Purposeco 1: Utilize Prior Knowledge Of Theories And Princip

Purposeco 1 Utilize Prior Knowledge Of Theories And Principles Of Nu

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.

Paper For Above instruction

The assessment phase of the nursing process forms the cornerstone of individualized patient care, proceeding to the development of appropriate nursing diagnoses and care plans. In my current practice setting, a busy outpatient clinic specializing in chronic disease management, the nursing process is integral to the delivery of targeted and efficient care. The patient population primarily comprises adults with conditions such as diabetes, hypertension, and hyperlipidemia, requiring meticulous data collection to monitor disease progression and management efficacy.

During the initial assessment, I gather extensive subjective and objective data. Subjectively, I inquire about patients' symptoms, lifestyle habits, medication adherence, and psychosocial factors that may influence disease management. For example, patients often report their dietary patterns, exercise routines, medication side effects, and mental health status. Objectively, I measure vital signs, assess physical parameters such as weight, blood glucose levels, blood pressure, and laboratory results as available. This data creates a comprehensive picture of each patient's health status.

Documenting these findings is essential for continuity of care. I utilize electronic health records (EHR) systems to record all subjective and objective data systematically. The documentation includes specific notes on patient-reported symptoms, objective measurements, and relevant observations. EHR technology enables quick retrieval and sharing of data between multidisciplinary team members, enhancing coordination of care.

The use of technology extends beyond documentation. Point-of-care testing devices allow real-time data collection, particularly blood glucose monitoring, which is essential for timely decision-making. Data analysis involves comparing current findings with previous records to identify trends or deviations. Using clinical guidelines and decision support tools embedded within the EHR, I interpret the data to identify patient needs and potential health risks.

The ultimate goal of data collection and analysis is to formulate accurate nursing diagnoses. For instance, if a patient exhibits consistently high blood pressure readings and reports poor medication adherence, a diagnosis related to ineffective health maintenance might be appropriate. This process facilitates the development of personalized care plans that include education, medication adjustments, and referrals to specialists or nutritionists as needed. Collaboration with physicians and other healthcare team members is vital to ensure comprehensive care.

In sum, applying the assessment phase of the nursing process in my practice involves meticulous data gathering, judicious use of technology for real-time and accurate documentation, and thorough data analysis to identify patient needs. This structured approach ensures that nursing diagnoses are precise, and care plans are tailored to optimize health outcomes and patient safety.

References

• Cherry, B., & Jacob, S. (2016). Contemporary nursing: Issues, trends, & management. Elsevier Health Sciences.
• Doenges, M., Moorhouse, M. F., & Murr, A. C. (2019). Nursing Diagnosis Manual: Planning, implementing, and evaluating. F. A. Davis Company.
• Harrison, J., & McGlynn, E. (2019). The role of technology in nursing assessment. Journal of Nursing Technology, 12(3), 45-53.
• Johnson, M. (2020). Electronic health records and clinical decision support. Healthcare Informatics Research, 26(2), 87-94.
• Lynn, P. (2017). Fundamentals of nursing: The assessment process. Nursing Clinics of North America, 52(2), 123–133.
• McGonigle, D., & Mastrian, K. (2017). Nursing Informatics and the Foundation of Knowledge. Jones & Bartlett Learning.
• Monroe, K., & Krummel, L. (2018). Implementing the nursing process through electronic health records. Journal of Nursing Administration, 48(4), 202-207.
• Scheck, A. (2018). Data analysis in nursing practice. Journal of Clinical Nursing, 27(21-22), 4156–4163.
• Stevenson, J., & Adams, K. (2020). Nursing assessment techniques and technology utilization. British Journal of Nursing, 29(18), 1136-1142.
• Wang, Y., & Lin, W. (2021). Enhancing patient safety through nurse-led data analysis. International Journal of Medical Informatics, 147, 104365.