NR 305 Week 1 Discussion, Exploring the Nurses Role in Health Assessment

NR-305: Health Assessment for the Practicing RN Week 1 Discussion Question (Exploring the Nurse’s Role in Health Assessment): “The nursing process is utilized in a variety of nursing roles and health care settings. Whether you are working in direct patient care, telehealth, or in a leadership role - the basic model is the same! Take this opportunity to share how the nursing process is utilized in your own practice settings! Please answer the following question in your initial post: Describe how you apply the first step (assessment) of the nursing process in your current practice setting. If you are not currently practicing as an RN, you may use an example from a prior clinical or work experience. Include the following information: • Briefly describe your practice setting and the typical patient population. • Provide examples of key subjective and objective data points you collect. • Describe how you document your findings. Is there technology involved? • Describe your process of data analysis. What is the end result of this process? (i.e., Do you formulate nursing diagnoses and care plans, collaborate with others and/or make referrals?) “Assessment is a fundamental nursing skill that underpins decisions about interventions and priorities in care delivery.” One of the components of the nursing process is assessment. “Assessment is a fundamental nursing skill that underpins decisions about interventions and priorities in care delivery” (Broom, 2007). I had the opportunity to be placed on the Telemetry unit during my clinical rotations. The typical patient population mainly consisted of male geriatric patients with cardiac problems. Therefore, my assessment focuses on these cardiac problems. “Before actually meeting the client and beginning the nursing health assessment, there are several things the nurse should do to prepare. It is helpful to review the client’s medical record.” (Weber & Kelley, 2018). Once I have read the patient’s medical records, I assess what needs to be done, gather up any equipment that is needed, and “take a minute to reflect on [my] own feelings regarding [my] initial encounter with the client” (Weber & Kelley, 2018). This is important to do “in order to avoid biases, judgment, and the possibility of projecting those judgments” (Weber & Kelley, 2018). I then head to the patient’s room, introduce myself, and identify the patient. I ask the patient what brought him/her to the hospital and how or what they are feeling at the moment. Since the patients in the telemetry unit are primarily patients with cardiac problems, I do a focused assessment on the cardiac system and anything related to it. “A focused assessment consists of a thorough assessment of a particular client problem and does not address areas not related to the problem” (Weber & Kelley, 2018). For instance, during one of my clinical rotations, an elderly patient stated that her family member who found her lying unconscious brought her in. This prompted immediate evaluation of any injuries, pain, and torn or bruised skin. The patient complained of her head and neck hurting, which prompted immediate attention, action, and communication of this. It was also necessary to investigate reasons why the patient had a syncope and fall episode. These reasons would prompt the need to question what medications the patient is taking, if she necessitates the use of assistive devices, if she was walking at home in the dark, or if she experienced an abnormal heart rhythm. She was attached to a cardiac monitor, which showed that she had experienced Atrial Fibrillation. Part of assessment involves observing and interviewing the patient in order to gather subjective and objective data. The subjective data I gather for cardiac patients includes their name, date of birth, age, occupation, lifestyle, family history, and personal history. With a patient who has hypertension, for example, it would be important to know if he/she has a sedentary lifestyle, does not exercise, and has a diet that is high in sodium. The objective data I gather for cardiac patients includes the assessment of chest pain, heart palpitations, blood pressure, pulse, perfusion, capillary refill, skin color, temperature, respiratory rate, oxygen status, and behavior. With a patient who is experiencing chest pain, for example, it would be important to assess where the pain is located at, what the pain feels like, how often it happens, what causes it to happen or feel better, and if it radiates elsewhere. If there is anything that is abnormal or requires immediate intervention, I immediately communicate these with the nurse and doctor as well as let my nursing professor know. With supervision, I document all of my findings in the electronic medical record (EMR), which is the technology that is used. “The goal [of EMR] is to have a single medical record for each patient-one that is accessible anywhere, any time, across the continuum of care” (Robles, 2009). This means that no matter what happens (such as a natural disaster) or where the patient goes (such as changing from one unit or facility to another), “health care workers [would be able] to treat [patients] quickly, adequately, and safely” (Robles, 2009). In terms of data analysis, I use my findings to formulate nursing diagnoses, develop a care plan, and implement interventions in order to help address the patient’s problems. Sometimes referrals need to be made. If the patient divulges information that necessitates this, I communicate this to the nurse, doctor, and nursing professor and have this be a part of the care plan as well. It is important that all parts of the nursing process as well as all patient needs are met. References: Broom, M. Exploring the assessment process. Paediatr Nurs. 2007 05;19(4):22-5. Robles, Jane, B.S.N., R.N. The effect of the electronic medical record on nurses' work. Creat Nurs. 2009;15(1):31-5. Weber, J., Kelley, J. (2018). Health assessment in nursing (p. 71). Philadelphia: Wolters Kluwer. for my patient. The nursing diagnosis would be based on the problem most pertinent to the patient’s health. Based on the nursing diagnosis, a care plan and interventions are implemented in order to address the patient’s problem. Documentation “helps identify health problems, formulate nursing diagnoses, and plan immediate and ongoing interventions” (Weber & Kelley, 2018). Subjective data includes, “biographical information (name, age, religion, occupation), history of present health concern, physical symptoms related to each body part or system (e.g., eyes and ears, abdomen), personal health history, family history, health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships, cultural beliefs or practices, family structure and function, community environment)” (Weber & Kelley, 2018). Objective data includes, “physical characteristics (e.g., skin color, posture), body functions (e.g., heart rate, respiratory rate), appearance (e.g., dress and hygiene), behavior (e.g., mood, affect), measurements (e.g., blood pressure, temperature, height, weight), results of laboratory testing (e.g., platelet count, x-ray findings)” (Weber & Kelley, 2018). Objective data in cardiac patients can include skin color, capillary refill, heart rate, I can also ask the patient if he/she is or has experienced chest pain or heart palpitations. chest pain, heart palpitations, BP, pulse, perfusion, cap refill, for example, if the patient, any sudden changes, consult the doctor, referrals EKG I document my findings in the electronic medical record (EMR). Documentation “helps identify health problems, formulate nursing diagnoses, and plan immediate and ongoing interventions” (Weber & Kelley, 2018). This way I can Subjective data: “Biographical information (name, age, religion, occupation), History of present health concern: physical symptoms related to each body part or system (e.g., eyes and ears, abdomen), Personal health history, Family history, Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity, relationships, cultural beliefs or practices, family structure and function, community environment).” Objective data: “Physical characteristics (e.g., skin color, posture), Body functions (e.g., heart rate, respiratory rate), Appearance (e.g., dress and hygiene), Behavior (e.g., mood, affect), Measurements (e.g., blood pressure, temperature, height, weight), Results of laboratory testing (e.g., platelet count, x-ray findings)” Checking cardiac monitor Technology involved: EMR (electronic medical record), the ID and medication scanner, cardiac monitor / EKG Lenox Hill Radiology 755 2nd Ave btwn 40 St -41 St 3rd Floor 10am