NR 305 Week 1 Discussion: Exploring the Nurse’s Role in Health Assessment (graded)

Purpose

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?)

Remember to use and credit the textbook or lesson, as well as an outside scholarly source, for full credit.

Grading

**To view the grading criteria/rubric, please click on the 3 dots in the box at the end of the solid gray bar above the discussion board title and then Show Rubric.

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This discussion seems like a perfect way to start off our session. I know in some facilities where I have worked, the nursing diagnosis process was addressed in the computer charting. I look forward to learning about your own practice settings and the patients you serve as we explore the first steps of the nursing process.

Please take a look at the grading rubric for weekly discussions and contact me know if you have any questions related to the posting requirements.

I work in a hospital’s medical and surgical telemetry floor for patients comprising adolescents and seniors. Our unit sees to it that the patients can recover smoothly from their surgery, and we are able to fulfill this task by closely monitoring crucial metrics that pertain to their health.

To do this, I collect a range of subjective and objective data points. For the former, our concern includes determining how the patients are generally feeling at specified hours. The subjective data points I collect also include how they feel the medications are affecting their overall condition. For the objective data points, these include basic information such as pulse and heart rates, blood pressure, oxygen intake, and body temperature.

Our clinical setting is among the 97% of healthcare establishments mentioned by Hebda & Czar as those extensively employing technology in collecting and assessing patient information (n.p.). In our case, all the vital signs are directed to a centralized monitor in one of the rooms. From there, we can see immediately all the important metrics we need to know pertaining to the patient we are monitoring. The system also has a built-in alarm that alerts us whenever the metrics surpass certain benchmarks set for each patient.

As part of our data analysis, we anticipate all the information that the physicians would look for whenever something comes up with a particular patient. Collating such information expedites the treatment process as the doctors can make crucial decisions when they already have the relevant information at hand.

Reference

Hebda, Toni, and Patricia Czar. “Handbook of informatics for nurses & healthcare professionals.” Boston: Pearson, 2013.

That is amazing that you have a location that you can monitor all of the patient vital signs.  In the hospital I work at, the only thing you can monitor from a central location is patient heart rate and rhythm.  All of the other vital signs are taken by the nurse in each patient room.  It would be so much easier to monitor patient vital signs if they were all visible in one place.  I hope that eventually our hospital will upgrade to a system that would allow for that kind of monitoring.

Hello Oluwadunni , Its nice that you are to monitor the patient vitals elactronically and in real time, on the facilty ened that is one thing we lack, we go in and manually check vitals on patients, in more acute care setteings its great to have remote VS monitoring as we all know changes in Vs can be one of the first objective changes noted, even before a patient may report not feeling well.

I work on the oncology/hematology and medical-surgical and telemetry unit. We take turns being charge nurse as well. My patient population is a wide range of disorders. Almost the entire population either has cancer or an autoimmune disorder of some sort. We also frequently get alcohol and opiate detox; and pancreatitis patients seem commonplace as well. We are also on the same floor as the psychiatric unit. Therefore, we do get psychiatric patients who are needing some medical attention prior to transfer. We also may have psychiatric patients who need observers and are waiting for placement to the psychiatric unit. Some valuable date is needed for our unit.

Commonplace subjective data on my unit are CIWA scores for detox patients, and pain level and nausea level. Most patients who are hospitalized with cancer treatment battle nausea. Subjective data include questions that we ask our patients (Weber and Kelley, 2018) “Feelings, sensations, symptoms” are subjective data (Weber & Kelley, 2018, p. 12). However, objective data is something “observable” (Weber & Kelley, 2018, p. 2018). So then, I can observe a patient is vomiting and even measure the emesis and that is an observation and is data that helps understand if the patient is getting too dehydrated.

We use Epic to document all patient data. We have flowsheets and we make a note per shift. I would document pain as 1-10 or nausea as mild, moderate, severe.

I typically will measure vital signs more frequently when patients are vomiting to make sure that patient did not become too hypovolemic. When a patient is in pain and on dilaudid, we will keep that patient on continuous pulse oximetry to determine if that patient desaturated. In the greater picture of managing pain and nausea, you can think of all the measurable outcomes that patient has from measuring urine output, bowel movements, and how much the patient is able to drink or eat. The end result is that I know when it is time to ask the doctor for some other medication to make sure that the patient is as well as possible, or when it is time to come to the bedside and I need a doctor’s help.

Gathering subjective data is helpful for the overall benefit of the patient and a population. Robinson and Smith (2016) surveyed oncology patient for improvement of symptoms of “pain, fatigue, nausea, and anxiety” with “therapeutic massage”. Although this reflects subjective data, there is still empirical evidence that shows improvements based on statistics. In this case, there was a 40% greater satisfaction rating in these patients overall from use of therapeutic massage (Robinson and Smith, 2016). Both subjective and objective data prove useful.

References

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

Robinson, J. and Smith, C. (2016). Therapeutic Massage During Chemotherapy and/orBiotherapy      Infusions: Patient Perceptions of Pain, Fatigue, Nausea, Anxiety, and Satisfaction. Clinical Journal of Oncology Nursing. 20(2): E34-E40.http://dx.doi.org.chamberlainuniversity.idm.oclc.org/10.1188/16.CJON.E34-E40 

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.

References:

Weber, J., Kelley, J., (2018). Nurse’s role in health assessment: collecting and analyzing data. Health Assessment in Nursing 6th ed., 1, 4-5.

Leslie, J., (2018). Employment of the nursing process to facilitate recovery from surgery: a case study. Online Journal of Issues in Nursing, 23(2). Retrieved from:  https://web-a-ebscohost-com.chamberlainuniversity.idm.oclc.org/ehost/detail/detail?vid=19&sid=9aa78ebd-30a8-4fdd-937d-a0b6e01ba575%40sessionmgr4006&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=130158150&db=ccmLinks to an external site.