ASSESSING

NURSING PROCESS

• ASSESING

• EVALUATING

• NURSING DIAGNOSIS

• IMPLEMENTING

• PLANNING

What is a Process?

- It is a series of planned actions or operations directed towards a particular result or goal.

- It is a systematic, rational method of planning and providing individualized nursing care.

Purpose of Nursing Process

• To identify a client's health status, actual or potential health care problems or needs,

• To establish plans to meet the identified needs, and

• To deliver specific nursing interventions to meet those needs.

Characteristics of the Nursing Process

• Data from each phase provide input into the next phase

  • The nursing process is regularly repeated event or sequence of events that is continuously changing rather than staying the same.

• The nursing process is client centered

  • The plan of care is according to client problems rather than nursing goals.

• The nursing process is an adaptation of problem solving and systems theory

  • Can be viewed as parallel to but separate from the process used by the physician

  • The system is open and flexible to meet the unique needs of client, family, group and community

• Decision making is involved in every phase of nursing process

• Nurses can be highly creative in determining when and how to use data to make decisions.

  • Facilitates the individualization of The nurse's plan of care.

• The nursing process is interpersonal and collaborative.

• It requires the nurse to communicate directly and consistently with clients and families to meet their needs,

  • Also requires that nurses collaborate, as members of the health care team, in a joint effort to provide quality of care.

• The universally applicable characteristics of nursing process means that it is used as a framework for nursing care in all types of health care settings, with clients of all age groups.

• Nurses must use variety of critical-thinking skills to carry out the nursing process.

  (refer to your book examples of critical thinking in the nursing process)

• It is cyclic and dynamic

• It is planned

• It is goal directed

• It permits creativity for the nurse and the client in devising ways to solve the stated health problem.

• It emphasizes the feedback, which leads either to reassessment of the problem or to revision of the care plan.

• It is universally applicable.

Benefits of the Nursing Process

CLIENTS

- By improving the quality of care they receive.

NURSE

- Enables the nurse to use time and resources efficiently

ASSESSMENT

• ASSESING

• Collect Data

• Organize Data

• Validate Data

• Document Data

ASSESSMENT

- Is the systematic and continuous, collection, organizing, validation and documentation of data (information)

- Is a continuous process carried out during all phases of the nursing process.

Types of Assessment

Initial Assessment

- performed within specified time after admission to a health care agency

Purpose

• To establish a complete database for problem identification, reference, and future comparison

  Example:

  • Nursing admission assessment

Problem-Focused Assessment

- ongoing process integrated with nursing care

Purpose:

• To determine the status of a specific problem identified in earlier assessment

  Example:

  • Hourly assessment of client's fluid intake and urinary output in an ICU

Time Lapsed Reassessment

- done several months after initial assessment

Purpose

• To compare the client's current status to baseline data previously obtained

  Example:

  • Reassessment o client's functional health patterns in a home care or outpatient setting or, in a hospital, at shift change.

Emergency Assessment

- during any physiologic or psychologic crisis of the client

Purpose

• To identify life-threatening problems

• To identify new or overlooked problems

  Example:

  • Rapid assessment of a person: airway, breathing status, and circulation during cardiac arrest

ACTIVITIES OF ASSESSMENT

• collect data

• validate data

• organize data

• recording data

Collecting Data

- Is the process of gathering information about a client's health status

- It must be both systematic and continuous to prevent the omission of significant data and reflect a client's changing health status.

Database

- is all the information about a client

- it includes the nursing health history, physical assessment, primary care provider's health history and physical examination result of laboratory and diagnostic tests, and material contributed by other health personnel.

Types of Data

Subjective Data

- Referred to as symptoms or covert data.

- Apparent only to the person affected and can be described or verified only by that person.

- Include the client's sensation, feelings, values, beliefs, attitudes, and perception of personal health and life situations

Examples:

Itching, pain and feelings of worry

Objective Data

- Referred to as signs or over data.

- Are detectable by an observer o can be measured or tested against an accepted standard.

- Can be seen, heard, felt or smelled and they are obtained by observation or physical examination. Examples:

• a discoloration of the skin blood pressure reading during physical examination

Constant Data is information that does not change over time such as race or blood type

Variable Data can change quickly. frequently or rarely such as blood pressure, age, and level of pain.

Sources of Data

- Could be primary or secondary sources.

- The CLIENT is the primary source of data.

- Secondary sources are:

• Support people: family members, friends and caregivers

• Client records: information documented by various health care professionals

• Health Care professionals Literature: professional journal and reference texts

  
  

Data Collection Methods

Observation/Observing

- Is to gather data by using the senses

- Is a conscious, deliberate skill that is developed through effort and with an organized approach.

USING THE SENSES TO OBSERVE CLIENT DATA

Interviewing

- Is a planned communication or a conversation with a purpose.

Examples:

• to get or give information. Identify problems of mutual concern, evaluate change, teach, provide support, or provide counseling or therapy

Types of Interview Questions

Closed Questions

- are restrictive and generally require only "yes" or "no" or short factual answers giving specific information

- often begins with "when", "where", Who". "what", “do (did, does)” or “is (are, was)”

Examples:

“what medication did you take?”

"Are you having pain now?"

"How old are you?"

Open-ended Questions

- Invite clients to discover and explore, elaborate, clarify, or illustrate their thoughts or feelings.

- Often begins with "what" or "how"

Example:

"How have you been feeling lonely?"

"What brought you to the hospital?"

"What would you like to talk about?”

Neutral Questions

- Is a question the client can answer without direction on pressure from the nurse, is also an open ended.

Example:

"How do you feel about that?"

"Why do you think you had the operation?

Leading Questions

- By contrast, is usually closed, and directs the client’s answer

Example:

“You’re stressed about the surgery tomorrow, aren’t you?”

“You will take your medicines, will you?”

Stages of Interview

The Opening

- The most important part of the interview because what is said and done at that time sets the tone for the reminder of the interview

- The purposes are to establish rapport and orient the client

Examining

- Also known as the "Physical Examination" or "Physical Assessment

- Is a systematic data collection method that uses observation, or detect health problems.

- It uses the techniques of inspection, auscultation, palpation, and percussion.

- It uses cephalocaudal (head-to-toe) approach or body system approach.

- Instead of giving a complete examination, the nurse may focus on a specific problem area noted from the nursing assessment.

- Alternately, the nurse may perform a screening examination.

SCREENING EXAMINATION also called a Review Systems.

- a brief review of essential functioning in a various body parts or systems.

Example:

Nursing Admission Assessment

Organizing Data

• The nurse uses a written (or computerized) format that organizes the assessment data systematically

This is referred to as a Nursing Health History, Nursing Assessment, or Nursing Database Form

Conceptual Models/Frameworks

• Gordon's Typology of Functional Health Patterns Framework

• Orem's Self-care Model

• Roy's Adaptation Model

• Wellness Model

• Non Nursing Model

• Body Systems Model

• Maslow's Hierarchy of Needs

• Developmental Theories

Validating Data

• Is the act of "double checking" or verifying data to confirm that it is accurate and factual.

• It helps the nurse to complete these tasks:

  • Ensure that assessment information is complete.

  • Ensure that objective and related subjective data agree.

  • Obtain additional information that may have been overlooked

  • Differentiate between cues and inferences

Cues - are subjective or objective data that can be directly observed by the nurse.

Ex. Temp - 39.6℃

Inferences - are the nurse's interpretation or conclusions made based on the cues.

Ex. Fever

Documenting Data

• To complete the assessment phase, the nurse records client data.

• Accurate documentation is essential and should include all data collected about the client's health status.

• Data are recorded in a factual manner and not interpreted by a nurse