Reflective Nursing

Case Study One
In this case study I will use Gibbs (1988) model of reflection to write a personal account of an abdominal examination carried out in general practice under the supervision of my mentor, utilising the skills taught during the module thus far.

What happened
During morning routine sick parade I was presented with a 21 year old male soldier experiencing severe acute, non specific, abdominal pain. Under the supervision of the medical officer (MO) I proceeded to carry out a full assessment and abdominal examination, using Byrne and Long’s (1976) model to structure the consultation.

I requested the patients’ consent before conducting the examination, as is essential before commencement of any medical procedure, be it a physical examination or a critical surgical procedure (Seidal et al, 2006).

The patient was quite agitated on arrival and appeared to be in a great deal of pain, and so before continuing with the physical examination I reassured him and made him comfortable in the treatment room.

On examination his abdomen was soft, palpable with no tenderness, on auscultation bowel sounds where normal, vital signs normal, with cramping centralised pain.

Feelings
I was feeling confident in my ability to deal with the patient and perform the examination effectively as I had practiced this several times previously using the university resources and mock OSCE with my facilitator. As I am often solely responsible for the care and management of patients during out of hours (OOH) I felt comfortable assessing and triaging the patient. However, under normal circumstances I would assess the patient and refer them to the MO if I was concerned about their condition, in order for a decision to be made.

I was also being closely monitored throughout which did increase the pressure to deliver the correct diagnosis and make appropriate decisions. However, by utilising the consultation model I feel I managed to keep a focused approach and ensure the correct questions where asked.

Evaluation
I feel I gained a good history from the patient by using the SOLER principles (Egan, 1990) taught in the history taking presentation. Thus allowing me to form a differential diagnosis and rule out certain causes, such as; constipation, and indigestion. Subsequently, the physical examination enabled me to confirm a diagnosis of acute abdomen. As the patient was not experiencing any worrying (red flag) symptoms associated with abdominal emergencies, such as; appendicitis or pancreatitis. However, I did forget certain aspects of the physical examination and had to be prompted by the MO. Although with more practice such incidence would be reduced.

Analysis
I was happy that I managed to rule out any distinct causes of the abdominal pain by performing the examination to collect data, analyse it, and use the results to make an appropriate decision (Schon, 1984). However, had I performed the examination without assistance I may not have gained all the information required to confirm diagnosis, as I did forget some aspects.

Conclusion
The MO seemed happy with my diagnosis and care plan, though he did highlight the importance of practicing the physical examination skills in order to become a more competent practitioner. Overall I feel gaining knowledge and skills in translating a patients’ history and physical examination results, has enabled me to become more confident in making a diagnosis and has improved my decision making skills.

Action Plan
In order to become a more capable and effective practitioner I must continue to perform physical examinations under the guidance of a more senior practitioner, and utilise their expertise during the decision making process.

Additionally, I will continue to develop my consultation and history taking skills by using Byrne and Long’s (1976) consultation model to assist my practice and aid future development.

References
BYRNE, P, S., LONG, B, E, L. (1976) Doctors talking to patients. London: HMSO EGAN, G. (1998) The Skilled Helper: A problem-management approach to helping. 6th edn. Pacific Grove, London: Brooks/Cole. GIBBS, G. (1988) Learning by doing: a guide to teaching and learning methods. Oxford: further education unit, oxford polytechnic SEIDAL, H, M., BALL, J, W., DAINS, J, E., BENEDICT, G, W. (2006) Mosby’s Guide to Physical Examination. 6th edn. Philadelphia: Elsevier. SCHON, D. (1984) The Reflective Practitioner: how professionals think in action. New York: Basic Books.