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L.E.A.R.N Note

L.E.A.R.N Note

Eurielle Valmonte

NUR 420

Loiza Azim

January 26, 2020

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L.E.A.R.N Note

Looking Back
During my second week of clinical, I was already on my own. My client was independent and can do
most ADL’s by herself. I took her vitals and did a head to toe assessment on her, starting with her head. I
even brought my school papers as a guide for the assessment. She was very talkative. As a sign of
respect, I stop what I was doing and listen to her stories and participated in the conversation. When she
was finally done talking, I continued the assessment. I realized that I was taking too long in the client’s
room. I quickly recorded everything down in my notebook, and as soon I was done, I looked for the
primary nurse. I found her and was ready to report the information. However, I realized that I forgot a
major vital, and I did not assess her as well as I thought I did. I forgot to record her respiratory rates, and
I forgot to feel for edema and pulses on her lower extremities.

Elaborate
When the nurse asked for this information, I told her I forgot to take it. I felt incompetent, and
embarrassed that a second-year nurse like me forgot to take vital information like that. This happened in
the nursing station, so I knew that other nurses overheard my mistake. This made me feel horrible.
Fortunately, the primary nurse was nice about it and told me to take the information later. However, a
start like this to my third week in clinical, or my first week in the hospital dropped my confidence as a
student nurse. When I realized how much time I took to do a vital and head to toe assessment, I felt
frustrated. I knew that I should have done the assessments while listening to her stories. However, her
talking while I was auscultating makes it difficult for me to assess her properly, and I feel doing
something else while having a conversation with someone is disrespectful.

Analyse
The key issue here is that I forgot to take important information about the client, such as respiratory
rate and information about her lower extremities. It may seem insignificant, but respiratory rate is a vital
sign that could assess the deterioration of a client. Take this journal article:

Respiratory rate has been labelled the most important vital sign as it is the most sensitive
indicator of acute deterioration. It is the most sensitive vital sign for determining illness acuity as
it provides more discriminating evidence of clinical deterioration than other vital signs.
Respiratory rate is an early indicator of hypoxia, hypercapnia, and metabolic and respiratory
acidosis. If there is a change in the patient's cardiac or neurological status, respiratory rate is
often the first vital sign affected. (Elliott & Baird, 2019)

Therefore, respiratory rate is necessary to take to care for a client, especially a client with atrial
fibrillation. Taking this vital sign will assess for any early signs of cardiac or respiratory changes.

There is another article that stresses the importance of a proper head to toe assessment. The head to
toe assessment is constantly overlooked because it is tedious and takes a lot of time that nurses do not
have. Furthermore, nursing students do not have enough practice to do a proper head to toe
assessment. In this article, it states that:

The sooner the patient is correctly assessed, the more likely a life-altering condition is
recognizable, nursing diagnosis formulated, appropriate intervention or treatment initiated, and
stabilizing care rendered. Physiological abnormalities manifested by changes in vital signs and
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L.E.A.R.N Note

level of consciousness often provide early warning signs that patient condition is deteriorating;
thus, requiring prompt intervention to forego an adverse outcome, decreasing morbidity and
mortality risk. In the fast-paced, resource-challenged healthcare environment today, thorough
assessment can pose a challenge for the healthcare provider but is essential to safe, quality
care. The importance of a head-to-toe assessment, critical thinking skills guided by research, and
therapeutic communication are the mainstays of safe practice. (Tammy & Wendy, 2019)

Thus, taking a proper and quick head to toe assessment could mean the difference between life and
death for a patient.

Taking too long to do the assessments is another key issue that I identified. I almost took one hour and
thirty minutes in the client’s room. If I had four or five patients, this will result in the neglect and
decreased quality care for the other patients. Thus, I researched about time management and
discovered an article for the importance, and strategies on how to manage time:

Determining the learning goals, scheduling realistic time to achieve the goals, prioritizing, using
activity log or to-do list, keeping the learning track, liaising appropriately with the teachers are some of
the tips which student can adapt to manage the time effectively. […] Arriving early to plan the work,
listing down the activities that need to be done, prioritizing these activities, estimating the time needed
for each activity, spending the time consciously, cautiously spending the time for unscheduled activities,
learning to say ‘no’, organizing the home life delegating the tasks are some of the strategies which can
be adapted for effective time management. (Nayak, 2018)

Therefore, I can use these strategies in my clinical to further improve my time management skills.

Revision
There are three key components that I learned from these three journal articles. The first one is the
importance of taking the client’s respiratory rates, especially if they have a cardiac or respiratory illness.
The second is the importance of a quick and proper head to toe assessments. A proper assessment can
quickly detect acute problems and can be treated immediately and efficiently by the nurse. The last key
component is time management strategies such as using an activity log or to-do list, arriving early to
plan out, and in my case, learning to say no to the patient, especially when they talk a lot.

New Perspective
In the future, I will arrive early to review the head to toe assessments and vitals signs. I will approximate
how long it will take, and make sure it is done within that amount of time. I will continue to use my
school worksheets as a reference guide to help me do my head to toe assessments. I will also observe
how the primary nurse manages her time effectively with other clients. I will not forget to take
important information for my client.
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L.E.A.R.N Note

References
Elliott, M., Baird, J. (2019). Pulse oximetry and the enduring neglect of respiratory rate assessment: a
commentary on patient surveillance. British Journal of Nursing. 28(19), 1156-1159.
doi:10.12968/bjon.2019.28.19.1156.

Nayak, G. S. (2018). Time management in nursing –hour of need. International Journal of Caring
Sciences. 11(3), 1997. http://www.internationaljournalofcaringsciences.org/docs/72_naya
k_special_11_3_2.pdf

Tammy, J., Wendy, J. (2019). Nursing admission assessment and examination. National Center for
Biotechnology Information. Retrieved January 27, 2019, from https://www.ncbi.nlm.nih
.gov/books/NBK493211/