NURSING PROCESS INTRODUCTION AND PHASE 1 ASSESSMENT

1. NURSING PROCESS
INTRODUCTION

2. INTRODUCTION
• Defined by “hall” in 1955
• 1967 Yura And Walsh proposed four
elements of nursing process
– Assessment
– Planning
– Implementation and
– Evaluation

3. PURPOSES
• To identify a client health status and actual
or potential health care problems or needs
• To establish plans to meet the identified
needs and to deliver specific nursing
interventions to meet those needs

4. DEFINITION
The nursing process is a systematic,
rational method of planning and providing
nursing care.
• The nursing process is cyclical ,that is its
components follow a logical sequence ,
but more than one components may be
involved at one time.

5. COMPONENTS
• Assessment
• Nursing diagnosis
• Planning
• Implementing and
• Evaluating

6. CHARACTERISTICS
• Dynamic
• Client centered
• Planned
• Interpersonal and collaborative
• Universally applicable
• Can focus on problems and strength

7. CHARACTERISTICS
• Open and flexible
• Humanistic and individualized
• Cyclical
• Outcome focused
• Emphasizes feedback and validation

8. BENEFITS
• Continuity of care
• Prevention of duplication
• Individualized care
• Standards of care
• Increased client participation
• Collaboration of care

9. STEPS OF NURSING
PROCESS

11. ASSESSMENT

12. Assessment
• Assessing is the systematic and
continuous collection , organization ,
validation and documentation of data
(information) as compared to what is
standard norm.
• It is continuous process.
• All phases of nursing process depend on
the accurate and complete collection of
data.

13. Purposes of assessment
• To establish a data base
• To identify health‐promoting behaviors
• To identify actual and/or potential health
problems

14. Types of assessment
• Initial assessment
• Problem focused assessment
• Emergency assessment
• Time lapsed assessment

15. • INITIAL ASSESSMENT:-
It is done within specified time after admission to Hospital
• Purpose:
To establish a complete data base for problem
identification, reference and future comparison
Eg: Admission assessment
• PROBLEM FOCUSED ASSESSMENT :-
Ongoing process integrated with nursing care
• Purpose :
To determine the status of specific problem identified in an
earlier assessment
Eg: Hry assessment of clients fluid intake and urinary output in an ICU

16. • EMERGENCY ASSESSMENT:-
During any physiologic or psychologic crisis of the client
• Purpose:
To identify the threatening problem and to identify
new or overlooked problem
Eg: Rapid assessment of person’s airway and breathing status and circulation during a
cardiac arrest
• TIME LAPSED REASSESSMENT:-
Several months after initial assessment
• Purpose :
To compare the clients current status to baseline data
previously obtained
Eg: Reassessment of the clients functional health patterns in a home care or
outpatient setting or in a hospital at shift change.

17. Steps of assessment/activities
in assessment phase
1. Collect data
2. Organize data
3. Validate data
4. Document data

18. 1. Collection of data
It is the process of gathering
information a client’s health status
• Systematic and continuous
• Reflect the clients changing health status
• Needs client and nurse active participation

19. Data can be………

20. Types of data
Subjective
data
Objective
data
•Described by only the
person who affected
•Included client
sensations ,feelings,
beliefs ,attitudes and
perception of health status
Eg:- Itching
Pain
Feelings of worry
•Referred to as signs or
overt data
•Related on observer
•Can be measured or
tested
Eg:- Discoloration of
skin
Blood pressure

21. Sources
of data
Client
Support
people
Client’s
records
Health care
professionals
Literature

22. Methods of data collection
Observing Interviewing Examining

23. Observing
Observation is conscious, deliberate skill that is
developed through effort and with an organized
approach.
 Eg:- Using the senses to observe client data
• Methods observation :
– Vision
– Smell
– Hearing
– Touch
• Aspects of data :
– Noticing data
– Selecting, organizing and interpreting the data

24. Interviewing
An interview is a planned communication or a
conversation with a purpose
Eg: Nursing health history
• Approaches of an interview:
– Direct interview
– Indirect interview
• Types of interview questions:
– Closed questions (Are you having pain now?)
– Open ended question (what brought you to hospital?)
– Neutral questions (how do you feel about that?)
– Leading questions (you are stressed about surgery
tomorrow aren't you?)

25. Interviewing
• Planning the interview and setting:
– Time
– Place
– Seating arrangement
– Distance
– Language
• Stages of an interview
– The opening and introduction
– The body or development
– The closing

26. Examination
• Techniques
– Inspection
– Palpation
– Percussion
– Auscultation
• Physical examination can be,
– Cephalocaudal approach
– Screening examination
– Review of systems

27. 2. Organizing data
The nurses use a written (or computerized) format
that organizes the assessment data systematically
 Conceptual models or frame works
Nursing models or frame work
Gordon's functional health pattern
Orem’s self care model
Roy’s adaptation model
Wellness model
Non nursing models
Body system model
Maslow’s hierarchy of needs
Developmental theories

29. Orem’s self care model……

30. Body system model………….

31. Maslow’s hierarchy of needs……….

32. 3. Validating data
Validation is the act of “double checking "or
verifying the data to confirm that it is accurate
and factual.

33. 4. Documenting data
Assessment data must be recorded
and reported.
Accurate and complete record
communicates information to health care
team.

34. Thank you