NR 509 Week 8 Physical Assessment Course Reflection Example

Reflection on Advanced Physical Assessment: The Word "Unremarkable" in My First Draft, the Liver Signs That Sent Me to a Man's Neck Veins, and the Jugular Pressure I Still Cannot Estimate With Confidence

Student Name

College of Nursing, Chamberlain University

NR 509: Advanced Physical Assessment

Instructor Name

Month Day, Year

Reflection on Advanced Physical Assessment: The Word "Unremarkable" in My First Draft, the Liver Signs That Sent Me to a Man's Neck Veins, and the Jugular Pressure I Still Cannot Estimate With Confidence

The Specific Starting Weakness

At the start of this course, my weakness was not that I missed findings. It was that I wrote down conclusions instead of observations. Nine years as an emergency nurse trained me to chart quickly and by exception, and it showed on the page. The first draft of my Week 2 documentation, a routine pre-employment examination of a young man with no symptoms, contained the lines "HEENT: unremarkable," "Lungs: clear," "Abdomen: benign" and "Neuro: grossly intact." Each was true. None of them told a reader what I had done.

What It Looked Like on the Page

My instructor's comment on that draft was a single question beside "Abdomen: benign": "Which of the four steps did you do, and in what position?" I realized I could not answer from my own note. I had inspected, listened, percussed and palpated, but the note would have read the same if I had only pressed on the belly once. The same was true of "HEENT: unremarkable," which could have meant a full otoscopic and fundoscopic examination or a glance at the face.

The final version of that note replaced each blanket statement with what was done and found: the Snellen line read with each eye, the pupils' response to direct and consensual light, the liver span by percussion, the absence of a splenic tip on deep inspiration, and reflexes graded at five sites on each side. It also added a section I had never written before: what I did not examine, and why. That section felt, at first, like admitting failure. I now think it is the most honest part of a note (Bickley et al., 2021).

What Changed It

Two things changed my documentation, and only one of them was feedback. The other was a patient. In Week 5, I examined a 63-year-old man with a swollen abdomen and found ascites and a large liver. My emergency habits would have written "ascites, probable cirrhosis" and moved on. Because the course had trained me to look for and record specific signs, I had deliberately checked for spider angiomata, palmar erythema, jaundice, gynecomastia and asterixis, and written down that each was absent. Seeing that list of negatives on my own page was what made me stop. A man with ascites and none of the signs of chronic liver disease needed his neck veins examined, and when I did, his jugular pressure rose with inspiration.

That was the moment I understood what the course was asking for. Recording negatives is not a documentation rule for its own sake. Written down with a purpose, they change what you do next. The blanket "benign" I would once have written would have hidden the very absence that led to the right diagnosis (McGee, 2022).

A Second Change: Keeping the Last Systems as Careful as the First

The comprehensive examination in Week 7 exposed a subtler problem. In my practice runs, my notes started strong and faded: detailed skin and head sections, then shorter entries as I tired, ending with "MSK: FROM" and "Neuro: intact." I changed my method rather than my stamina. I began writing each system's entry immediately after examining it, using the same four elements every time: position, side, what was done, what was found. In the final Week 7 note, the neurologic entry recorded slow relaxation of the ankle reflexes on both sides, a finding that supported the thyroid diagnosis. If I had written "Neuro: intact," it would have been lost.

A Third Change: The Assessment That Argues

The SOAP note in Week 6 showed me a habit I had not noticed. My first draft of the assessment for a woman with a painful red eye listed four diagnoses in order: keratitis, conjunctivitis, acute glaucoma, uveitis. It looked complete. But nothing in it said why conjunctivitis was second rather than first, or what made glaucoma unlikely. The revision attached a finding to each alternative: the white spot in her cornea and her reduced vision against simple conjunctivitis, the small reactive pupil and soft eye against angle closure, the epithelial defect against uveitis.

Writing the assessment that way changed my examination the next time. Once I knew I would have to name the finding that excluded each possibility, I started checking for those findings deliberately during the examination, rather than hoping they would appear. The documentation standard reached back into the bedside skill, which is the change I least expected from a course about writing things down.

What Is Still Unresolved

Two skills remain weak, and I would be claiming too much if I said otherwise. The first is estimating jugular venous pressure. In the Week 5 patient, the pulsation was obvious because the pressure was very high. In my classmates and in practice patients with normal pressures, I often could not separate the internal jugular pulsation from the carotid, and my estimates varied by several centimeters between attempts. My documentation now says so when I am unsure, which is honest but not yet competent.

The second is the pelvic examination. I performed one comprehensive pelvic examination in the course, with a chaperone and a supervising clinician, and I noted a mildly enlarged, irregular uterus. I am not confident I would have found it without being told to expect fibroids from the history. One supervised examination is not enough to trust my hands.

Forward Practice, Made Concrete

For the jugular pressure, I have arranged to examine the neck veins of every adult patient I see during my next clinical rotation in a cardiology clinic, write down my estimate before looking at the echocardiogram or the clinician's note, and compare them. I will keep a simple log of the difference. If my estimates are not within a few centimeters of the reference by the end of the rotation, I will ask the preceptor to watch me do it.

For the pelvic examination, I have asked my women's health preceptor for supervised practice on at least ten patients next term, with the preceptor examining after me and telling me what I missed. For documentation, I will keep the discipline that changed most this term: no system recorded as normal without the position, side, maneuver and result that make "normal" mean something, and a written list of what I did not examine, in every note.

References

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bates' guide to physical examination and history taking (13th ed.). Wolters Kluwer.

McGee, S. (2022). Evidence-based physical diagnosis (5th ed.). Elsevier.