Examining Different Patients in Nursing

Discussions

Two of the seven “crucial conversations” that healthcare professionals struggle with that contribute to patient harm and unacceptable error rates that I have noticed are broken rules and incompetence. I have seen nurses deliberately neglect to follow protocol because they did not think it necessary or were rushed to do something else and did not want to take the time to do the procedure correctly. I have also seen nurses who did not know the standards of care they should have known and did not exercise these standards when dealing with patients. They also demonstrated an inability to critically think about situations and lacked an awareness of certain subjects.

What I can do to deter these issues is to alert the head nurse so that we can all have a conversation about it, about why it is important to follow protocol and why it is necessary that nurses have their expected competencies and be able to practice at a high standard. I would even suggest that it be mandatory for all nurses to engage in continuing education. I would also suggest that nurses engage in the peer-review so that we can better police ourselves.

SOAP Note

Patient Information: MG, 38, FM

S.

CC (chief complaint): “feel gassy at night, wake up with abdominal pain”

HPI: 38 year old female MG

Location: abdomen

Onset: years ago

Character: gassy, cramps after lying down at night

Associated signs and symptoms: irritable bowel

Timing: bothersome especially at night

Exacerbating/relieving factors: propping sides up with pillows, colon cleansing tea

Severity: 5/10

Current Medications: none

Allergies: none

PMHx: none

Soc Hx: does not exercise, drinks alcohol moderately every night

Fam Hx: IBS on mother’s side of family

ROS:

HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclera; Ears, Nose, Throat: no indications of issues

SKIN: clear

CARDIOVASCULAR: heart rate norm

RESPIRATORY: lungs are clear

O.

Physical exam: palpitation of abdomen, digital rectal exam, test for occult blood, pelvic exam to rule out ovary issues

Diagnostic results: IBS

A.

Differential Diagnoses: ovary cyst

P.

Increase fiber intake; exercise

Newborns should be held in mother’s lap if possible or lying down on table. Infants may be approached the same way but ideally can be examined quickly when lying down. School-aged child should be approached at the same level as the child—not towering over. An adult patient can be approached by having the patient sit upright at the exam table.

One common diagnosis for the pediatric patient would be seasonal allergies; one less common diagnosis would be rabies. I would be able to differentiate them from each other on exam by conducting a physical examination of the patient.

One approach of the physical exam of the pregnant woman that differs from that of the adult patient is that the pregnant woman should be made to feel comfortable and not be asked to move into position for examination until the time is required, while the adult patient can be asked to wait in position for examination while the physician gets ready to come in.