For the purpose of this essay, I will discuss the case of a five years old patient presenting to my place of work with the symptom of shortness of breath (SOB). To maintain confidentiality the pseudonym “Ryan” will be used to refer to the child and Ryan’s mother will be frequently referred to as “mum”. As this assignment is a critical evaluation of my own practice, elements of it will be written in the first person. Webb (1992) considers writing in the first person acceptable when personal experiences and opinions have played a significant role in shaping the ideas presented.
My current role is that of unscheduled care practitioner (paediatric specialist) within a health centre, which aims to compliment the services of local GP surgeries. I am employed to carry out same day consultation, assessing and managing patients presenting with a vast variety of illnesses and injuries.
The first part of this work will be pertinent with the history taking process within a consultation; the second part will focus on assessment and physical examination. This essay aims to demonstrate comprehensive history taking and a structured approach to the consultation. A thorough assessment and examination of the respiratory system will follow, together with a rationale for examination skills used and a critical analysis of the clinical findings.
On searching the literature, many models of consultation were found. However, one that follows a logical approach, which is applicable to most clinical settings is the Calgary-Cambridge guide developed by Silverman, Kurtz and Draper (2004). As observed by Munson (2007) this model provides an easy-to-use structure that complements the traditional nursing holistic assessment. I choose this guide as it encourages a patient-centred, active partnership between the nurse practitioners and the patient, based on therapeutic communication, whilst it advocates the value of reflective practice to aid personal and professional development (Gibbs, 1988, Benner, 1984). The model is concise, clear and evidence based, fostering the ability to gather patient information through a structured history and physical examination.
It consists of five main sections: initiating the session, gathering information, explanation and planning, and closing the session. Physical examination of the patient is situated between the second and third section.
INITIATING THE SESSION
This stage involves preparing for the encounter, establishing a rapport with the patient and identifying the reason/s for the patient attendance. Chafer (2003) observed that a lack of attention to the pre-consultation stage can have adverse effects on the clinical reasoning and the ability to perform effectively during the consultation. I began by reading the triage notes to ascertain the patient presenting complaint, his age and any previous medical history noted. The triage note read: ‘5 years old with shortness of breath’. I previewed the computer records to check for previous attendances. Chafer (2003) agrees that the patient’s notes and records should be checked to raise awareness of previous problems or any regular treatment/medication the patient is taking. In my place of work, we do not have access to patient’s medical records, other than the details of any previous attendances in the out- of-hours providers. Computer records showed that my patient had been seen twice before in primary care with episodes of shortness of breath/ exacerbations of asthma. The medication records also showed that Ryan used a short acting beta 2 agonist.
With this information in mind and the presentation of shortness of breath, I began formulating a hypothesis that the reason for my patient’s attendance could be a further episode of exacerbation of asthma. However, I strived to keep an open mind and refrain from making a premature diagnosis. As observed by Walsh, Crumbie and Reveley (2004) the nurse practitioner should start the consultation with a fresh...
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