Physical Assessment and Clinical Judgement

Physical Assessment
Discuss your critical thinking process when doing a physical assessment.
During physical assessment the first obligation is to collect data through observation, health history, and interview, analysis of symptoms, diagnostic data, physical examination, and laboratory data (Sutter, 2015). The approach used requires the use of skillful assessment. My critical thinking process during a physical assessment entails the following;
Observation: Through observation I attentively take note of the behavior and general appearance of the patient. During observation I check the mood, emotional responses, interactions, physical responses and any safety issues. Through observation I get useful pointers to the status of the patient, both mental and physical. I am also keen to observe non-verbal communication that indicate feelings, anxiety, pain, or/and anger. Through application of observational skills I am able to detect warning signs in good time (Rubenfeld & Scheffer, 2015).
Interview: I interview the patient with an intention of interacting with them. The purpose of this interaction is to gather information concerning the health history of the client and the current situation. This will help me make a determination concerning the health needs of the patient. I use effective communication skills to gather the information I need. I will observe nonverbal behavior in the course of the interview.
Inspection: During inspection I look for the condition that can be observed through the nose, ears, eyes, or other physical body parts. I can inspect the skin color, the bruises, body parts and their size, abnormalities, odors, and sounds. Through inspection I may be able to find important pointers to the health condition.
I also use auscultation, palpation, and percussion physical assessment techniques (Rubenfeld & Scheffer, 2015).
How do you use clinical judgment to prioritize your care?
Clinical judgment entails having some clear opinion or idea after a period of reflection (Phaneuf, 2008). The word ‘clinical’ is used in reference to the patient. As a nurse the process of making clinical judgment is always difficult. It requires professional and intellectual maturity. I must demonstrate the ability to pay particular attention, ability to reason, and to make a summary of the situation so as to come to a logical conclusion on the right priorities. I am required to have some prior training so as to comprehensively understand the various situations and organize them in order of priority in order to facilitate quick recovery for the patient. My clinical judgment process entails observation, identification of relevant information, deduction of the relationship existing between or among various elements and to employ reason, experience and critical thinking before making a priority decision. Clinical judgment requires intellectual processing of observed information through reason and judgment. I will connect pieces of information gathered and review them in order to determine the existing relationship with the already established facts. Further, I will examine and interpret observed data rationally and critically. After this I will interpret the symptoms and signs from a given patient condition and set my priorities.
How do you evaluate your diagnostic reasoning skill after you have identified a patient problem? Explain how you use problem identification as a fluid, rather than static, process.
I am able to evaluate my diagnostic reasoning skills after identification of patient problem by testing whether the diagnosis results are in conformity with the expected signs and symptoms for a particular condition. If the identified patient problem fits perfectly with the prescribed diagnosis for a particular condition then my diagnostic reasoning skills with regard to that condition is proven as effective. I understand that a patient can display a certain behavior that points to a certain problem even though the actual condition is different. For this reason the identified problem is always relative and not static pending the identification of other supporting physical assessment results. I cannot make a decisive conclusion based on an identified problem without collaboration of the findings with other physical assessment results.
References
Phaneuf, M. (2008). Clinical Judgment – An Essential Tool in the Nursing Profession. Diagnostic Infirmier, 16–17. https://doi.org/10.1080/08952841003719224
Rubenfeld, M. G., & Scheffer, B. K. (2015). Critical thinking tactics for nurses: Achieving the IOM competencies. Burlington, MA: Jones & Bartlett Learning
Sutter, J., (2015). Critical Thinking in Nursing Practice Nursing Assessment, SlidePlayer. Retrieved 15 February, 2019 from https://slideplayer.com/slide/3968205/