reflect on pattern recognition in diagnoses. Explain how pattern recognition of patient symptoms might help lead to a diagnosis hypertension

Nurs6531 clinicalPracticum Journal Entry

 

 

 

Varnie Stevenson

Varnie.stevenson@waldenu.edu

Indiana Department of Health

Dr. Moye

317-221-3400

MMoye@MarionHealth.org

 

 

Day one of week #1:My first day of clinical I have the opportunity to do a head to toe assessment on a 28 years- old male that came to the clinic today complaining of Coughing for about two days, and he states it is not getting better. He also says he experience chills and sweat a lot.He did not have any past medical history.

 During my assessment, I noticed that his abdomen was soft and not distended he had hypoactive bowel sounds. His last bowel movement was on Feb 28th; I saw 3/1/ The only abnormality with his assessment was a diminished lung sound in his lower base.  His pain was mostly felt above and below his eyes as well as behind his nose.

The entire day was full of teaching and fun. The patient was very receptive to learning. Base on his assessment my preceptor determines that the patient had a sinus infection. We discussed his dietary options, and hydration because due to him sweating at night, he can quickly become dehydrated. He was advice to take over the counter Zyrtec 10 mg Po. Once for two. He was also advised if he chooses to used nasal decongestant continuously for periods of 10 to 14 days it will cause rebounds.

Day Two of week #2:I was assigned a 26-year-old female who came in complaining of itching of her vagina and discharge. She past medical history of the same issue.Since she was a female, Dr. Moye had advised me to always have a female nurse with me when I’m doing my head to assessment. After the assessment, she consented to a wet mouth swap, a vagina swap for yeast infection done. Pelvic exam was also done. I had two patients on this day, but we saw eight patients. With these two patients, I had to do some prioritizing before I can do anything else. My patient lab result came back positive for yeast.  My preceptor was made aware. She claims to have multiple sexual partners. She was educated on safe sex. The clinic regularly gives patient a brown paper bag that contains pamphlet for safe sex and condom. Over the counter, Monistat was recommended before her discharge. 

 

Day Three: of week#3 I was a little nervous on this morning when I enter the room, where 21 years female was sitting waiting to see a doctor. She kept saying “I have had a pain in the lower ride side of my stomach for two days. I have been vomiting, and I continue to be nausea during these few days.”

 

The patient was a 21years- old soft spoken female presents to the clinic by her mother and father complaining of sharp stabbing right lower quadrant pain for the past two days.  She states the Pain started in her periumbilical area and moved to the right lower quadrant. She states all they have done has not made the pain better or worse. The pain is persistent.  She has a fever last night high of 100.4. Patient has been nausea since 5 am that morning, with two episodes of vomiting early this morning. She has had three loose diarrheas since late night. She has not eaten in two days. The last meal she ate was last night, chicken noodle soup. After a head to toe assessment, Dr. Moye decided to send her to our affiliate hospital for further assessment.

My clinical experience has been great so far.

 

Timeline

Practicum Timeline
Practicum to be taken in by Varnie Stevenson	Submit NP Clinical Skills and Procedures Checklist Dr. Moye	Continue to see patients with Dr. Moye  and continue to train on the computer system and start to write soap note.	Finish all requirements by April 7th and start seeing patients and doing a head to assessment independently	Completion of e-portfolio documents
February 28th	March 1-28 continue clinical	March 24th continue to see patients with my precetor.	April 7th	April 7th have a conference call with Dr. COLE
March 27-28 computer training and patient assignment	April 11-26	April	May continue to see patient and writing note	May 1-10 continue procedures checklist.

 

 

 

Attachments:

• 1505628359-Practicum Journal Entry.docx