NURSING PROCESS ASSESSMENT PHASE

DEFINITION

• Nursing process is an assertive problem solving approach to the identification and treatment of patients problems it provides an organizing framework for the practice of nursing and the knowledge, judgment and actions that nurses do to provide patient care.

Nursing process requires skills of nurses such as

1. Cognitive skills - Reasoning & Thinking
2. Affective skills - Feelings & Values
3. Psychomotor skills - Actions & Doing

PHASES OF NURSING PROCESS - OVERVIEW

PHASES OF NURSING PROCESS

• Assessment: 
  • Assessment is the collection of patient information which provides the basis for plan of care
  • Analysis of the Assessment data and making judgment regarding the nature of data results in formulation of nursing diagnosis.
• Nursing Diagnosis:
  • It is the act of identifying the patients actual and potential health problems or life processes and labelling using concise statement that describes the individual response to the health problems.
• Planning: 
  • The identification of the problem and formulation of nursing diagnosis provides direction for the development of patient outcomes or goals and identification of nursing interventions to accomplish the goals.
• Implementation:
  • It is the working phase where the planned interventions are applied and the activities are carried out on the client.
• Evaluation: 
  • It is the continuous activity of the nursing process that determines if the patients outcome have been met as a result of nursing interventions
  • If the outcome are not met, a review of the steps of nursing process is necessary to determine the reasons why the outcomes are not met and revise the nursing process.

ASSESSMENT PHASE

Data Collection:

• Accurate data collection is the foundation for appropriate diagnosis, planning and intervention.
• A human is a biophysical & spiritual being that has needs and problems in various dimensions such as biophysical, psychological socio cultural, spiritual and environmental.
• It involves a systematic and continuous collection, validation and communication of client data as compared to what is standard/norm.
• It includes the client’s perceived needs, health problems, related experiences, health practices, values and lifestyles.

Types of Data:

• Subjective Data:
  • It is also referred to as Symptom/Covert data
  • Information from the client’s point of view or are described by the person experiencing it.
  • Information supplied by family members, significant others; other health professionals are considered subjective data
  • Example: Pain, Nausea, Vomiting, Diarrhea, etc.
• Objective Data:
  • It is also referred to as Sign/Overt data
  • Those that can be detected observed or measured/tested using accepted standard or norm.
  • Example: pallor, diaphoresis, vital signs, skin discoloration, Examination of body parts.

METHODS OF DATA COLLECTION

• Interview:
  • It is a planned, purposeful conversation or communication with the client to get information, identify problems, evaluate change, to teach, or to provide support or counseling.
  • it is used while taking the nursing history of a client.
• Observation:
  • Gather data by using the 5 senses and instruments.
• Examination: 
  • Anthropometric Measurements Such as height, weight, BMI, circumference
  • Physical Examination ( Head to Toe Assessment)
  • Review of Body Systems
  • Interpretation of Laboratory Results

ASSESSMENT PHASE

• Data Validation: 
  • It is the act of “double-checking” or verifying data to confirm that it is accurate and complete.
  • Interpretation is done based on the cues-Subjective or objective data observed by the nurse; it is what the client says, or what the nurse can see, hear, feel, smell or measure.
• Data Organization:
  • Organisation is done based on the priority needs/ problems of the client
  • It Uses a written or computerized format that organizes assessment data systematically.
• Data Analysis:
  • The data obtained is compared against standards(i.e. accepted measurements, Patterns & values) and identify significant cues.
  • Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic values, normal growth and development pattern.
• Data Communication:
  • Record all data collected about the client’s health status
  • Data are recorded in a factual manner not as interpreted by the nurse
  • Record subjective data in client’s word; restating in other words what client says might change its original meaning.