Nursing Process

 Assessment (gather subjective and objective data, family history, surgical history,
medical history, medication history, psychosocial history)
 Analysis or diagnosis (formulate a nursing diagnosis by using clinical judgment;
what is wrong with the patient)
 Planning (develop a care plan which incorporates goals, potential outcomes,
interventions)
 Implementation (perform the task or intervention)
 Evaluation (was the intervention successful or unsuccessfu

Nursing assessment
nursing assessment, plans nursing care in consultation with individuals/ groups, significant
others & the interdisciplinary health care team and responds effectively to unexpected or
rapidly changing situations.

What is the purpose of assessment?

The purpose of assessment is to establish a database about a client’s physical and

emotional well-being, intellectual functioning, social relationships, and spiritual condition.

What are the types of assessments?

The types of assessment are (1) the comprehensive assessment; (2) the focused assessment,
concentrated upon the presenting problem of the client; (3) the ongoing assessment; and
(4), the emergency assessment.

What is the difference between subjective and objective assessment data?

Subjective data are information from the client’s point of view (“symptoms”), including
feelings, perceptions, and concerns obtained through interviews. Objective data are
observable and measurable data (“signs”) obtained through observation, physical
examination, and laboratory and diagnostic testing.

1. Aim
The guideline specifically seeks to provide nurses with:

 Indications for assessment

 Approach to assessment in children
 Types of assessments
 Structure for assessments

Safety considerations:
1. Perform hand hygiene.
2. Check room for contact precautions.
3. Introduce yourself to patient.
4. Confirm patient ID using two patient identifiers (e.g., name and date of birth).
5. Explain process to patient.
6. Be organized and systematic in your assessment.
7. Use appropriate listening and questioning skills.

Steps on assessing patients

1. General Impression.
2. Level of Consciousness.
3. Open Airway [A]
4. Check Breathing [B]
5. Check Pulse [C] *check skin.
6. Check Major Bleeding.

Assessing personal data

1. INTERVIEWING
a. Phases of the Interview
The nursing interview has three basic phases: introductory, working, and summary
and closing phases
b. Introductory Phase
After introducing himself to the client, the nurse explains the purpose of the
interview, discusses the types of questions that will be asked, explains the reason for
taking notes, and assures the client that confidential information will remain
confidential
c. Working Phase
The nurse elicits the client’s comments about major biographic data, reasons for
seeking care, history of present health concern, past health history, family history, and
review of body systems for current health problems, lifestyle and health practices, and
developmental level

2. Special Considerations during the Interview

a. Gerontologic Variations in Communication
b. Cultural Variations in Communication
c. Emotional Variations in Communication