Nursing Observation

Overall I think that I had a decent day. There were definitely things that I felt I did not spend enough time on and other things that I didn’t get to due to other activities, but also things that I didn’t think of until after I left. Overall one of my main focus points of the day with P.L. was to improve his overall mood. From the moment I met him I got the sense that he was in a depressed and solemn mood. As I talked to him I found out that for the past three months he has been in and out of the hospital and that seems to be talking a toll on his mood. When I can into his room to do certain assessment and asked his permission, most of the time his response was disengage. I did end up engaging him in conversation before each of my assessments, usually about his past. He talked a lot about his time in the military and seemed to be a positive subject for him, especially when I ask about all the places he’s been and his favorite place he’s been. I noticed that when we were conversing about this subject he was more
engaged and responded better to my requests related to my assessments. In the beginning of the day I was very uncomfortable when I got to my pod. I wasn’t really sure who I was supposed to talk to or who to get the nurse handoff report from. After I got that figured out I wasn’t really sure what I was supposed to do with my patient. I didn’t want to over step, but I also didn’t know where to start. After I introduced myself to my patient when he woke up I go into the flow of things. One of the things that I need to figure out is a balance of being in the room and out of the room. I don’t want to be overbearing, but I also don’t want to be unhelpful or not there for my patient. I think it will take time to find a good balance and it will also depend on the patient. The nurse with me also taught me a lot with other patients as well. She taught me how to use a bladder scanner and let me watch her prepare and administer medications. I think that it really help watching how other nurses do and perform different activities, because not only am I a visual learner, but I think that it builds a good relationship. Hygiene is an area that I would like to focus more on in the future, much of the time when I wasn’t going the health assessment to the neurological assessment the patient was sleeping or on the phone talking to a relative. I found that it was most important to do the most important assessments first in case I was unable to complete the full assessment. For my patient it was most important to complete neurological and vital sign assessments first when I was doing any assessment. When I was doing my head-to-toe assessment I also decided to start with the abdominal assessment because he has been constipated and a rectal suppository had been administered thirty minutes before I started my head-to-toe assessment. I prioritized my patient’s priority problems this week based on the most pressing concerns that I felt I had for my patient that day.
I felt that impaired tissue perfusion had the highest risk for patient injury, which is why I placed that as my top priority. I placed imbalanced nutrition: less than body requirements because the P.L. has consumed so little nutritional calories that day, 0% at breakfast and minimal at lunch which was unrecorded as he was still working on it when I left. This in concerning because inadequate nutrition slows the healing process and can cause skin integrity impairment. Also, because of the lack of nutrition and medication side effect P.L. was constipated and hadn’t had a BM since 1/18 and is nauseated. Lastly, I placed impaired physical mobility last because with the spinal injury and immobilization of the neck along with the medications side effects and impaired nutrition, this patient has a higher risk of
falling.