The Nursing Process ASSESSMENT

Nursing Process Dynamic, ongoing Facilitates delivery of organized plan of nursing care Involves 5 parts –Assessment –Diagnosis –Planning (goal making) –Implementation –Evaluation

Assessment Systematic Deliberate (planned, organized) Collection of information (data) –Patient’s current and past health status –Functional status –Past and present coping patterns

Types of Nursing Assessments Initial Focused Emergency Time-lapsed

Assessment Priorities Health orientation Development stage Need for nursing Practical considerations

2 parts of Assessment Collection and verification of data from primary source (the patient) secondary source (family, health records, other healthcare professionals) Analysis of data

Assessment Purpose Formulate a database about the patient’s –Perceived needs –Health problems –Responses to the problems Extra information about –Related experiences –Health practices –Goals/values/expectations about healthcare system

Critical Thinking Used by nurse collecting data An active, organized thought process A simultaneous synthesis of nurse’s –Knowledge –Clinical experience –Standards of practice –Critical thinking standards and attitudes

Data Collection Characteristics Complete Factual Accurate Relevant

Data Collection Methods Observation Interview –Preparatory –Orientation –Working –Termination Techniques of Physical Assessment

DATA COLLECTION Types of Data –Subjective –What the patient or family member says –Goes in “---” (quotation marks) –Other sources Health care team members Health record

DATA COLLECTION –Objective –Observed data (What is not spoken) –Findings from physical exam –Results from diagnostic or lab tests –Information from pertinent nursing or medical literature

Documentation of Data Clear and concise Appropriate terminology –Usually on a designated form Physical assessment –Usually by Review of Systems Overview of symptoms Diet Each body system

Data Validation Verifies understanding of information Comparison with another source patient or family member record health team member

Data Interpretation Process of inferential reasoning and judgment (critical thinking) Interpretation of what information is relevant to present status Summary of data Provides focus for nursing attention