Assessment is the accurate collection of comprehensive data pertinent to the patient’s health or the situation (“American Nurses Association,” 2010). Assessment is the first step in the nursing process and the most important. Assessment is the accurate collection of the patient’s health date including both subjective and objective information. Subjective data includes information that can only be described or verified by the patient. This may include chest pain, headache, or body aches. Objective date is data that can be observed and measured. This type of data is obtained using inspection, palpation, percussion, and auscultation during the physical exam. Objective data can also be provided through diagnostic testing. This is important for proper diagnosis, planning, and intervention. Examples of this may include vital signs, warm and moist skin, and coughing up yellow colored sputum.
The second standard in the nursing process is diagnosis. During this step, the registered nurse analyzes the assessment data to determine the diagnosis or issues (“American Nurses Association,” 2010). Analysis involves recognizing cues, sorting through and organizing or clustering the information, and determining patient strengths and unmet needs. These findings are compared with documented norms...
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... directed by the client’s changing status throughout the process. The nurse may collaborate with the client, family, significant others, and other members of the health care team in applying steps of the nursing process. The following standards shall be used by a registered nurse, using critical thinking and clinical judgment in applying the nursing process for each client under the registered nurses care: assessment, analysis and reporting, planning, implementation, and evaluation (“Ohio Board of Nursing,” 2008).
As a registered nurse new to the practice, I try to implement the laws and standards of practice into caring for my patients on a daily basis. I try to adhere to the scope of practice and the rules and regulations. It is my obligation as a heath care professional to do what is in the best interest of my patient while staying within these guidelines.
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