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

NR 305 Week 1 Discussion – Exploring the Nurse’s Role in Health Assessment

The first step of the nursing process is assessment. This involves critical thinking skills, which include data collection and subjective and objective data performed by clinicians. Assessment is the first step of the nursing process, and inaccuracy will affect the judgment of the other phases (Weber & Kelley, 2018). Since assessment is the first phase of the nursing process, whenever a patient is admitted, the first step of the admission process is to perform a head-to-toe assessment. I currently work as a home visiting nurse working one on one with patients in the comfort of their homes. My caseload ranges seeing 15 – 25 patients, and for the most part of the job, I do the admission process.

During the assessment process, I do collect objective and subjective data, which will guide me in formulating the rest of the nursing process. The objective data is an observation of what I am able to see or measure, and this includes heart rate, measuring blood pressure, respiratory rate and temperature using a thermometer, physical examination, and a list of the patient’s medications. I then move on to the subjective data. Subjective data is gathered from the patient telling you something that you cannot use your five senses to measure (DuPont, 2017). I do this by asking the patient about any feelings/concerns, pain rating, and symptoms that might be ongoing, such as a complaint of running out of breath or having diarrhoea for the past few days.

After gathering all the data using my notes, I then transfer them to the electronic application. This is a detailed application that has a list of all the information that needs to be documented on a patient and includes the patient’s demographic, history and diagnosis, pain, integumentary, cardiac, respiratory, elimination, endocrine, functional and nutritional status. After gathering all these data, we then collaborate with the doctor and other members of the healthcare team. Based on the data collected by the md, diagnoses are formulated, care plans are developed from the nursing assessment, and referrals are made if it is applicable to the patient, such as physical/speech/occupational therapy, home health aid, podiatrist, dietician, etc.

NR 305 Week 1 Discussion – Exploring the Nurse’s Role in Health Assessment

The challenges that I face as a home health nurse is when a patient has a piece of new equipment that I have never worked with before, such as high technology glucometer or IV poles, and I need to teach the patient how to use it, I have to go through the instruction pages and try to figure it out. Unlike nurses who work in a hospital setting, they get training whenever there is a piece of new equipment, or even just watching other nurses use it will make them master the equipment.

References:

DuPont, S. (2017, June 11). Objective Vs. Subjective Data: How to tell the difference in Nursing. Retrieved from https://www.nrsng.com/objective-vs-subjective-data/

Weber, J.R. & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Philadelphia, PA: Wolters Kluwer

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NR 305 Week 1 Discussion – Exploring the Nurse’s Role in Health Assessment

.Describe how you apply the first step (assessment) of the nursing process in your current practice setting. If you are not currently practising 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