amazed how easy this skill seemed to them of course experience helps in that area.
I had the opportunity to participate an assessment of a month old child. During this experience I was able to understand the doorway assessment I learned about in growth and development and it made more sense to me . I was able to take a set of vitals on this baby, weighed a diaper for the I&O and was shown how to assess the IV site on an infant. I realize how very important a quiet baby is during the assessment because of this experience. Assessing an infant is different than adults. Infants are a bit

harder to assess if they are not calm. Upset babies respirations will increase. I learned how to feel for the fontanel and dehydration signs in infants. There is so many parts to assessment and each and every part is an important step in keeping your patient on the path to recovery.
Post-op assessment require that you check patients pedal pulse, this is something I would not have thought to be important but I have since discovered that pedal pulse is a warning sign for post-op patients. The smallest part of assessing a patient is just as important as the biggest parts. So a pedal pulse takes a minute or two to be sure it’s present and equal in both feet but the importance of doing this step in your assessment lasts forever because you deterred your patient a problem by doing a full head to toe assessment.
Though, hands on assessments are most important, I have learned I do not always have to touch my patient to assess their condition. I can learn a lot from them just by listening to them and taking a good look at them. Patients also need more than a physical assessment. Physical head to toe is done at the beginning of your shift but you do and you can assess everyone with every interaction.
There are many parts to assessment. The physical, of course, but as a nurse you must figure out the needs of each patient beyond the physical. They need emotional support as well. We must look at the whole picture when assessing. Do they need physical therapy? Home care? Support services? Are they going to need additional information on ways to be safe at home. Maybe the patients going to a rehabilitation facility after discharge so they may need to be assessed for which facility they would

gain the most from. We must assess if they require special equipment to improve on their independence. Assessing your patients doesn’t stop at taking a pulse or blood pressure. So, assessment is very important and is easily done at every interaction once you see it done in the clinical setting. I still have so much to learn when doing a patient assessment but now I understand my role of assessing the patient as a licensed practical nurse and I understand the importance of every interaction assessment.

Clinical Journal One

Milford Regional Medical Center

The nursing process is an assessment, diagnosis, plan, implementation and evaluation of our patients. As a practical nursing student this is something we are learning and improving on daily. Assessment is the most important part of the nursing process. This process is becoming clearer every day spent in the clinical setting.
The assessment part of the process is done with every interaction of our patients we are taught in school. I thought how could that be assessing something takes a considerable amount of time so assessing every patient, every interaction sounded absurd to me.
Currently my clinical setting is a post surgical unit. The nurses on this unit are registered nurses with varying amounts of experience. As I observe the nurses, I have noticed they actually do assess everyone, every time. I was amazed how easy this skill seemed to them of course experience helps in that area.
I had the opportunity to participate an assessment of a month old child. During this experience I was able to understand the doorway assessment I learned about in growth and development and it made more sense to me . I was able to take a set of vitals on this baby, weighed a diaper for the I&O and was shown how to assess the IV site on an infant. I realize how very important a quiet baby is during the assessment because of this experience. Assessing an infant is different than adults. Infants are a bit