nursing

1. Assessing
Nursing 102

2. Learning Outcomes
 Describe the phases of the nursing process
 Identify major characteristic of the nursing
process
 Identify the purpose of assessing
 Identify the four major activities Associated with
the assessing phase
 Differentiate subjective and objective data, and
primary and secondary data

3. Learning Outcomes
 Identify three method of data collection
 Compare directive and non- directive
approaches to interviewing
 Compare close and open ended questions
 Describe important aspect to interview
setting

4. Nursing Process
 Is a systematic, client-centered method for
structuring the delivery of Nursing care
 Purposes of the nursing process:
1. Identify a client’s health status
2. Identify actual or potential health care problems or
needs
3. Establish plans to meet the identified needs
4. Deliver specific nursing interventions to meet those
needs

5. Components of the nursing process:
 Assessing
 Diagnosis
 Planning
 Implementing
 Evaluating.

8. Assessing
 Collecting Data
 Organizing Data
 Validating Data
 Documenting Data
 Goal:
- Establish a database about client response to
health concerns or illness
- The client may be an individual, a family, or a
group.

9. Diagnosing
 Analyzing and synthesizing data
 Goals:
 Identify client strength
 Identify health problem that can be
prevented or solved
 Develop a list of nursing and
collaborative problems

10. Planning
 Determine how to prevent, resolve or reduce
identified priorities client problems
 Determine how to support client strength
 Determine how to implement nursing interventions
in an organized, individualized and goal directed
manner
 Goals:
 Develop an individualized care plan that specifies
client goalsdesired outcomes
 Related nursing intervention

11. Implementing
 Carrying out and documenting planned nursing
intervention
 Goals:
 Assist clients to meet desired outcomes and goals
 Promote wellness
 Prevent illness or disease
 Restore health
 Facilitate coping with altered function

12. Evaluating
 Measuring the degree to which goalsoutcomes
have been achieved
 Identify factors that negatively or positively
influence goal achievement
 Goal:
 Determine whether to continue, modify or
terminate the plan of care

13. Characteristic of nursing
process
 Cyclic and dynamic nature
 Client centeredness
 Focus on problem solving and decision
making
 Interpersonal and collaborative style
 Universal applicability
 Use critical thinking in all phases

14. Assessment
 Is the systemic and continuous collection,
organization, validation, and
documentation of data (information)
 All phases of the nursing process depend
on the accurate and complete collection of
data.

15. Types of Assessment
 Initial nursing assessment:
Performed within specified time period
Establishes complete data base
 Problem-focused assessment:
Ongoing process integrated with care
Determines status of specific problem
 Emergency assessment:
Performed during physiologic or psychological crisis
Identifies life threatening problems
Identifies new or overlooked problem
 Time–lapsed assessment:
Occur several months after initial
Compares currant status to baseline

16. Process of Assessment
Collecting data
Organizing data
Validating Data
Documenting
Data

17. Collecting data
♣ Is the process of gathering information about a
client health status
♣ It must be systematic and continuous to prevent
the omission of significant data
♣ Database: is the all information about client,
which include health history, physical assessment
and examination, results of diagnostic and
laboratory test
♣ Data about client should include past history as
well as current problem

18. Subjective Data
 Symptoms or covert data
 Apparent only to the person affected
 Can be described only by person affected
 Includes sensations, feelings, values,
beliefs, attitudes and of personal health
status and life situation

19. Objective Data
 Signs or overt data
 Detectable by an observer
 Can be measured or tested against an accepted
standard
 Can be seen, heard, felt or smelled
 Obtained through observation or physical
examination

20. 4. Which of the following are objective
data and which are subjective data.
A. Nausea
B. Vomiting
C. Unsteady gait
D. Anxiety
E. Bruises on the right arms and
face
F. Temperature 39

21. Sources of data
 Client
 Other individuals
 Previous records
 Consultations
 Diagnostics studies
 Relevant literature

22. Source of Data
 Primary source
- The client
 Secondary sources
 All other sources of data such as (family member,
spouse, support person, primary care
provider,….etc)
 Should be validated if possible

23. Method of data collection
1. Observing:
 Gathering data use the senses
 Used to obtain following type of data:
Skin color (vision)
Body or breath odors (smell)
Lung or heart sound (hearing)
Skin temperature (touch)

24. 2. Interviewing:
 Planned communication or conversation with a
purpose
 Used to:
Identify problems with mutual concerns
Evaluate change
Teach
Provide support
Provide counseling or therapy
Method of data collection

25. ☺Approaches to interview
Directive approach:
 Nurse establishes purpose
 Nurse control the interview
 Used to gather or give information
when time is limited, e.g in an
emergency

26. Non- directive approach:
 Rapport building
 Client controls subject matter,
purpose and pacing
Note: combination of directive and
non- directive approaches usually
appropriate during the information
gathering interview

27. Types of interview questions:
Closed Questions
♦ Restrictive
- Yes No
- Factual
♦ Less effort and information
from client
♦ e.g “what medication you
take know
“ Are you having pain know
Open ended Questions
♦ Specify broad topic to
discus
♦ Invite longer answers
♦ Get more information from
client
♦ Useful to change topics and
elicit attitude
♦ e.g “how have you been
feeling lately “

28. Time:
 Patient free of pain
 Limited interruption
Place:
 Private
 Comfortable environment
 Limited distraction
The interview settings

29. Seating arrangement:
 In hospital
 In clinic
 In office
Distance:
 Comfortable
Language:
 Use easily understood terminology
 Interpreter or translator

30. Method of data collection
3. Examining (physical examination):
 Systematic data collection method
 Uses observation and inspections, auscultation,
palpation and percussion
Blood pressure (Bp)
Pulses
Heart and lung sound
Skin temperature and moisture
Muscle strength

31. Organizing Data
 Using written format
 Or according to model or frame work

32. Verifying Data
 Double check personal observation
 Double check equipments
 Check with experts and team member
 Recheck outliers
 Compare objective and subjective data
 Clarify statements
 Use references to explain phenomena

33. Documenting Data
 Record the client’s data.
 Should be accurate,
 recorded in factual manner and not
interpreted by the nurse (a
judgment).