nursing process assessment

• Nursing Process


  The cornerstone of the nursing profession
• The Nursing Process


  A systematic problem-solving approach used to identify, prevent, and treat actual or potential health problems; and promote wellness
• Nursing Process


  A scientific and systematic way to plan, implement and evaluate care for individuals, families, groups, and communities
• History of the Nursing Process

  1. The term nursing process and the framework it implies are relatively new

  2. Hall originated the term (care, cure, core), 3 steps: note observation, ministration, validation

  3. Johnson (1959), "Nursing seen as fostering the behavioral functioning of the client"

  4. Orlando (1961) identified 3 steps: client's behavior, nurse's reaction, nurse's action. "Nursing process set into motion by client's behavior"

  5. Weidenbach (1963) were among the first to use it to refer to a series of phases describing the process

  6. Wiche (1967) "Nursing is defined as an interactive process between client and nurse". 4 steps: Perception, Communication, Interpretation, Evaluation

  7. Yura and Walsh (1967) suggested the 4 components -APIE

  8. Knowles (1967) described nursing process as: discover, delve, decide, do, discriminate
• American Nurses Association published standards of nursing practice. Diagnosis distinguished as separate step of nursing process (1973)
• American Nurses Association published Nursing - a Social Policy Statement. Diagnosis of actual and potential health problems delineated as integral part of nursing practice (1980)
• American Nurses Association published Standard of Clinical Nursing Practice. Outcome identification differentiated as a distinct step of the nursing process. Therefore, the six steps of the nursing process are as follows: A.D.OI.Ρ.Ι.Ε. (1991)
• Nursing Process


  It is a systematic, rational method of planning and providing individualized nursing care
• The Nursing Process

  • It is the underlying scheme that provides order and direction to nursing care
  • It is the essence of professional nursing practice
  • It has been conceptualized as a systematic series of independent nursing actions directed toward promoting an optimum level of wellness for the client
  • It is cyclical; the components follow a logical sequence, but more than one component may be involved at any one time
  • Open, flexible
  • Humanistic and individualized
  • Cyclical
  • Outcome focused (results oriented)
  • Emphasizes feedback and validation
• Characteristics of the Nursing Process


  • Dynamic
  • Client-centered
  • Planned
  • Interpersonal and collaborative
  • Universally applicable
  • Can focus on problems or strengths
• Benefits of using the nursing process


  • Continuity of care
  • Prevention of duplication
  • Individualized care
  • Standards of care
  • Increased client participation
  • Collaboration of care
• Benefits of the NURSING PROCESS: for the Client


  • QUALITY CLIENT CARE
  • CONTINUITY OF CARE
  • PARTICIPATION BY CLIENTS IN THEIR HEALTH CARE
• Benefits of the NURSING PROCESS: for the Nurse


  • CONSISTENT AND SYSTEMATIC NURSING EDUCATION
  • JOB SATISFACTION
  • PROFESSIONAL GROWTH
  • AVOIDANCE OF LEGAL ACTION
  • MEETING PROFESSIONAL NURSING STANDARDS
  • MEETING STANDARDS OF ACCREDITED HOSPITALS
• PHASES OF THE NURSING PROCESS


  • Assessment
  • Diagnosis
  • Outcome Identification
  • Planning
  • Implementation
  • Evaluation
• Assessment


  The deliberate and systematic collection of data to determine a client's current and past health status and to determine the client's present and past coping patterns
• Assessment


  The systematic and continuous collection, validation, and communication of patient data
• Assessment is the first and most critical step of the nursing process. Accuracy of assessment data affects all other phases of the nursing process. A complete database of both subjective and objective data allows the nurse to formulate nursing diagnosis, develop client goals, and intervenes to promote health and prevent disease
• Types of Assessment

  • Initial Assessment: Performed within specified time after admission to a health care agency
  • Problem Focused Assessment: Ongoing process integrated with nursing care to determine specific problems identified in an earlier assessment and to identify new or overlooked problems
  • Emergency Assessment: Done during psychiatric or physiological crisis of the client to identify life threatening problems
  • Time Lapsed-Reassessment: Done several months after initial assessment to compare the client's status to baseline data previously obtained
• Initial comprehensive assessment


  An initial assessment, also called an admission assessment, is performed when the client enters a health care from a health care agency. The purposes are to evaluate the client's health status, to identify functional health patterns that are problematic, and to provide an in-depth, comprehensive database, which is critical for evaluating changes in the client's health status in subsequent assessments
• Problem Focused Assessment


  • Status determines a specific problem identified during previous assessment
  • A problem focus assessment collects data about a problem that has already been identified. This type of assessment has a narrower scope and a shorter time frame than the initial assessment. In focus assessments, nurses determine whether the problems still exist and whether the status of the problem has changed (i.e. improved, worsened, or resolved). This assessment also includes the appraisal of any new, overlooked, or misdiagnosed problems. In intensive care units, may perform focus assessment every few minutes
• Time Lapsed Reassessment (or Ongoing assessment)


  Comparison of client's current status to baseline obtained previously, detection of changes in all functioning health problems after an extended period of time
• Emergency Assessment


  • Identification of life-threatening situation
  • Emergency assessment takes place in life-threatening situations in which the preservation of life is the top priority. Time is of the essence for rapid identification of and intervention for the client's health problems. Often the client's difficulties involve airway, breathing and circulatory problems (the ABCs). Abrupt changes in self-concept (suicidal thoughts) or roles or relationships (social conflict leading to violent acts) can also initiate an emergency. Emergency assessment focuses on a few essential health patterns and is not comprehensive
• Medical vs. Nursing Assessments

  • Medical assessments: Target data pointing to pathologic conditions
  • Nursing assessments: Focus on the patient's response to health problems
• Activities of Assessment

  • COLLECT DATA
  • VALIDATE DATA
  • ORGANIZE DATA
  • RECORDING DATA
• Assessment involves reorganizing and collecting CUES

  • Objective (overt)
  • Subjective (covert)
• Steps of Assessment

  • Collection of data
  • Validation of data
  • Organization of data
  • Recording/documentation of data
• Collection of data

  • Gathering of information about the client
  • Includes physical, psychological, emotional, socio-cultural, spiritual factors that may affect client's health status
  • Includes past health history of client (allergies, past surgeries, chronic diseases, use of folk healing methods)
  • Includes current/present problems of client (pain, nausea, sleep pattern, religious practices, medication, or treatment the client is taking now)
• Types of Data

  • SUBJECTIVE DATA: Also referred to as symptoms or covert data, are apparent only to the person affected and can be described or verified only by that person
  • OBJECTIVE DATA: Also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard
• Sources of Data

  • Primary Source - Direct Source: Client, usually BEST source
  • Secondary Source (Indirect Source): Family Members, Client's records, Other health care professionals Verbal reports, Literature
• Data Collection


  Consider time, needs of patient, developmental stage, physical surroundings, past and present coping patterns
• Data Characteristics


  • Complete
  • Factual
  • Accurate
  • Relevant
• Approaches to Collecting Data for Assessing Client's Health


  • ABDELLAH'S 21 Nursing Problems
  • DOROTHEA OREM'S Components of Universal Self-Care
  • GORDON'S Functional Health Patterns
  • Correlating a Body Systems Physical Examination with Data Gathered by Functional Health Area
• Dorothea Orem's Components of Universal Self-Care


  • Maintenance of sufficient intake of air, water, and food
  • Provision of care associated with elimination process and excrement
  • Maintenance of a balance between solitude and social interaction
  • Prevention of hazards to life, functioning and well- being
  • Promotion of human functioning and development within social groups in accord with potential known limitations and the desire to be normal
• GORDON'S FUNCTIONAL HEALTH PATTERNS


  • Health Perception - Health Management Pattern
  • Nutritional - Metabolic Pattern
  • Elimination Pattern
  • Activity - Exercise Pattern
  • Cognitive - Perceptual Pattern
  • Sleep - Rest Pattern
  • Self-perception - Self-concept Pattern
  • Role-Relationship Pattern
  • Sexuality - Reproductive Pattern
  • Coping - Stress Tolerance Pattern
  • Value Belief Pattern
• Clinical Skills used in Assessment

  • Observation
  • Interviewing
  • Physical Examination
  • Intuition
• Data collection methods

  • Observation
  • Interviewing
  • Physical Assessment
• Observation


  To gather data using senses
• Interviewing


  An interview is a planned communication or a conversation with a purpose
• Types of questions

  • Open-ended questions
• Interview Phases

  • Preparatory phase
  • Introduction
  • Working phase
  • Termination