Nursing Process-Assessment Part 1

Embed Size (px)

Citation preview

  • 8/3/2019 Nursing Process-Assessment Part 1

    1/21

    Nursing Process: Nursing

    Assessment

    George Ann Daniels, MS, RN

  • 8/3/2019 Nursing Process-Assessment Part 1

    2/21

    Assessment

    Continuous and systematic collection,validation, and communication of client

    data .(Harrington, 1996)

  • 8/3/2019 Nursing Process-Assessment Part 1

    3/21

    Assessment

    Purpose: Collect, validate and organize data

    about a clients state of wellness, functional

    ability, physical status, strengths, and

    responses to actual and potential health

    problems.

    Initial, focused, time-lapsed and emergencyassessment are done depending on the

    circumstances

  • 8/3/2019 Nursing Process-Assessment Part 1

    4/21

    Essential pre-assessment

    activities Choose a framework for assessment and

    documentation

    Gordons functional health patterns

    Control the environment

    Work on assessment skills

    Observation

    Interviewing

    Physical exam

    Intuitions

  • 8/3/2019 Nursing Process-Assessment Part 1

    5/21

    Types of Data

    Subjective: facts presented by the client that

    show his/her perception

    Objective: facts that are observable and

    measurable by the nurse, involves use of the

    senses

    Seeing

    Hearing

    Smelling

    Touching

  • 8/3/2019 Nursing Process-Assessment Part 1

    6/21

    Cues

    A word used to describe the individual

    pieces of data or hints about what is going

    on with the client

    Also called assessment findings

    Cues are analyzed to arrive at appropriate

    NDX

  • 8/3/2019 Nursing Process-Assessment Part 1

    7/21

    Sources of Data

    Primary: from the client, considered the

    most reliable if the client is deemed a good

    historian

    Nursing judgment

    Secondary: significant others, the medical

    or health record, lab tests, diagnosticprocedures, meds, past medical HX, other

    health team members, and literature review

    Data needs to be validated

  • 8/3/2019 Nursing Process-Assessment Part 1

    8/21

    Organization of Data

    Need to use an organized assessment

    framework to help cluster assessment data

    (cues)into meaningful groups

    RSU uses Gordons Functional Health

    Patterns

  • 8/3/2019 Nursing Process-Assessment Part 1

    9/21

    Health Perception-Health

    Management Clients awareness of personal health and

    well-being; health practices; understanding

    of how health practices contribute to health

    status

    To assess this pattern, focus on a general

    survey of the clients health status and theirusual health behaviors

  • 8/3/2019 Nursing Process-Assessment Part 1

    10/21

    Nutritional-Metabolic Pattern

    Patterns of food and fluid intake,

    relationship of intake to metabolic needs;

    skin assessment, fluid volume,thermoregulation

    To assess this pattern, focus on eating

    habits, appraisal of appetite, weight loss orgain, changes in skin, hair,or nails.

  • 8/3/2019 Nursing Process-Assessment Part 1

    11/21

    Elimination Pattern

    Patterns of excretory function (Bowel,

    Bladder,and Skin), and client perception of

    same

    Assess usual bowel and bladder elimination

    habits,laxative use, excretory function of

    skin (e.g. excessive perspiration)

  • 8/3/2019 Nursing Process-Assessment Part 1

    12/21

    Activity -Exercise

    Patterns of exercise, activity, leisure

    recreations, and ADL; factors that interfere

    with desired or expected individual pattern

    Assess mobility status, exercise routine,

    leisure activities, cardiovascular status

  • 8/3/2019 Nursing Process-Assessment Part 1

    13/21

    Sleep- Rest pattern

    Patterns of sleep and rest-relaxation periods

    during 24 hour day. As well as quality and

    quantity

    Assess regular sleep habits and routine

  • 8/3/2019 Nursing Process-Assessment Part 1

    14/21

    Cognitive-Perceptual Pattern

    Adequacy of sensory modes, such as vision,

    hearing taste, touch, smell, pain perception,

    cognitive functional activities

    Assess changes in cognitive function,

    ability to hear, see, and speak, presence of

    pain, numbness, or other sensations

  • 8/3/2019 Nursing Process-Assessment Part 1

    15/21

    Self-perception- Self-concept

    Pattern Individuals attitudes about self, perception

    of abilities, body image, identity, general

    sense of worth and emotional patterns

    Assess descriptions of self, physical

    appearance, effects of illness, major life

    accomplishments and changes

  • 8/3/2019 Nursing Process-Assessment Part 1

    16/21

    Role- Relationship Pattern

    Client's perception of major roles and

    responsibilities in current life situation

    Assess client's perceptions of key

    relationships, observation of interactions

    with others

  • 8/3/2019 Nursing Process-Assessment Part 1

    17/21

    Sexuality-Reproductive Pattern

    Client's perceived satisfaction or

    dissatisfaction with sexuality.

    Reproductive stage and pattern

    Assess clients appraisal of his or her sexual

    role and sexual health.

  • 8/3/2019 Nursing Process-Assessment Part 1

    18/21

    Coping-Stress Tolerance Pattern

    General coping pattern, stress tolerance and

    management, support systems, and

    perceived ability to control and managesituations

    Assess current stress level, coping ability,

    ability to endure life stressors, physiologicresponses to stress

  • 8/3/2019 Nursing Process-Assessment Part 1

    19/21

    Value- Belief Pattern

    Values, goals, or beliefs that guide choices

    or decisions.

    Assess identification of valued people and

    possessions, source of support, religious

    practices

  • 8/3/2019 Nursing Process-Assessment Part 1

    20/21

    Measurement Criteria for ANA

    Standard I: Assessment: The nurse collects

    client health data

    Data collection involves client, significant

    others, and healthcare providers when

    appropriate

    The priority of data collection activities isdetermined by the clients immediate condition

    or needs

  • 8/3/2019 Nursing Process-Assessment Part 1

    21/21

    Pertinent data are collected using

    appropriate assessment techniques and

    instruments

    Relevant data are documented in a

    retrievable form

    The data collection process is systematic

    and ongoing