COMPREHENSIVE HEALTH ASSESSMENT

Assessment Three: Self-assessment of comprehensive health assessment

Assessment Three: Self-assessment of comprehensive health assessment

Introduction

As my profession is working in a renal haemodialysis department, I will put light on a personal experience with a patient suffering from Acute Renal Failure (ARF). It occurred with one of my clients. I would highlight my learning and development which I gained through this experience. I would reflect upon this incident that how it made me more effective in achieving my preferred practice. I would describe my opinion, thinking and approach about the incident that occurred. It will also show the quality care I provided; the skills that I developed during my training and what I learned from the incident thereafter.

Background of the Case

SM arrived in the ED I work in brought in by the ambulance crew. I got the hand over from ambulance crew, which was vague, but stated that the patient (SA) had been found on the floor, unconscious and smelt strongly of alcohol. On his arrival to the ED, the patient was very abusive and uncooperative. On primary survey, I noticed minor lacerations on the back of his head which was not actively bleeding. SM was unable to give the history of events that led to his being in an ED but according to the London Ambulance Service (LAS) someone had called an ambulance after finding him unconscious. Initially, he was unresponsive and then had been abusive to the LAS crew. On initial assessment in the Accident and Emergency (A&E), the patient was alert but incredibly abusive and uncooperative, refusing all initial treatment and interventions. After settling down, SM allowed me to do his observations, insert a cannula and take some bloods for investigation. I also changed him into a hospital gown. I used the ABCDE tool for the assessment as per Advanced Trauma Life Support (ATLS) guidelines, and I was satisfied that SM showed no life threatening injuries. The ABCDE assessment is as follows: A- airway, B- breathing, C- circulation, D- disability, E- exposure.

Patient's Name: SA

Patient and Setting: SA, a 68 years old woman in the emergency department.

The compliant: for the past several years, the patient wakes up short of breath. Recently the patient cannot even walk to the mailbox without being exhausted. Her legs have started to swell and she has gained 15 pounds in the past coupe, of weeks. Present Illness: SA complains fatigues and dyspnea for several months, she gave up exercising for about 2 months ago because of a recent diagnosis of osteoarthritis and the fact that she gets tired walking. She coughs with sputum and feels fatigues and cannot perform her usual activities for the daily living, she also noted BLE edema for several weeks. However she denies chest pain. Medical History: CAD and HTN diagnosed at the age of 50, TEDM diagnosed at the age of 63 and OA diagnosed at the age of 65.

Surgical History: non contributory

Social and Family History: Mother: HTN; father: died at the age of 65 ...