Nursing process
Assess
Diagnose
Plan
Implement
Evaluate
Assessing
The systematic and continuous collection, validation, analysis, and communication of patient data, or information.
Types of Nursing Assessments
Initial comprehensive
Focused
Emergency
Time-lapsed
Initial Comprehensive Assessment
Performed shortly after admittance to hospital
Initial Comprehensive Assessment
Performed to establish a complete database for problem identification and care planning
Initial Comprehensive Assessment
Performed by the nurse to collect data on all aspects of patient's health
Focused Assessment
May be performed during initial assessment or as routine ongoing data co
Focused Assessment
Performed to gather data about a specific problem already identified, or to identify new or overlooked problems
Focused Assessment
Performed by the nurse to collect data about the specific problem
Emergency Assessment
Performed when a physiologic or psychological crisis presents
Emergency Assessment
Performed to identify life-threatening problems
Emergency Assessment
Performed by the nurse to gather data about the life-threatening problem
Time-Lapsed Assessment
Performed to compare a patient's current status to baseline data obtained earlier
Time-Lapsed Assessment
Performed to reassess health status and make necessary revisions in plan of care
Time-Lapsed Assessment
Performed by the nurse to collect data about current health status of patient
Establishing Assessment Priorities
Health orientation
Developmental stage
Need for nursing
Nursing assessments
Focus on the patient's response to health problems
The Primary Source of Information
patient
Focused assessment
the nurse gathers data about a condition that has already been diagnosed.
When a physiologic or psychological crisis presents, the nurse performs an
emergency assessment
Compares a patient's current status to baseline data obtained earlier.
time-lapsed assessment
Characteristics of Data
Purposeful
Complete
Factual and accurate
Relevant
Sources of Data
Patient
Family and significant others
Patient record
Other healthcare professionals
Nursing and other healthcare literature
minimum data set
specifies the information that must be collected from every patient and is a structured assessment form to organize or cluster these data.
The Skill of Nursing Observation
Determines the patient's current responses (physical and emotional).
Determines the patient's current ability to manage care.
Determines the immediate environment and its safety.
Determines the larger environment (hospital or community).
Phases of a Nursing Interview
Preparatory phase
Introduction
Working phase
Termination
Nurse gather all the information needed to form the subjective database
Working phase
Patient database is obtained
working phase
Nurse prepares the patient and the environment for the interview
preparatory phase
conclusion of the interview
termination
Purpose of a Nursing Physical Assessment
Appraisal of health status
Identification of health problems
Establishment of a database for nursing intervention
Allow patient to verbalize freely
Open-ended
Elicit specific information
Closed
Validate what is heard
Validating
Avert misconceptions
Clarifying
Encourage patient to elaborate on thoughts and feelings
Reflective
Place events in chronological order
Sequencing
Obtain more patient information
Directing
When to Verify Data
When there is a discrepancy between what the person is saying and what the nurse is observing
When the data lack objectivity