The Nursing Process

1. The Nursing Process ASSESSMENT

2. Nursing Process • Dynamic, ongoing • Facilitates delivery of organized plan of nursing care • Involves 5 parts • Assessment • Diagnosis • Planning (goal making) • Implementation • Evaluation

3. Assessment • Systematic • Deliberate (planned, organized) • Collection of information (data) • Patient’s current and past health status • Functional status • Past and present coping patterns

4. Types of Nursing Assessments • Initial • Focused • Emergency • Time-lapsed

5. Assessment Priorities • Health orientation • Development stage • Need for nursing • Practical considerations

6. 2 parts of Assessment Collection and verification of data from primary source (the patient) secondary source (family, health records, other healthcare professionals) Analysis of data

7. Assessment Purpose • Formulate a database about the patient’s • Perceived needs • Health problems • Responses to the problems • Extra information about • Related experiences • Health practices • Goals/values/expectations about healthcare system

8. Critical Thinking • Used by nurse collecting data • An active, organized thought process • A simultaneous synthesis of nurse’s • Knowledge • Clinical experience • Standards of practice • Critical thinking standards and attitudes

9. Data Collection Characteristics • Complete • Factual • Accurate • Relevant

10. Data Collection Methods • Observation • Interview • Preparatory • Orientation • Working • Termination • Techniques of Physical Assessment

11. DATA COLLECTION • Types of Data • Subjective • What the patient or family member says • Goes in “---” (quotation marks) • Other sources • Health care team members • Health record

12. DATA COLLECTION • Objective • Observed data (What is not spoken) • Findings from physical exam • Results from diagnostic or lab tests • Information from pertinent nursing or medical literature

13. Documentation of Data • Clear and concise • Appropriate terminology • Usually on a designated form • Physical assessment • Usually by Review of Systems • Overview of symptoms • Diet • Each body system

14. Data Validation Verifies understanding of information Comparison with another source patient or family member record health team member

15. Data Interpretation Process of inferential reasoning and judgment (critical thinking) • Interpretation of what information is relevant to present status • Summary of data • Provides focus for nursing attention