Nursing process 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


  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
• 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, body language, touch, posture, clothing
• 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


  The most common approach to gathering important information. An intended communication or a conversation with a purpose Directive - nurse ask questions Non Direct - rapport building, client is the one talking
• 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


  The process of verifying the data to ensure that it is accurate and factual
• Documenting Data


  Once all the information has been collected, data can be recorded and sorted
• Components of the Nursing Process

  • Evaluation
  • Rationale of Nursing Orders
  • Nursing Actions and Nursing Orders
  • Goals and Outcomes Criteria
  • Scientific Basis
  • Nursing Diagnosis
  • Cues

  
• Types of Nursing Diagnosis

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

  • General
  • Specific
• Initial nursing assesment:

  • Performed within specified time after admission
  • To establish complete data for problem identification

   
• Problem-focused assesment:

  • Monitor the status of a specific problem identified in an early assessment
• Emergency assesment

  • assesmnt done during emergy situations to identify any life-threatining situations 
• Time- lapsed assessment

  • Several months after initial assessment