NR 305 Week 1 Discussion – Exploring the Nurse’s Role in Health Assessment

The first step of the nursing process is assessment. This involves critical thinking skills, which include data collection and subjective and objective data performed by clinicians. Assessment is the first step of the nursing process, and inaccuracy will affect the judgment of the other phases (Weber & Kelley, 2018). Since assessment is the first phase of the nursing process, whenever a patient is admitted, the first step of the admission process is to perform a head-to-toe assessment. I currently work as a home visiting nurse working one on one with patients in the comfort of their homes. My caseload ranges seeing 15 – 25 patients, and for the most part of the job, I do the admission process.

During the assessment process, I do collect objective and subjective data, which will guide me in formulating the rest of the nursing process. The objective data is an observation of what I am able to see or measure, and this includes heart rate, measuring blood pressure, respiratory rate and temperature using a thermometer, physical examination, and a list of the patient’s medications. I then move on to the subjective data. Subjective data is gathered from the patient telling you something that you cannot use your five senses to measure (DuPont, 2017). I do this by asking the patient about any feelings/concerns, pain rating, and symptoms that might be ongoing, such as a complaint of running out of breath or having diarrhoea for the past few days.

After gathering all the data using my notes, I then transfer them to the electronic application. This is a detailed application that has a list of all the information that needs to be documented on a patient and includes the patient’s demographic, history and diagnosis, pain, integumentary, cardiac, respiratory, elimination, endocrine, functional and nutritional status. After gathering all these data, we then collaborate with the doctor and other members of the healthcare team. Based on the data collected by the md, diagnoses are formulated, care plans are developed from the nursing assessment, and referrals are made if it is applicable to the patient, such as physical/speech/occupational therapy, home health aid, podiatrist, dietician, etc.