HEALTH ASSESSMENT

NURSING PROCESS

Sets of actions used to determine, plan, implement and evaluate nursing care.

Systematic, rational method of planning and providing individualized care.

PURPOSE

To help CHARACTERISTICS

It is problem-oriented

It is goal-oriented

It is orderly and planned, step-by-step

It is universally applicable to all patients, families, and communities that nursing serves

FIVE COMPONENTS OF THE NURSING PROCESS

Overview of the Nursing Process

Assessing- collecting, organizing, validating, and documenting client data.

Diagnosing- analyzing and synthesizing data

Planning- determining how to prevent, reduce, or resolve the identified priority client problems.

Implementing- carrying out (or delegating) and documenting the planned nursing interventions.

Evaluating- measuring the degree to which goals/ outcomes have been achieved.

Nursing Process in Action

Assessing

- collect data, organize data, validate data, document data

Diagnosing

- analyze data, identify health problems, risks and strengths, formulate diagnostic statements

Planning
Prioritize problems/diagnoses, formulate goals/desired outcomes, select nursing interventions,
write nursing interventions

Implementing

Reassess the client, determine the nurse’s need for assistance, implement the nursing
interventions, supervise delegated care, document nursing activities

Evaluating

Collect data related to outcomes, compare data with outcomes, relate nursing actions to client
goals/outcomes, draw conclusions about problem status, continue, modify, or terminate the
client’s care plan.

Assessment: The First Phase of the Nursing Process

the most critical phase of the nursing process

deliberate and systematic collection of data to determine client’s current and past health and
functional status.

determines client’s current and past coping patterns

Assessment: The First Phase of the Nursing Process

is ongoing and continuous throughout all the phases of the nursing process.

A Critical Thinking Approach to Assessment

Subjective & Objective Data

HEALTH HISTORY GUIDELINES

INTERVIEW

A planned communication or a conversation with a purpose

PURPOSES OF INTERVIEW
Get or give information

Identify problems of mutual concern

Evaluate change

Teach

Provide counseling or therapy

Approaches to Interviewing

DIRECTIVE INTERVIEW

Highly structured, elicits specific information

Nurse establishes purpose of and controls the interview

Used to gather and get information when time is limited

Approaches to Interviewing

2. NON-DIRECTIVE INTERVIEW

Rapport building

Nurse allows client to control the purpose, subject matter, and pacing.

NOTE: A combination of Directive and Non-directive interview approaches is usually

appropriate during information-gathering interview.

TYPES OF COMMUNICATION

VERBAL
NON-VERBAL

Types of Interview Questions

1. CLOSED-ENDED QUESTIONS

Used in directive interview

Restrictive, generally requires a “yes” or “no” or short factual answers giving specific
information

Often begin with “when”, “where”, “who”, “what”, “do (did,does)”, “is (are, was)”

Types of Interview Questions

2. OPEN-ENDED QUESTIONS

Used in non-directive interview

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

Answers are longer than two words

Gives clients freedom to divulge information that they are ready to disclose

Useful in the beginning of an interview or to change topics and to elicit attitudes

May begin with “what” or “how”

Types of Interview Questions

3. NEUTRAL QUESTIONS

Client can answer without direction or pressure from the nurse

Is open-ended, used in non- directive interviews

Types of Interview Questions

4. LEADING QUESTIONS

Is closed, used in directive interview

Directs client’s answer

Gives clients less opportunity to decide whether the answer is true or not

NON VERBAL COMMUNICATION

FACIAL EXPRESSION

ATTITUDE

SILENCE

LISTENING

STRUCTURE/PHASES OF AN INTERVIEW

OPENING (or Introductory)

Most important part of the interview, sets tone for the remainder of the interview

Purpose is to establish rapport and orient the interviewee

The nurse must be careful not to overdo this stage

In this stage, the Nurse explains the purpose & nature of the interview, like what information is
needed, how long will it take, & what is expected of the client, how the information will be used,
& that the client has the right not to provide data.

STRUCTURE OF AN INTERVIEW

2. BODY (Working)
Client communicates what he or she thinks, feels, knows, perceives in response to questions
from the nurse.

Effective development of the interview demands that the nurse use communication techniques
that make both parties feel comfortable & serve the purpose of the interview

STRUCTURE OF AN INTERVIEW

3. CLOSING (Summary and Closing)

The nurse terminates the interview when the needed information has been obtained.

In some cases, the client may terminates the interview

Closing is important for maintaining the rapport and trust and for facilitating future interactions.

STRUCTURE OF AN INTERVIEW

The following techniques are commonly used to close an interview:

Offer to answer questions.

Conclude by saying “Well, that’s all I need to know for now.” Preceding a remark with the word
‘well’ generally signals that the end of the interaction ids near.

Thank the client. You may also shake the client’s hand.

Express concern for the person’s welfare and future.

Plan for the next meeting, if there is to be one, or state when it will happen next.. Include the
day, time, place, topic, and purpose.

Provide summary to verify accuracy & agreement. Summarizing not only terminates the
interview but also reassures the client that the nurse has listened.

PLANNING THE INTERVIEW AND SETTING

Nurse should review available information.

Nurse reviews the institution’s data collection form if there’s any, otherwise, the nurse may
prepare an interview guide.

CONSIDERATIONS DURING AN INTERVIEW

Time

Place

Seating Arrangement

Distance

Language

GUIDELINES DURING AN INTERVIEW

Listen attentively, using all your senses, and speak slowly and clearly.

Clarify points that are not understood.

Plan questions to follow a logical sequence.

Ask only one question at a time. Multiple questions limit the client to one choice and may
confuse the client.

GUIDELINES DURING AN INTERVIEW

Acknowledge the client’s right to look at things the way they appear to him and not the way they
appear to the nurse or someone else.

Do not impose your own values on the client.

Avoid using personal examples, such as saying, “if I were you,…”

Nonverbally convey respect, concern, interest, and acceptance.

GUIDELINES DURING AN INTERVIEW

Be aware of the client’s and your own body language.

Be conscious of the client’s and your own voice inflection, tone, and affect.

Sit down to talk with the client (be at an even level).

Use & accept silence to help the client search for more thoughts or to organize them.

Use eye contact to be calm, unhurried, and sympathetic.

Interview Guidelines

gerontologic variations in communication

cultural variations

emotional variations