Paper Example on Nursing Practice

Introduction

The assessment process in clinical practice is one of the essential steps that facilitate treatment procedures. Through the physical assessment and examination, a nurse can understand the diagnostic tests appropriate to the patient's condition (Bickley & Szilagyi, 2012). In my Shadow Health assessment, the fact that the patient was cooperative contributed to the success of the assessment process. In the first instance, the patient provides all the relevant information essential to the treatment process by explaining the past health history, and the event that led to the back pains. In the second event, the patient describes the instance of the car accident, the fact that she was wearing a seatbelt, and the persistence of the headaches.

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In the first instance, the assessment outcomes suffice to be valid since the objective analysis of the patient's case assert that she was not involved in any other accident apart from the instance of heavy lifting. However, the second assessment regarding the headaches after the car accident is not sufficiently objective. Firstly, the patient talks about the headaches as well as the sore neck. However, the assessment only provides information about post-traumaticneuralgia, disregarding the sore neck. The evaluation should be improved by ensuring it covers all the health issue details(Khanal, Bhusal, Sigdel, & Bajracharya, 2016). Regardless, the first assessment asserts the patient suffers from muscle-strain related back pains while the second assessment proves that the accident led to head injuries and sore neck.

The questions regarding the origin or the history of the health problem yielded the most information. Also, the question about the physical symptoms is crucial to understand the severity of the health issue. The two questions were practices they provided information about the past health issues that could have contributed to either the headaches or back pains. However, the assessment requires further diagnostic tests. In both cases, it is crucial to scan the head for any internal injuries as well as the patient's back to evaluate the presence of a bone fracture or muscle strain that may be causing the back pains (Kramer, 2017). The diagnostic tests are essential in providing a clear and better understanding of the health issue.

Subsequently, there are differential diagnoses that assess the possible origins of particular health issues such as the back pains and the headaches (Goodman, Heick, & Lazaro, 2017). In this case, the differential diagnoses evaluate the impact of the prolonged sitting positions. Also, in the second incident involving the car accident, the physician should assess for any pressure or muscle strain around the neck that may be inhibiting blood flow which can also lead to the headaches. On the other hand, there are various teaching given to the patient such as stretching techniques, the education regarding changing sitting positions, and the adjunct therapy of tropical heat as well as the use of ice to reduce the pain. Additionally, the patient should also engage in physical exercises to keep the body fit.

Conclusion

Currently, the patient should not be given any medication prescription because she is already using the over-the-counter drugs. Subsequently, the fact that the assessment processes do not involve actual diagnoses inhibits the prescription of any medication. This assessment provides sound critical thinking and clinical decision making by incorporating the physical examination before the diagnoses. The physical assessment is vital in guiding the diagnosis process and the treatment interventions(Goodman et al., 2017). The fact that the assessment involves the evaluation of the physical appearance of the patient portrays sound clinical decision making. However, the assessment should also include diagnoses since the patients sought to seek professional advice to understand the actual problem rather than getting opinions.

References

Bickley, L., & Szilagyi, P. G. (2012). Bates' guide to physical examination and history-taking. Lippincott Williams & Wilkins.

Goodman, C. C., Heick, J., & Lazaro, R. T. (2017). Differential Diagnosis for Physical Therapists-E-Book. Elsevier Health Sciences.

Khanal, S., Bhusal, M., Sigdel, M. R., & Bajracharya, S. R. (2016). Acquisition of history taking, physical examination and communication skills through early clinical exposure among pre-clinical students. Journal of Institute of Medicine, 39(1).

Kramer, D. (2017). Health History and Physical Exam. In Primary Well-Being: Case Studies for the Growing Child (pp. 25-44). Springer, Cham.