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THE NURSING PROCESS
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  1. THE NURSING PROCESS Chapter 2 The Nursing Process: Assessment Step: Developing the Client Database

  2. Competencies for Chapter 2: The Assessment Step • By the end of this unit the student will: • Define assessment • Describe the 3 parts to developing a client database • Differentiate between subjective and objective data and list examples of each • Briefly describe 3 characteristics of data • List 4 sources of data • List 4 methods of data gathering • Describe proper patient interviewing technique • Define Initial, Focused, Emergency, and Time-lapse assessments • Describe the purpose of data validation

  3. Assessment Step: • Assessing • Systematic and continuous collection, validation, and communication of client data • Data • Client information that reflects or pertains to health functioning • Database • All pertinent client information collected by the nurse and other healthcare professionals

  4. Assessment Step: Developing a client database involves: • Systematic gathering of data • Sorting and organizing data • Documenting data

  5. Assessment Step: Types of data • Subjective:What client reports, believes, or feels • Objective:What can be observed Characteristics of data • Complete • Factual and accurate • Relevant

  6. Sources of Data: • Client, client’s family, friends, caregivers • Medical record-laboratory/diagnostic studies • Other healthcare professionals • Nursing/healthcare literature

  7. Data Gathering Methods: • Observation • Interview • Nursing physical assessment • Nursing History

  8. Interviews: • Know your purpose • Research the records • Request an interview • Conduct the interview • Conclude the interview

  9. Interviewing Techniques: • Establish rapport • Be sensitive to client’s needs • Use active listening • Ask open-ended questions • Avoid closed-ended, leading, or probing questions • Avoid agreeing or disagreeing • Remain objective

  10. Planning Data Collection: • Initial assessment • Focused assessment • Emergency assessment • Time-lapse assessment

  11. Assessment Priorities: • Health orientation • Developmental stage • Need for nursing • Practical considerations

  12. Data Validation: • The act of confirming or verifying • Keeps the data free from error, bias, and misinterpretation • Invalid information can lead to inappropriate nursing care

  13. Data Communication: • Immediately report critical findings verbally • Documentation • Use designated forms • Record in a timely fashion • Record in computer or in ink

  14. Chapter 2 - Summary • Systematic gathering of data • Interviewing • Sorting and organizing data • Documenting Data

  15. Chapter 2 – Summary • Assessment Step should provide: • A holistic view of the client • Data on the client’s state of wellness, response to health problems, and risk factors