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

  
• ADPIE


  An easy way to remember the components of the nursing process
• Assessment


  The first phase of the nursing process. It involves: Collection of Data, Organization of Data, Validation of Data, Documenting the clients' health status

  
• 4 Types of Assessment

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


  The 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 healthcare personnel
• Types of Data Collection

  • Subjective Data (Symptoms)
  • Objective Data (Signs)
  • Verbal Data
  • Nonverbal Data
• 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, such as body language, general appearance, facial expressions, gestures, eye contact, proxemics, touch, posture, clothing
• Sources of Data


  • Primary Source (the client)
  • Secondary Source (family members, support persons, records and reports, other health professionals, laboratory and diagnostics)
• Methods of Data Collection

  • Interviews
  • Physical examination
  • Observation
• Health Interview


  The most common approach to gathering important information. An intended communication or a conversation with a purpose: to obtain or provide information, to identify problems
• Approaches to Health Interview


  • Directive Interview (nurse directly asks questions, controls the interview)
  • Non-directive Interview (rapport building, allows the client to do the talking)
• Phases of Interview


  1. Introductory Phase

  2. Working Phase

  3. Termination Phase
• Physical Examination


  The nurses uses techniques of inspection, auscultation, palpation and percussion to provide a more accurate diagnosis, planning, and better interventions and evaluation
• Observation


  Gathering of data by using the senses (sight, touch, hearing, smell, and taste) to learn information about the client
• Validating Data


  The process of 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 gathered, to create accessible documentation for the whole health care team
• Nursing Diagnosis Components


  • Cues
  • Independent (cite reference)
  • Dependent (cite reference)
  • Interdependent (cite reference)
• Nursing Diagnosis Types


  • Independent
  • Dependent
  • Interdependent/Collaborative
• Nursing Diagnosis Characteristics


  • General
  • Specific (cite reference)
• Nursing Diagnosis Sources


  • Subjective
  • Objective
  • (Nanda)
• 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