NURSING PROCESS Assessment

• A method of problem identification and problem solving (Gordon, 1994).
• A key systematic method for taking independent nursing action (Ralph &
Taylor, 2014).
Components of the Nursing Process
• It is a systematic, deliberate process by which the nurse collects and
analyzes data about the patient.
• Assessing is a continuous process carried out during all phases of the
nursing process
Four Interrelated Nursing Activities in Assessment

Assessment • Collect data

• Organize data
• Validate data
Evaluation Diagnosis • Document data

Cue(s)

• A piece of information or data that influences decisions.

• Acquired through the use of the five senses (touch, smell, hearing, sight,
taste)
Outcome
Implementation
Identification
I. COLLECTING DATA

Data Collection
Planning
• The process of gathering information about a client’s health status.
• It must be both systematic and continuous to prevent the omission of
Nursing Process (ANA, 2014) significant data and reflect a client’s changing health status.
• Cyclical Types of Data
• Dynamic
• Interpersonal • Subjective Data
• Collaborative o Covert data
• Universally applicable o Symptoms
o Not measurable
Nursing Process (AACN, 2008) o Can be obtained only from what the client tells the nurse
o Include client’s thoughts, beliefs, feelings, sensation, perception of
• Framework for providing specific nursing care to individuals, families and
self and patient’s health problems
communities
• Orderly and systematic Note:
• Interdependent
o Data from significant others and other health professionals may
• Patient centered using patient’s strengths
also be subjective if they consist of opinion and perception rather
• Appropriate for use throughout life span
than fact.
• Can be used in all settings
o You may not always be able to obtain subjective data.
 • Objective Data Problem- Ongoing process To determine the status Hourly intake
o Signs focused integrated with of a specific problem and output
o Overt data assessment nursing care identified in an earlier (I&O) of an
o Can be detected by someone other than the client assessment ICU client
o Measurable
To identify new or
Example: overlooked problems
Emergency During any physiologic To identify life- Rapid ABC
Subjective data Objective data assessment or psychologic crisis of threatening problems (airway,
Description Covert data: Overt data: the client breathing,
• Symptoms • Signs circulation)
• What the pt says • Can be observed by others assessment
• Can be perceived and • Measured against a standard during
verified only by the pt cardiac arrest
Examples • Itching • Pulse rate of 100 bpm Time- Several months after To compare the client’s Reassessment
• Pain • BP of 120/80 mmHg lapsed initial assessment current status to of a client’s
• Anxiety • Skin pale and cool to touch assessment baseline data previously functional
• “I am afraid” • Urine output of 350 ml obtained health
• “I feel week all over” • X-ray/laboratory results pattern in
• Skin turgor OPD
• Posture
Data Collection Method
Sources of Data
1. Observation – gathering of data with the use of senses
1. Primary data: the CLIENT • Vision – body size, skin color, and lesions
• The best source of data is the client, unless the client is too ill, • Smell – body and breath odors
young, or confused to communicate clearly. • Hearing – lung and heart sounds
• The client can provide subjective data no one else can offer. • Touch – skin temperature and moisture
2. Secondary data: obtained from sources OTHER THAN THE CLIENT 2. Physical Examination – 4 PA techniques
• Significant others • Inspection – examination by careful and critical observation
• Other health care providers • Auscultation – examination by listening with the stethoscope
• Client’s written record, past and present hospitalization • Palpation – examination by touching and feeling
o Parts of the hand used: fingerpads, ulnar/palmar surface,
Types of Assessment dorsal surface
Type Time performed Purpose Example • Percussion – examination by touching, tapping and listening
Initial Within specified time To establish a complete Nursing 3. Nursing Interview
assessment after admission to database for problem admission • Purposeful, focused interaction
health care agency identification, reference assessment • To obtain subjective data about the effects of the illness on
and future comparison patient’s daily functioning and ability to cope
• To obtain subjective data for nursing health history

2 Approaches:
 1. Directive interview 1. To ensure complete, accurate and factual information
• Highly structured, controlled by nurse 2. To eliminate nurse’s own biases, errors and misperceptions of the
• To obtain specific factual information (Eg. age, sex, data
analysis of symptoms) 3. To avoid jumping to faulty conclusion, premature closure
• The nurse establishes the purpose of the interview and
A nurse must validate data when:
controls the interview by asking closed-ended questions.
2. Nondirective interview 1. Subjective and objective data, interview, physical examination do not agree.
• Allow patient to control and to express 2. The client’s statements differ at different times in the assessment.
• Time consuming 3. The data seem extremely abnormal.
• Promote communication and rapport 4. Factors are present that interfere with accurate measurement.
• The nurse encourages communication by using open-
III. ORGANIZING DATA
ended questions and empathetic responses.
4. Medical Records Review • Use of a written or computerized format that organizes the assessment
• The nurse reads a medical record (patient’s chart) to add to the data systematically.
comprehensive assessment • Using Gordon’s 11 Functional Health Patterns to organize/cluster the
• Purposes: assessment data
o To guide the other activities of data collection based on • Using Maslow’s Basic Human Needs to prioritize problem
high frequency health problems associated with medical • The NANDA-I taxonomy serves its intended purpose of sorting/categorizing
diagnosis and treatments identified in the chart nursing diagnosis to help nurses locate nursing diagnosis within the
o To relate the past health care history of the patient to the taxonomy
present episode
o To identify what medication the patient is taking so that
the assessment can include the effectiveness of the
medication and the occurrence of any side effects.

Component of Nursing Health History

1. Biographical data
2. Chief complaint (reason for visit)
3. History of present illness
4. Past health status
5. Review of system and effects on functioning
6. Social and family history
7. Lifestyle, habits, daily living patterns
8. Spiritual well-being IV. RECORDING DATA
9. Psychological data
• Record in ink on the form provided by the agency
10. Perception of health status and illness
• Write legibly and neatly
11. Client’s expectation of caregivers
• Use acceptable and appropriate abbreviations
II. VALIDATING THE DATA • Record subjective data in client’s own words
• Record cues not inferences
• The act of “double-checking” or verifying data in order to:
• Avoid vague generalities (eg. good, normal)
o Example: The nurse records a client’s breakfast intake:
✓ Coffee 240 ml, juice 120 ml, 1 egg, 1 slice of toast
(objective)
✓ Appetite good (judgement)