LESSON 1

• Nursing process


  A systematic, rational method of planning and providing individualized nursing care
• Significant concepts in this chapter

  • Assessment
  • Nursing Diagnosis
  • Planning and Implementation of Care
  • Health Education
  • Recording and Reporting
  • Evaluation of Care
• Assessment


  The initial step of the nursing process that involves the collection, organization, and analysis of data about the client's health
• Purpose of assessment


  • Serves as the basis for developing a care plan to address the client's needs
  • Generates baseline data used to evaluate the effectiveness of interventions or a measure to determine the client's progress
• What this lesson covers

  • Gordon's functional health patterns
  • Psychosocial assessment
  • Cultural and spiritual assessment
  • Diagnostic and laboratory examinations
• Gordon's functional health patterns


  A systematic and standardized approach to data collection that enables nurses to determine the aspects of health and human function to plan nursing care
• Gordon's 11 functional health patterns

  • Health Perception–Health Management
  • Nutritional-Metabolic
  • Elimination
  • Activity-Exercise
  • Sleep-Rest
  • Cognitive-Perceptual
  • Self-Perception–Self-concept
  • Role-Relationship
  • Sexuality-Reproductive
  • Coping–Stress Tolerance
  • Value-Belief
• Psychosocial assessment


  Includes a mental status examination to construct a picture of the client's current emotional state, mental capacity, and behavioral function
• Importance of nurse's self-awareness


  • The nurse's own biases and values can influence the interpretation of assessment data
  • Self-awareness is vital in any interaction to understand the patient's self-concept
• Factors influencing psychosocial assessment

  • Client participation/feedback
  • Client's health status
  • Client's previous experiences/misconceptions about health care
  • Client's ability to understand
  • Nurse's attitude and approach
• Client participation/feedback


  A thorough and complete psychosocial assessment requires active client participation
• Client's health status


  Can affect the psychosocial assessment if the client is anxious, tired, or in pain
• Client's previous experiences/misconceptions about health care


  Can elicit emotions that interfere with obtaining an accurate psychosocial assessment
• Client's ability to understand


  The nurse must determine the client's ability to hear, read, and understand the language being used in the assessment
• Nurse's attitude and approach


  Can influence the psychosocial assessment if the client perceives the nurse as non-accepting, defensive, or judgmental
• Factors to consider when conducting the interview

  • Environment
  • Input from family and friends
  • Phrasing questions
  • Nurses' behaviors
• Environment


  The nurse should conduct the psychosocial assessment in a comfortable, private, and safe environment for both the client and the nurse
• Input from family and friends

  The nurse should obtain their perceptions of the client's behavior and emotional state
• Phrasing questions

  The nurse may use open-ended questions to start the assessment, and use more direct questions if the client cannot organize their thoughts or has difficulty answering open-ended questions