Week 1 Discussion: Exploring the Nurse’s Role in Health Assessment

Week 1 Discussion: Exploring the Nurse’s Role in Health Assessment Professor and Class, I currently practice nursing in a medical-surgical/telemetry unit. I live in an area in southern Florida that has a large influx in the population of residents in the winter months. In general, I believe the median age in Naples Florida is 65 years old. The majority of my patients are usually 65 years old if not older. According to, “Older adults are at greater risk than younger individuals for systemic and degenerative diseases, nutritional deficits, and cognitive impairments. It is often during the physical assessment that signs of physiologic disease are first detected. These abnormal findings identify the need for a more in-depth examination of the affected body system (e.g., an abnormal heart rate and/or chest discomfort can prompt the treating clinician to order an EKG or echocardiogram)”. We get a lot of cardiac-related patients and tend to see a lot of CHF and chest pain patients. We also have a lot of patients coming and going from the Cath lab on our floor. “Subjective data consist of information elicited and verified only by the client. Interviewing is the means by which subjective data are gathered (Weber, 2017). Some examples of subjective data that I collect on my patients have a cardiac-related problem like chest pain might be asking questions like, “Are you having any chest pain now?”, “Can you rate your chest pain on a scale of 1-10?”, “Does the pain get worse with exertion?”. “Can you describe the chest pain, and does it travel anywhere else in your body?”. Objective data for a patient with chest pain could be vital signs, trending their cardiac enzyme levels, monitoring their heart rhythm with constant telemetry, obtaining an EKG, listening to their heart sounds, checking their skin looking for any open areas, redness, edema, etc.… I document my findings on a computer using the program Cerner Power chart. I also monitor my patient’s lab values and the doctor's progress notes, and history and physical using this same program. There are times when the family might also be at the bedside and might also contribute to the data that I collect, and I will also obtain the patient's prior medical history and verify a list of their current medications and compliance with their medications. I often have to clarify information with the patient and their family or ask further questions to ensure I have as much accurate information as possible. Based on my findings I always document, and collaborate with other members of the healthcare team, for example, I delegate certain things to the CNA like if the patient is diabetic requiring blood glucose monitoring, if the patient requires assistance with ambulation to and from the bathroom or chair, if the patient needs to have their input and output recorded, etc. I also notify the physician if the patient has any critical or abnormal labs via tiger-text a text messaging app that we use to communicate with physicians. I might also collaborate with respiratory therapy, physical therapy, speech therapy, or occupational therapy if necessary. I also am responsible for initiating any necessary care plans for my patients and implementing any necessary safety measures that they may need. Thank you, Mia Caple, C., Kornusky, J. (2018). Physical Assessment in Older Adults: Performing. Retrieved from: Weber, J. R., Kelley, J. H. (2017). Health Assessment in Nursing, 6th Edition [VitalSource Bookshelf version]. Retrieved from vbk://9781496380005