NR 305 Week 2: Reflection on the Nurse’s Role in Health Assessment (Graded)

I work in on the Intermediate Care floor of my hospital. The process of my assessment can vary depending on the reason for admitting the patient. Most all assessments are head to toe assessments, but if the patient was admitted due to a stroke or head injury, we have to add in neuro checks. To start the assessment, I introduce myself to the patient and explain my role as their nurse and ask if I can begin the assessment. Then as I perform my assessment, I explain what I am doing and answer any questions they may have. I will ask them if they know what day it is, where they are, and why they were admitted to the hospital. When we get a new patient on the floor, every available nurse comes to help get the patient settled in. The patient is then washed down with chlorhexadine wash, dried, we apply telemetry pads to their chest and a pulse oximeter to their finger, a blood pressure cuff to the accessible limb, put them in a clean gown, and go over the orders from the doctor. Should the patient need any labs immediately, it is the nurses job to collect the specimen and send it to the lab via pneumatic tube. I will go over the health history with the patient and ask if there is anyone they would like for me to contact or if they have a Medical Power of Attorney. I then write that info on the whiteboard in the patient’s room along with my name, my title, the CNA’s name, the date, day of the week, and I ask the patient what is the most important question they have for the care team that day. I go over all of the patient’s medications and any OTCs they may be taking. I ask if the patient is having any pain and then check the MAR for medication for the pain, if any. Then I order the patient food if they are not NPO and let them settle in while I pull their meds and prepare to go through their chart to read about the patient diagnosis and what we are treating them for. That information will help me to adjust my assessment to to look for specific things. The majority of the population we see on outlr floor are older patients, although we may get some younger ones from time to time.

Discussion

Purpose

The purpose of this reflection is for learners to reflect on the nurse’s role in health assessment in various care settings.

Course Outcomes

This assignment enables the student to meet the following course outcomes:

CO 1: Demonstrate a head to toe physical assessment. (PO 1)

CO 3: Describe physical, psychosocial, cultural, and spiritual influences on an individual’s health status. (PO 1)

Due Date

During the assigned week (Sunday the start of the assigned week through Sunday the end of the assigned week):

• Posts in the discussion at least two times, and
• Posts in the discussion on two different days

Total Points Possible

50 points

Directions

• Reflection is an activity that involves your deep thought into your own experiences related to the concepts of the week. Answers should be detailed. In reflections students:
  • Demonstrate understanding of concepts for the week
  • Engage in meaningful dialogue with classmates and/or instructor
  • Express opinions clearly and logically, in a professional manner
• Use the rubric on this page as you compose your answers.
• Scholarly sources are NOT required for this reflection
• Best Practices include:
  • Participation early in the week is encouraged to stimulate meaningful discussion among classmates and instructor.
  • Enter the reflection often during the week to read and learn from posts.
  • Select different classmates for your reply each week.

 Reflection Questions

Reflect on your current or prior practice setting.

• Paragraph One: Briefly describe the type(s) of nursing health assessments you commonly perform.
  • Explain how your nursing health assessments are focused or comprehensive.
  • Provide examples of key subjective and objective data collected by nurses in this setting.
• Paragraph Two: Describe the typical patient population in your practice setting.
  • What are some special considerations that you have used for obtaining an accurate health history and physical assessment in this patient population?
  • Examples may include age, lifestyle, financial status, health status, culture, religion, or spiritual practices.

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. See Syllabus for Grading Rubric Definitions.

As I work in the Emergency Department, I typically preform more of a focused assessment. We see many patients during the day in the setting I work in, so we work up their chief complaint. Typically when I get a new patient I go into the room and triage them.  This consists of asking them why there are here, checking vitals and obtaining a history on the patient as well as hooking them up to or monitors. This triage is when I collect the subjective data, I record what the patient tells me they are experiencing and about their pervious medical history. We then begin the workup to receive objective data about what is going on with the body. We do this by listening to the lungs and heart, doing ECG’s, drawing labs, and collecting urine. 

I work in West Virginia which is ranked to be one of the most obese states. With this statistic for out state we often see those that are diabetic patients which is important to keep into consideration. We also serve in an area that is heavily populated with drugs. Overdoses account for a percentage of our patients as we see atleast one a day. We must keep these two things into consideration when assessing our patients for the safety of their own health and saftey. Majority of our patients are ages 40-80, they do not live an active lifestyle. Many are homeless or do not work everyday. Many of our patients are of the lower class and may not get to eat everyday. Most of our patients are extremely ill weather it be acutely or chronically, however we see many more chronically ill patients that are there to be admitted to the hospital. 

 Currently, I am working nightshift in an Emergency Department and typically we perform focused assessments. According to where I am station in the emergency department that night, I may triage the patient or receive them after triage in the patient room. According to Merriam-Webster Dictionary, triage is defined as, “the sorting of patients (as in an emergency room) according to the urgency of their need for care” (Staff, 2023). When patients enter the emergency department to be triaged that’s when we obtain the subjective and objective data. We obtain subjective data such as chief complaint and pain scale. Next we obtain the objective data such as EKG and labs. An example would be a patient that came into the emergency department for abdominal pain. Once triaged the patient is placed in a room where we can do a focused assessment on the abdomen.

      Working in the emergency department we acquire a large variety of individuals, everything from infants to geriatrics; from CEOs to miners. For this specific area we see many individuals. Some with shortness of air from COPD, from being employed in mines or factories; those who have overdosed and/or seek recovery, and people with congestive heart failure and obesity. One particular population we see often is psychiatrics. Some special considerations I take when obtaining an accurate health and physical assessment is the individual’s age. In this area, a large geriatric population is seen in the emergency department, I find that these older individuals like to be treated with respect, such as saying yes mam’ or no sir. The older patient is more likely to cooperate and leave with a better experience.