Feb 23, 2024 N305 Week 1 Discussion Exploring the Nurse’s Role in Health Assessment
N305 Week 1 Discussion Exploring the Nurse’s Role in Health Assessment
N305 Week 1 Discussion Exploring the Nurse’s Role in Health Assessment
I apply the first step of the nursing process in my current practice at the orthopedic surgery center (which are mainly elective surgeries with patient population that varies from children to geriatrics) by review of the patient chart, obtaining data acquired by our PAT department when the patients surgery is scheduled which includes: surgery being completed; patient complete health history through a program called simple admit; review of physicians current H&P; obtaining records of testing prior to coming in. I also collaborate with the admission nurses who verify and review all of the information obtained by the PAT department nurses. We consistently use a nursing framework “to help organize information and promote the collection of holistic data.” (Weber, Kelley, 2014) Prior to bringing the patient back to the OR suite I review the chart, which includes all of the previous stated information obtained by my colleagues; introduce myself to the patient; obtain two patient identifiers; verify procedure, allergies, pertinent health history and NPO status with patient. I also verify that the surgeon has marked the correct surgery site and that anesthesia has spoken to the patient as well. I am then able to bring the patient back to the OR suite to begin their procedure. Nursing assessment should be completed three times for patients having surgery: prior to surgery, shortly after surgery (in recovery as well as prior to discharge from the surgery center) and generally two weeks after surgery in follow-up. This is good practice to provide the best support for positive surgical recovery. (Leslie, 2018) This is how we complete the nursing assessment in the surgery center that I work in and has shown positive outcomes for our patients.
Our current means of documentation is what I consider to be “behind in the times” as we still complete all documentation on paper. The patients do have EHR through the orthopedic practice, however for their surgical procedure we continue to have a paper chart and complete all of our documentation of surgical procedure, recovery and post op education on paper. Anesthesia documentation is also completed entirely on paper. I find this to be a greater chance for error in documentation considering I came from a hospital OR setting originally where they do have complete EHR records for patients.
Processing data analysis in my current clinical setting seems to overlap throughout the process of patients having surgery. We complete nursing diagnoses and complete holistic care through the critical thinking process, however I have yet to find where actually document this within the patient record. I know from the hospital EHR record our nursing diagnoses and care plans were contained within the electronic charting. I find that this is something my current employer needs to work on to incorporate this documentation better. I currently when recovering patients update and add my additional assessment information by summarizing it on the back of the PACU record sheet. We do also collaborate with DME as well as PT to offer complete care for our patients prior to their discharge.
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This week’s graded topics relate to the following Course Outcomes (COs).
CO 1 – Utilize prior knowledge of theories and principles of nursing and related disciplines to explain expected client behaviors, while differentiating between normal findings, variations, and abnormalities. (PO 1)
CO 5 – Explore the professional responsibilities involved in conducting a comprehensive health assessment and provide appropriate documentation. (PO 6)
Discussion
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! Hint: Your assigned readings will be helpful in formulating your answers.
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?)
Discussion Questions (DQ)
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• One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
• I encourage you to incorporate the readings from the week (as applicable) into your responses.
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N305 Week 1 Discussion Exploring the Nurse’s Role in Health Assessment
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currently work in a Telemetry unit with no specific specialty. The patient population is diverse, ages 18 and up. I apply the first step of the nursing process in my current practice. On admission, I use initial comprehensive assessment, collecting subjective and objective data. “Subjective and objective data collection are an integral part of this process (Toney-Butler, 2020).” Subjective data including patient’s name, date of birth, religion, specific values, health history, past medical history and family history. I also collect information regarding their lifestyle and health background, like nutrition, cultural practices, family structure, and current housing. The objective assessment usually ties in to the subjective. In my practice setting, I do a full systemic assessment on admission, starting from the head to the toes. Assessing the patients level of consciousness, heart sounds, breath sounds, abdominal tenderness, perfusion, skin discolorations/wounds, and vital signs.
To document my findings, I use cued or checklist style charting on the EMR. Cued or checklist “makes document like data entry because it requires nurses to place marks in boxes instead of writing a narrative (Weber, p 51).” In my Telemetry unit, we use MediTech in particular. Although I use a checklist, I still input data in comment sections that follow under each category.
While performing my assessments, I analyze the collected data in mind. I formulate nursing diagnosis and care plans with evidence-based practice depending on the patient’s admission diagnosis, health history, and the data I’ve collected from my assessment. Once I’ve collected my data, gathered my information, and applied critical thinking, I collaborate with the interdisciplinary team depending on patients concerns and patient care priority. All collaborations are then documented on MediTech focusing on patient care plan and interdisciplinary team communication.
References:
Toney-Butler, T. (2019, July 30). Nursing Admission Assessment and Examination. Retrieved July 07, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK493211/
Weber, J.R. & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Wolters Kluwer.
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I work on a telemetry unit at a community hospital. My county has a large population of elderly people due to the many “over 55” developments in the area so the majority of the patients I care for are 70 years or older. When caring for elderly patients you have to worry about things you might not worry about with younger patients such as falls, pressure ulcers, deconditioning, constipation, and hospital related delirium. Some of the key objective information I collect are vital signs, skin assessment, PERRLA, heart, lung, and abdominal sounds. Some of the key subjective information I collect are symptoms, pain, eating habits, and bowel patterns. I document my findings in our computer system, Cerner. Documenting findings in the computer allows all health care providers that are involved in the patients care to share information, while helping to reduce errors (Kelley & Weber,2018). One specific example of what I assess and document is the Hopkins fall assessment. We input if the patient has had a fall in the last five months, how many high fall medications they are on, their cognition, how many pieces of medical equipment they are attached to, and what their mobility is like. Once all of that information is put in, the computer formulates a score which places them in low, moderate, or high fall risk. Our hospital policy is that if they are high fall risk, they must have a bed alarm and a Posey alarm on. The Hopkins score, along with other assessment tools such as the Braden scale or Glascow helps identify a potential problem and alerts healthcare professionals to pay more attention (Galvao & Aparecida, 2018). As helpful as these tools are, we still must use our own judgement and intervene accordingly.
References
Galvão Bueno Cardona, R., & Aparecida Barbosa, D. (2018). The importance of clinical practice supported by health assessment tools. Revista Brasileira de Enfermagem, 71(4), 1815–1816. https://doi-org.chamberlainuniversity.idm.oclc.org/10.1590/0034-7167-2018710401
Weber, J.R. & Kelley, J.H. (2018). Health assessment in nursing (6th ed.). Wolters Kluwer.
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