HEALTH ASSESMENT

REFLECTIVE JOURNAL

Name: Cacal, Justine Rain B. Final Grade: ____________

Year Level: 1 – N22B Date: January 28, 2024

CASE #1

Today, I talked with Mr. Michaels, a 51-year-old who came to the hospital two days ago because his chest was hurting. I
checked some tests the doctor ordered, like heart tests, X-rays, and blood tests, to understand how he's doing.
Mr. Michaels told me he feels better today and isn't in as much pain. But his wife is worried because she thinks he seems
sad. This makes me think we need to consider both his physical and emotional health for his care. When his wife came to
see him, she was cheerful, but she confided in me that he seems depressed or something.

Looking at the tests and how Mr. Michaels acted during our talk, I noticed some important things. While his temperature,
heart rate, and breathing were okay, his blood pressure was a bit high, which could be a sign of heart issues. Also, he
talked slowly, sighed a lot, and seemed tired. These things, combined with his vital signs, give us a better picture of how
he's really doing.

As a healthcare student, I need to think about how Mr. Michaels' emotions might be affecting his recovery. It's common for
people with heart problems to feel down, and that can slow down getting better. So, going forward, I want to talk more with
Mr. Michaels about his feelings and maybe get someone who can help with emotions involved. Keeping an eye on both
how he feels inside and how his body is doing will be important for making sure he gets better.

Talking with Mr. Michaels today showed me how important it is to think about both the body and emotions when taking
care of patients. This thinking will guide how I help him in the future, making sure he gets the right care for both his heart
and his feelings.

CASE #2

Mrs. Reyes, a 33-year-old mom of two, is in the hospital because she's been told she has diabetes. Today, when I went
into her room, she seemed surprised about having diabetes. She said, "The doctor says I have diabetes. I can't see how I
could have diabetes. No one in my family has diabetes. I feel fine, I don't see how I can make myself change the way I
eat. Dieting drives me crazy, that's why I weighed 190 pounds when you weighed me."

I asked her a bit more, and she told me she's been extra tired lately and has to pee more than usual. Checking her chart, I
saw her fasting blood sugar was higher than normal at 144. Her vital signs are T (temperature): 98.10 F; P (pulse): 88 and
regular; R (respiratory rate): 24; BP (blood pressure): 144/88.

Mrs. Reyes is having a hard time accepting that she has diabetes, maybe because it's not in her family, and she finds it
tough to change how she eats. Her feelings about dieting and her frustration with her weight are important to consider.
These emotional parts might affect how she handles her diabetes.

The tiredness and frequent peeing she mentioned are common signs of diabetes. Her higher blood sugar and slightly high
blood pressure are things we need to pay attention to.

As a student in healthcare, this case teaches me that dealing with diabetes isn't just about the body, it's about how a
person feels too. Mrs. Reyes' emotions and thoughts about her diet and weight are crucial in managing her diabetes. I
need to talk more with her, understand her feelings, and create a plan that helps with both her physical and emotional
needs. This way, we can work together to manage her diabetes better.
 Criteria 4 3 2 1

Critical Synthesize available Prioritizes available Summarizes Repeats basic

thinking skills information and information for available information with
Situational possible patient documentation and information for prompting for
analysis outcomes for discussion documentation and docummentation
documentation and discussion
discussion with
colleagues, and
relates ongoing
findings to potential
complication

Clinical Makes clinical Makes clinical Makes clinical Recognizes

judgement decisions correctly decisions correctly, decisions correctly variations in
with sound clinical e.g, priorities in with some prompts, patient conditions,
reasoning and patient care e.g selection of but needs help in
modifies nursing nursing prioritizing
interventions based interventions
on patients
condition

Response to Consistently Participates Usually reacts and Sometimes reacts

clinical participates spontaneously most participates and participates
situation spontaneously and of the time and appropriately in appropriately in
appropriately in appropriately in patient care within patient care within
patient care within patient care within the expected time the expected time
the expected time expected time

COMPUTATION OF GRADE

Formula for Grading

Raw Score/Total Score x 60+40 = Grade

Clinical Instructor: _______________ Date: _______________