Purpose

This week’s graded topics relate to the following Course Outcomes (COs).

• CO 1 – Utilize prior knowledge of theories and principles of nursing and related disciplines to explain expected client behaviors, while differentiating between normal findings, variations, and abnormalities. (PO 1)
• CO 5 – Explore the professional responsibilities involved in conducting a comprehensive health assessment and provide appropriate documentation. (PO 6)

Discussion

The nursing process is utilized in a variety of nursing roles and health care settings. Whether you are working in direct patient care, telehealth, or in a leadership role – the basic model is the same! Take this opportunity to share how the nursing process is utilized in your own practice settings! Hint: Your assigned readings will be helpful in formulating your answers.

Please answer the following question in your initial post:

Describe how you apply the first step (assessment) of the nursing process in your current practice setting. If you are not currently practicing as an RN, you may use an example from a prior clinical or work experience. Include the following information:

• Briefly describe your practice setting and the typical patient population.
• Provide examples of key subjective and objective data points you collect.
• Describe how you document your findings. Is there technology involved?
• Describe your process of data analysis. What is the end result of this process? (i.e., Do you formulate nursing diagnoses and care plans, collaborate with others and/or make referrals?)

Remember to use and credit the textbook or lesson, as well as an outside scholarly source, for full credit.

Solution:

I am currently working as an acute care nurse providing care to patients with acute illness and postoperative care services to patients following surgery or treatment for chronic illness. Examples of subjective data I collect include a description of the current health problem, commonly known as chief complaint, the patient’s report of past medical history, and perceptions or events relating to events that brought the patient to the health care facility to seek treatment. Examples of objective data collected are vital signs such as temperature, respiration rate, oxygen concentration, blood pressure, pulse, and heart rate. Objective data also include collection of physical examination of the body systems such as respiratory