Nursing Process- Assessment

Overview of Nursing Process Purpose of Nursing Process:

The nursing process guides our care, it helps us to identify the patient’s needs, establish goals of care, communicate our plan, and evaluate our care.

Characteristics of the Nursing Process

It has purpose, it is goal driven

It is organized

It is creative

Steps of the Nursing Process Assessment Analysis (Nursing Diagnosis) Planning Implementation Evaluation

Assessment- the first phase Data collection phase The purpose= establish a data base Through assessment includes 3 parts:

1) Nursing history 2) Physical exam 3) Lab/ diagnostic test data

Data Data should be:

Descriptive Concise Complete

Data should be validated Types of data

Subjective Objective

Data should be organized Gordon’s functional health patterns Systems organization

Sources of Data Client Family or significant other Health team members Medical record Literature review

Methods of Data Collection Health history and interview

Interviewing steps Introduction

Set a time limit Ask if they have questions before starting Assure confidentiality

Interview techniques Problem solving Problem seeking Direct questions Open-ended questions

Methods of Data Collection Interview (continued)

3 phases of interview 1) Orientation 2) Working 3) Termination

Health history includes: Bio info, reason for seeking health care, present illness,

past health history, family history, environmental history, psychosocial history, review of systems

Methods of Data Collection Physical Exam

Exam done systematically Techniques used:

Inspection Palpation Percussion Auscultation

Methods of Data Collection Laboratory/ Diagnostic Tests

Ordered by physician based on symptoms or illness

Results are compared to established norms

Common lab tests: CBC, ABGs, FBS, UA, C & S, CXR, EEG, EKG