The Nursing Process Step 1: Assessing - Comprehensive Nursing Principles and Practice

Foundations of the Nursing Process

  • The nursing process is defined as a systematic, patient-centered, and goal-orientated method of caring.
  • It serves as a comprehensive framework for nursing practice.
  • The individual steps within the nursing process are not isolated or separate items; instead, they function as interdependent parts of a unified whole.

Defining Nursing Assessment

  • Assessment constitutes the first step of the nursing process.
  • It is the systematic and continuous collection, validation, and communication of patient data.
  • Collected data reflects how health functioning is enhanced through health promotion or compromised by illness and injury.

The Clinical Database

  • A database consists of all pertinent patient information collected by the nurse and other healthcare professionals.
  • It is a vital step in the nursing process because all subsequent steps (diagnosing, planning, implementing, and evaluating) depend on data that is complete, accurate, factual, and relevant.
  • An effective database enables the design and implementation of a comprehensive plan of care.
  • Data should be organized or clustered during collection to ensure it is systematic. One primary model used for this organization is Maslow’s Hierarchy of Human Needs, which includes:
    • Physiological needs
    • Safety needs
    • Esteem (referred to as "Exterm" in organizational diagrams)
    • Self-actualisation

The Four Types of Nursing Assessments

  • Comprehensive Initial Assessment
    • Performed shortly after a patient is admitted to a health care agency or service.
    • Purpose: To collect data on all aspects of the patient’s health and establish a complete database for problem identification and care planning.
  • Focused Assessment
    • May be performed during the initial assessment or as part of routine ongoing data collection.
    • Purpose: To gather information about a specific problem that has already been identified, or to identify new or overlooked problems.
  • Emergency Assessment
    • Performed when a physiologic or psychological crisis presents.
    • Purpose: To identify and gather data specifically regarding life-threatening problems.
  • Time-Lapsed Assessment
    • Performed to collect data regarding a patient’s current status to compare it against baseline data obtained earlier.
    • Purpose: To reassess health status and make necessary revisions to the established plan of care.

Differentiating Medical and Nursing Assessments

  • Medical Assessments: These assessments target data that points specifically toward pathologic conditions.
  • Nursing Assessments: These assessments focus on the patient’s subjective and objective responses to health problems.

Objective Versus Subjective Data

  • Objective Data
    • Definition: Observable and measurable data that can be seen, heard, or felt by someone other than the person experiencing them.
    • Examples: Elevated body temperature, skin moisture, or the act of vomiting.
  • Subjective Data
    • Definition: Information perceived only by the affected person.
    • Examples: The experience of pain, feeling dizzy, or feeling anxious.

Sources of Patient Data

  • The Patient: This is the primary and first choice for data collection whenever possible.
  • Family and significant others.
  • The Patient record.
  • Other healthcare professionals.
  • Nursing and other healthcare literature.

Methods of Data Collection

  • Observation of both verbal and non-verbal communication.
  • Interviewing the patient.
  • Nursing Assessment components:
    • Nursing history (provides subjective data).
    • Physical examination (provides objective data).
  • Consulting and collaborating with the healthcare team.

Nursing Observation and Interviewing

  • Nursing Observation
    • This is the conscious and deliberate use of the five senses to gather data.
    • Every nurse-patient interaction is viewed as an opportunity to observe and interpret meaningful data.
  • The Interview
    • An interview is defined as planned communication.
    • The primary goal of the nurse interviewing the patient is to obtain a nursing history.
    • The interview process consists of four distinct phases:
      1. Preparatory phase
      2. Introduction phase
      3. Working phase
      4. Termination phase

Strategies for a Successful Interview

  • Maintain focus on the patient throughout the interaction.
  • Listen to the patient with full attention.
  • Inquire about the patient’s main problem first.
  • Pose all questions and comments in an appropriate manner.
  • Avoid comments and questions that impede or block communication.
  • Utilize silence and physical touch appropriately to facilitate comfort and sharing.

Types of Clinical Questions

  • Closed Questions: Used to elicit specific, brief information.
  • Open-ended Questions: Designed to allow the patient to verbalize freely.
  • Reflective Questions: Used to encourage the patient to elaborate on their thoughts and feelings.
  • Direct Questions: Used to validate or clarify previously obtained information.

Purposes of Physical Assessment and Collaboration

  • Physical Assessment serves three primary functions:
    • Appraisal of the patient’s health status.
    • Identification of health problems.
    • Establishment of a database to guide nursing interventions.
  • Collaboration with other healthcare professionals is a necessary component of the data collection and assessment process.

References

  • Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2008). Fundamentals of nursing: The art and science of nursing care. (6th ed.). Philadelphia: Lippincott Williams & Wilkins.
  • Wolters Kluwer/Lippincott Williams & Wilkins (2008). Assessing. Retrieved August 22, 2010 from www.thepoint.lww.com/downloads/thePoint_