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

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.

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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 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.

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.

I 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.

First of all, I would like to introduce myself, my name is Erika and i am a telemetry nurse in New Jersey. I work with medical/surgical patients at a hospital located in a diverse city.

In my place of work, the nursing process is used commonly in both physical and electronic aspects of patient care. Nursing process is composed of steps including: Assessment, Diagnosis, Outcome, Planning, Implementation and Evaluation. The first step, Assessment which is the topic of discussion, is widely used in my clinical setting. This step includes systematic and continuous data collection; processing, examination and arrangement of the data collected; and recording and communication of the data collected. This is the first thing we do upon meeting the patient. Head-to-toe assessment is the most common type of assessment method we perform and this information is put in the Electronic Health Record (EHR) under Nursing Assessment.

Other methods we use for assessment are Subjective vs Objective, in which we get to interview the patient more regarding their situation, review-of-system and use of SBAR (Situation, Background, Assessment and Recommendation) when giving a report to the oncoming shift.

The nursing assessment involves the collection of information about physiological , psychological, sociological, and spiritual needs of particular patients. It is the first step on a patient’s successful assessment. The compilation of subjective and objective data is an integral part of that process. Part of the test involves gathering data such as vital signs and pain level. The assessment determines a patient’s current and potential care needs by enabling a nursing diagnosis to be established. The nurse recognizes normal and abnormal physiology of the patient and encourages priority care and interventions (Toney-Butler , 2019)

Toney-Butler, T. J. (2019, July 30). Nursing Admission Assessment and Examination. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK493211/

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