Fund- Assessment

• Nursing Process


  A method of planning nursing actions in providing patient-focused care. A form of scientific reasoning and requires the nurse's critical thinking to provide the best care possible to the client. A series of organized steps designed for nurses to provide excellent care
• Characteristics of the nursing process

  • Patient-centered
  • Interpersonal
  • Collaborative
  • Dynamic and cyclical
  • Requires critical thinking
• Nursing Process Steps


  1. Assessment

  2. Diagnosis

  3. Planning

  4. Implementation

  5. Evaluation

  
• Assessment


  1. Collection of Data

  2. Organization of Data

  3. Validation of Data

  4. Documenting the clients' health status
• 4 Types of Assessment

  • Initial nursing assessment
  • Problem-focused assessment
  • Emergency assessment
  • Time-lapsed reassessment
• Subjective Data


  Feelings, perceptions, thoughts, sensations, or concerns that are shared and described only by the patient
• Objective Data


  Data collected via the senses, such as sight, touch, smell, or hearing, and compared to an accepted standard
• Verbal Data


  Spoken or written data such as statements made by the client or by a secondary source
• Nonverbal Data


  Observable behavior transmitting a message without words
• Primary Source


  The client is the only primary source of data and the only one who can provide subjective data
• Secondary Source


  A source is considered secondary data if it is provided from someone else other than the client
• Methods of Data Collection

  1. Interviews

  2. Physical examination

  3. Observation
• Health Interview


  1. Directive Interview

  2. Non-directive Interview
• 3 Phases of Interview

  1. Introductory Phase

  2. Working Phase

  3. Termination Phase
• Physical Examination


  The nurses uses techniques of inspection, auscultation, palpation and percussion
• Observation


  Gathering of data by using the senses
• Validating Data


  Verifying the data to ensure that it is accurate and factual
• Organization of Data


  Nursing health history form or Nursing assessment form

  
• Documenting Data


  Recording and sorting the information collected
• Excellent record-keeping is fundamental so that all the data gathered is documented and explained in a way that is accessible to the whole health care team and can be referenced during evaluation
• Collection of Data


  Process of gathering information about a client's health status

  It includes

  - Health history

  - Physical examination

  - Results of laboratory and Diagnostic tests

  - Materials contributed by other helathcare personnel