Apprenticeship Learning Log

 

Date of Learning: 08/10/24

Time: 9:30 – 16:30

Title of learning activity: Consolidation of history taking and assessment skills.

Wound care / Suture / Clip / Drain Removal.

 

Diary of Learning activity

(itemise learning activity and reflect on the main points of learning from each. You should identify for each entry the relevant KSB)

Reflection on Learning Activity (include model of reflection e.g. Driscoll or Gibbs):

 

During today’s session, we explored the consolidation of history taking and assessment skills. The primary purpose of this process is to synthesise theoretical knowledge, effective communication, and clinical reasoning to deliver care that is safe, evidence-based, and person-centred.

 

Key Components of History Taking:

Introduction and Consent: Introduce yourself, confirm patient identity, explain purpose, and gain consent.

1. Presenting Complaint (PC): Document the main reason for the consultation in the patient’s own words (what brought patient to the clinic or consultation)
2. History of Presenting Complaint (HPC): Use the SOCRATES or OLDCART framework for symptoms (Site, Onset, Character, Radiation, etc.)

1. Family History (FH): Genetic or hereditary conditions.
2. Social History (SH): Smoking, alcohol, occupation, living situation, support networks.
3. Medication and Allergies
4. Past Medical / Surgical / Psychiatric History
5. System Review (Screen other systems to identify associated or unrelated symptoms)

Don’t ask questions, if you won’t do anything about it.

Use Communication Skills

• Active listening and empathy.
• Use of open and closed questions appropriately.
• Adapt approach for age, cognitive ability, and cultural background.
• Use of SBAR for handover and structured communication.

The main purpose of consolidating history taking and assessment skills is to enable practitioners to differentiate between acute conditions (those that develop suddenly, are short in duration, and can often be resolved with appropriate treatment and chronic conditions (which are long-term, require ongoing management and monitoring, and are typically incurable)

 

During the afternoon session we discussed: Wound Care, Suture, Clip, and Drain Removal.

Wound care and the removal of sutures, clips, and drains are essential clinical skills that require a good understanding of anatomy, infection control, and wound healing processes. The primary aim is to promote optimal healing, prevent infection, and ensure patient comfort and safety. This procedure involves assessing the wound site for signs of healing or complications, such as redness, swelling, discharge, before proceeding with removal.

Nursing Associate must apply principles of aseptic technique, adhere to local and national policies, and use clinical judgement to determine the most appropriate course of action. Effective communication and patient education are also fundamental to ensure informed consent and to support self-care following the procedure. Consolidating these skills enhances clinical competence, decision-making, and the delivery of safe, effective, and person-centred care within the NHS setting.

 

 

KSBs addressed:

 

K9: Understand the aims and principles of health promotion, protection and improvement and the prevention of ill health when engaging with people

K21: Understand co-morbidities and the demands of meeting people’s holistic needs when prioritising care

S1: Act in accordance with the Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates (NMC, 2018), and fulfil all registration requirements

S2: Keep complete, clear, accurate and timely records

S3: Recognise and report any factors that may adversely impact safe and effective care provision

S10: Provide, promote, and where appropriate advocate for, non-discriminatory, person-centred and sensitive care at all times, reflecting on people’s values and beliefs, diverse backgrounds, cultural characteristics, language requirements, needs and preferences, taking account of any need for adjustments

S19: Recognise when capacity has changed recognise and how a person’s capacity affects their ability to make decisions about their own care and to give or withhold consent

S20: Recognise people at risk of abuse, self-harm and/or suicidal ideation and the situations that may put them and others at risk