NR 305 Discussion: Reflection on the Nurse’s Role in Health Assessment

Sample Answer for NR 305 Discussion: Reflection on the Nurse’s Role in Health Assessment Included After Question

Purpose

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

 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.

A Sample Answer For the Assignment: NR 305 Discussion: Reflection on the Nurse’s Role in Health Assessment

Title: NR 305 Discussion: Reflection on the Nurse’s Role in Health Assessment

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.

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. 

I work in Interventional Radiology at our local hospital. We mostly do focused assessments. We have patients come in for elective procedures for all different biopsies, lower extremity angiograms, port placements, dialysis and central line placements, lumbar punctures, myelograms, nephrostomy tube insertions and exchanges. We ask pertinent health history, allergies, medications. We look in the back of the patients mouth to confirm the mallampati score. We listen to the patient’s heart, lungs and abdomen and as were doing that we look at the patient’s skin for abnormalities.

After the procedure, we do the same assessment, but we also pay special attention to the site that we punctured. If it’s a lumbar puncture or myelogram, we also do a neurological assessment. We do subjective data and take patients symptoms and the problems that are occurring with their tubes or lines and write them down for the doctor. We also do objective data and take all the patients vital signs, write down the lab results and document the irregularities we find on our assessment of the patient and their tubes or lines.

We have patients of ages 18 and above. Most of our patients are alert and oriented but if they are not, we have family that come with them that can answer all of our questions and sign the consent. Our patients are of all religions, cultures, and financial statuses. I feel that most of our patients are being diagnosed with cancer, fighting cancer of some kind or are dialysis patients.