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11. Assessing LEARNING OUTCOMES After Completing This Chapter, You Will

11. Assessing LEARNING OUTCOMES After Completing This Chapter, You Will

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Published by: twy113 on Oct 05, 2009
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After completing this chapter, you will be able to:1.
Describe the phases of the nursing process.
Identify major characteristics of the nursing process.
Identify the purpose of assessing.
Identify the four major activities associated with the assessing phase.
Differentiate objective and subjective data and primary and secondary data.
Identify three methods of data collection, and give examples of how each is useful.
Compare directive and nondirective approaches to interviewing.
Compare closed and open-ended questions, providing examples and listing advantages anddisadvantages of each.
Describe important aspects of the interview setting.
Contrast various frameworks used for nursing assessment.KEY TERMSassessing,
closed questions,
directive interview,
leading question,
neutral question,
nondirective interview,
objective data,
open-ended questions,
review of systems,
screening examination,
subjective data,
Hall originated the term
 in 1955, and Johnson (1959), Orlando (1961), and Wiedenbach (1963) were among the first to use it to refer to a series of phases describing the practiceof nursing. Since then, various nurses have described the process of nursing and organized the phasesin different ways.The purpose of the nursing process is to identify a client's health status and actual or potential healthcare problems or needs, to establish plans to meet the identified needs, and to deliver specific nursinginterventions to meet those needs. The client may be an individual, a family, or a group.
The use of the nursing process in clinical practice gained additional legitimacy in 1973 when the phases were included in the American Nurses Association (ANA)
Standards of Nursing Practice.
TheStandards of Practice within the most current
Scope and Standards of Nursing Practice
(seeBox 1-1 on page14) include the five phases of the nursing process: assessment, diagnosis, planning,implementation, and evaluation (ANA, 2004). Most states have since revised their nurse practice actsto reflect the nursing process. SeeFigure 11-1 for an illustration of the nursing process in action.
Phases of the Nursing Process
Although nurse theorists may use different terms to describe the phases of the nursing process, theactivities of the nurse using the process are similar. For example,
may also be called
may be called
An overview of the five-phase nursing process is shown in Table 11-1on page 178. Each of the five  phases is discussed in depth in this and subsequent chapters of this unit. The phases of the nursing process are not separate entities but overlapping, continuing subprocesses (seeFigure 11-2 on page 179). For example, assessing, which may be considered the first phase of the nursing process, is alsocarried out during the implementing and evaluating phases. For instance, while actually administeringmedications (implementing), the nurse continuously notes the client's skin color, level of consciousness, and so on.Each phase of the nursing process affects the others; they are closely interrelated. For example, if inadequate data are obtained during assessing, the nursing diagnoses will be incomplete or incorrect;inaccuracy will also be reflected in the planning, implementing, and evaluating phases.
Characteristics of the Nursing Process
The nursing process has distinctive characteristics that enable the nurse to respond to the changinghealth status of the client. These characteristics include its cyclic and dynamic nature, clientcenteredness, focus on problem solving and decision making, interpersonal and collaborative style,universal applicability, and use of critical thinking.
Data from each phase provide input into the next phase. Findings from evaluation feed back intoassessment. Hence, the nursing process is a regularly repeated event or sequence of events (a cycle)that is continuously changing (dynamic) rather than staying the same (static).
The nursing process is client centered. The nurse organizes the plan of care according to client problems rather than nursing goals. In the assessment phase, the nurse collects data to determine theclient's habits, routines, and needs, enabling the nurse to incorporate client routines into the care planas much as possible.
The nursing process is an adaptation of problem solving (see Chapter 10) and systems theory (seeChapter 24 ). It can be viewed as parallel to but separate from the process used by  physicians (the medical model). Both processes (a) begin with data gathering and analysis, (b) baseaction (intervention or treatment) on a problem statement (nursing diagnosis or medical diagnosis),and (c) include an evaluative component. However, the medical model focuses on physiologicalsystems and the disease process, whereas the nursing process is directed toward a client's responses todisease and illness.
Decision making is involved in every phase of the nursing process. Nurses can be highly creative indetermining when and how to use data to make decisions. They are not bound by standard responses
and may apply their repertoire of skills and knowledge to assist clients. This facilitates theindividualization of the nurse's plan of care.
The nursing process is interpersonal and collaborative. It requires the nurse to communicate directlyand consistently with clients and families to meet their needs. It also requires that nurses collaborate,as members of the health care team, in a joint effort to provide quality client care.
The universally applicable characteristic of the 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 a variety of critical-thinking skills to carry out the nursing process.Table 11-2 provides examples of critical thinking in the nursing process.
The Nursing Process in Action
The nursing process is a systematic, rational method of planning and providing nursing care. Its purpose is to identify a client's health care status, and actual or potential health problems, to establish plans to meet the identified needs, and to deliver specific nursing interventions to address those needs.The nursing process is cyclical; that is, its components follow a logical sequence, but more than onecomponent may be involved at one time. At the end of the first cycle, care may be terminated if goalsare achieved, or the cycle may continue with reassessment, or the plan of care may be modified.Amanda Aquilini, a 28-year-old married attorney, was admitted to the hospital with an elevatedtemperature, a productive cough, and rapid, labored respirations. In taking a nursing history, NurseMary Medina, RN, finds that Amanda has had a "chest cold" for two weeks, and has beenexperiencing shortness of breath upon exertion. Yesterday she developed an elevated temperature and began to experience "pain" in her "lungs."
Figure 11-1.
The nursing process in action.
Figure 11-2.
The five overlapping phases of the nursing process. Each phase depends on theaccuracy of the other phases. Each phase involves critical thinking.
is the systematic and continuous collection, organization, validation, and documentation of 
(information). In effect, assessing is a continuous process carried out during all phases of thenursing process. For example, in the evaluation phase, assessment is done to determine the outcomesof the nursing strategies and to evaluate goal achievement. All phases of the nursing process dependon the accurate and complete collection of data. There are four different types of assessments: initialassessment, problem-focused assessment, emergency assessment, and time-lapsed reassessment (seeTable 11-3). Assessments vary according to their purpose, timing, time available, and client status. Nursing assessments focus on a client's responses to a health problem. A nursing assessment shouldinclude the client's perceived needs, health problems, related experience, health practices, values, andlifestyles. To be most useful, the data collected should be relevant to a particular health problem.Therefore, nurses should think critically about what to assess. The Joint Commission on Accreditationof Healthcare Organizations (2005) requires that each client have an initial assessment consisting of ahistory and physical performed and documented within 24 hours of admission as an inpatient.The assessment process involves four closely related activities: collecting data, organizing data,validating data, and documenting data (seeFigure 11-3).
Figure 11-3.
Assessing. The assessment process involves four closely related activities.

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