Nursing Process- Assessment
Overview of Nursing Process
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Purpose of Nursing Process:
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The nursing process guides our care, it
helps us to identify the patient’s needs,
establish goals of care, communicate our
plan, and evaluate our care.
Characteristics of the Nursing
Process
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It has purpose, it is goal driven
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It is organized
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It is creative
Steps of the Nursing Process
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Assessment
Analysis (Nursing Diagnosis)
Planning
Implementation
Evaluation
Assessment- the first phase
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Data collection phase
The purpose= establish a data base
Through assessment includes 3 parts:
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1)
2)
3)
Nursing history
Physical exam
Lab/ diagnostic test data
Data
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Data should be:
 Descriptive
 Concise
 Complete
Data should be validated
Types of data
 Subjective
 Objective
Data should be organized
 Gordon’s functional health patterns
 Systems organization
Sources of Data
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Client
Family or significant other
Health team members
Medical record
Literature review
Methods of Data Collection
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Health history and interview
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Interviewing steps
Introduction
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Set a time limit
Ask if they have questions before starting
Assure confidentiality
Interview techniques
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Problem solving
Problem seeking
Direct questions
Open-ended questions
Methods of Data Collection
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Interview (continued)
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3 phases of interview
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1)
2)
3)
Orientation
Working
Termination
Health history includes:
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Bio info, reason for seeking health care, present illness,
past health history, family history, environmental history,
psychosocial history, review of systems
Methods of Data Collection
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Physical Exam
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Exam done systematically
Techniques used:
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Inspection
Palpation
Percussion
Auscultation
Methods of Data Collection
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Laboratory/ Diagnostic Tests
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Ordered by physician based on symptoms
or illness
Results are compared to established
norms
Common lab tests: CBC, ABGs, FBS, UA,
C & S, CXR, EEG, EKG