Nursing Student Physical Assessment

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Physical Assessment E.D. is a 19-year old G3 P1 T2 A0 L3 African-American female who had a normal spontaneous vaginal delivery on 09/15/2015 at 1350. The student nurse assessed E.D. on 09/16/15 at 0800. E.D. is awake, alert and oriented to person, time, event, and place. She is sitting upright in bed in semi-fowler’s position in no apparent distress. She has an ID bracelet, verifying her correct name and date of birth. She displays appropriate behavior, calm and cooperative. She is a reported height of 60 inches. Her vital signs are as follows: pulse is 88 beats per minute, strong and regular 2+ on upper and lower extremities bilaterally; respiratory rate 12 breaths per minute, unlabored; blood pressure 116/72 mmHg taken on the right arm;…show more content…
The adolescent mothers can become isolated from their peer groups because of the change in their lifestyle and responsibilities. She may be isolated from school and the normal contacts. Her social sphere may be restricted to other pregnant teenagers, the child’s father, and her relatives (NurseReview, 2008). Self-Evaluation Strengths 1. Education: Demonstrates curiosity and inquiry. During my clinical rotation, I completed my reading and independent learning, but remained approachable, proactive, observant, and interested in the hands on learning experience and different techniques performed on the unit. 2. Nursing Practice: Demonstrates beginning leadership skills such as preparation, initiation, cooperation, engagement, flexibility and accepting constructive feedback. While on the NIMC unit, I was shown the proper practices for feedings, diaper change and assessment at first, but later on I began to practice theses skills independently without the reminder of my preceptor. Opportunities for Improvement 1. Scholarship: Compares observed clinical practice with published practice standards. I need to practice being more proactive in observing and researching for evidence-based practices that I have participated in or observed during patient

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