ANGELES UNIVERSITY FOUNDATION

College of Nursing

ACADEMIC YEAR 2018 – 2019

HEALTH ASSESSMENT

MODULE NO. 1
REVIEW OF THE NURSING PROCESS

Rationale:
This self-instructional module is designed and prepared to meet the Health
Assessment requirements of BSN 1 students in developing their knowledge and skills in the
promotion of overall Health Assessment. It presents knowledge of identifying the different
phases of nursing process, describing the nurses role in nursing assessment, utilizing the
nursing process in health assessment, review the different phases of the nursing process,
and understanding of the students on how to obtain basic and relevant information.
Nursing process is a step-by-step method of providing care to clients. While
progressing through each step, the nurse uses a variety of skills that are purposeful and
promote a systematic, orderly thought process. The nursing process consists of five steps-
assessments, diagnosis, planning and outcome identification, implementation and
evaluation. Understanding and applying concepts of the nursing process will help the nurse
identify priorities, plan, provide health care and evaluate patient progress.

Learning Objectives
Upon completion of this module, the learner should be able to:
1. Review and identify the different phases of the nursing process.
2. Utilize the nursing process in health assessment

Recommended Preparation:
Before going to the program the learner must have an adequate knowledge in
Anatomy and Physiology and Nursing Care Management 100 (Foundations of Nursing
Practice). Also the learner is advised to read the following glossary.

 CLIENT CENTERED- care is focused on the client.

 COLLABORATION- communication with other disciplines to solve problems.
 DECISION MAKING- a skill used throughout the nursing process, is based on a
systematic and scientifically based theories.
 MEDICAL DIAGNOSIS- are determined by the physician or nurse practitioner
indicating a disease or disorder identified or to be ruled out.
 NURSING DIAGNOSIS- is a clinical judgment about individual, family or community
responses to actual or potential health problems or life processes.
 NURSING PROCESS- defined as an organized, systematic method of planning and
providing individualized care to clients.
 PROCESS- defined as a series of planned actions or operations directed toward a
particular result or goal.

THE NURSING PROCESS

The Nursing Process is the cornerstone of the Nursing profession. It is synonymous
with the problem- solving approach for discovering the healthcare and nursing care needs
of the patients. Therefore, it is through the Nursing Process that nursing was able to build
its own scientific body of knowledge. Thus, Nursing evolved to become a profession.
 Lydia Hall originated the term “Nursing Process” in 1955.
 The nursing process is an organized, systematic manner of providing goal-
oriented and humanistic care that is both efficient and effective.

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  The nursing process is organized and systematic because it is composed of five
sequential and interrelated steps: Assessment, Nursing Diagnosis, Planning,
Implementation and Evaluation.
 The nursing process is efficient because it is relevant to the needs of the patient.
It promotes patient satisfaction and progress.
 The nursing process is effective because it utilizes resources widely in terms of
human, time and cost resources.

PHASES OF THE NURSING PROCESS

Step 1: ASSESSMENT
Assessment provides significant information, assembled to establish a client
database. This phase involves several steps:
1. Data collection
2. Validation
3. Interpretation
4. Documentation

Types of Data:
Subjective data – information given verbally by the patient and not directly observed by the
nurse.
Objective data – information observed by the nurse that can be noted by another observer.
They are perceptible to the senses.

Step 2: DIAGNOSIS

Diagnosis is the classification of a disease, condition or human response based upon

scientific evaluation of signs and symptoms, patient history and diagnostic studies.
Diagnosis involves analysis of collected data. After analysis, a list of nursing diagnoses or
labels describing client problems or strengths is formulated. The nurse uses critical-thinking
and decision making skills in developing nursing diagnoses.

Nursing Diagnosis
It is a statement of client’s potential or actual alteration of health status. It uses the
critical-thinking skills of analysis and synthesis. It uses PRS/ PES format.

P - problem P – problem
R – related to factors E – etiology
S – signs and symptoms S – signs and symptoms

Step 3: PLANNING AND OUTCOME IDENTIFICATION

Planning involves determining beforehand the strategies or course of actions to be

taken before implementation of nursing care while outcome identification refers to
formulating and documenting measurable, realistic, patient-focused goals. This phase of
the nursing process organizes the proposed course of action for resolution of actual
problems and prevention of risk problems. This task involves several steps:
1. Establishing priorities
2. Establishing patient’s goals and outcome criteria
3. Planning nursing interventions
4. Writing a nursing plan of care

Step 4: IMPLEMENTATION

Implementation involves execution of the nursing care plan. As planned interventions

are performed the nurse must continue to assess the client’s condition before, during and
after each intervention is carried out. Reporting and documentation of collected data are
important. Both positive and negative responses are reported and documented. Negative

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responses to treatment may require additional intervention. Implementation includes the
following:
1. Reassessing
2. Setting priorities
3. Performing nursing interventions
4. Recording actions

Step 5: EVALUATION

It involves assessing the patient’s response to nursing interventions and then

comparing the response to predetermined standards or outcome criteria. During evaluation
(appraisal of results), the nurse determines if client goals were met, partially met or not
met. If the goal has been met, the nurse must decide if or when nursing activities will
cease. This decision will depend on the client’s status. If the goal has been partially met or
not met, the nurse reactivates each step of the nursing process. Data must be collected to
determine why the goal was not achieved and what modifications to the care plan are
necessary.

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