a simple power point about a phase of nursing process (assessment), and about types of collecting data and types of data

1. University of slemany
Faculty of medicine
School of nursing
A.L.baxan lava sattar
2012-2013

2. Nursing process
assessment

3. Introduction to
nursing :
Nursing is an art of applying scientific
principle in a humanitarian way to care of
people .the nursing process serves as the
organization framework for the practice of
nursing.

4. Nursing process:
Is a systematic method by which nursing :
plans and avoid care for patients .
The involves a problem-solving approach
that enable the nurse to identify patient
problems and potential at-risk needs
(problems) and to plan , deliver , and
evaluate nursing care in an orderly
,scientific manner.

5. Components of nursing process :
The nursing process consists of five dynamic and
interrelated phases:
1-assessment.
2-diagnosis.
3-planning.
4-implementation.
5-evaluation.

6. Assessment
Is the systematic and continuous :
-collection
-organization
-validation
-documentation of data

7. *The nurse gathers information to identify the health
statue of the patient .
*Assessment are made initially and continuously
throughout patient care.
*The remaining phases of the nursing process depend
on validity and completeness of the initial data
collection.

8. Purpose of assessment
To establish database : all the information about a client
: it includes:
-the nursing health history
-physical examination
-the physician’s history
-results of laboratory and diagnostic tests

9. Purpose :
Assessment is part of each activity the nurse dose for and
with the patient
The purpose is
-to validate a diagnosis
-to provide basis for effective nursing care
-it helps in effective decision making
-basis for effective diagnosis
-it promote holistic nursing care
-to provide effective and innovative nursing care
-to collecting data for nursing research
-to evaluation of nursing care

10. Assessment types:
1-The initial assessment
2- Focused Assessment
3- Time-Lapsed Assessment
4-Emergency Assessments

11. 1-The initial assessment
also known as triage, helps to determine the nature of
the problem and prepares the way for the ensuing
assessment stages. The initial assessment is going to be
much more thorough than the other assessments used
by nurses. Components may include obtaining a
patient's medical history or putting him through a
physical exam, or preparing a psychosocial assessment
for a mental health patient. Other components may
include obtaining a patient's vital signs and taking
subjective statements from the patient, as well as
double-checking the subjective symptoms with the
objective signs of the condition.

12. 2- Focused Assessment
The focused assessment is the stage in which the
problem is exposed and treated. Due to the importance
of vital signs and their ever-changing nature, they are
continuously monitored during all parts of the
assessment. Depending on the malady, initial treatment
for pain and long-term treatment for the root cause of
the malady is administered and monitored. Part of the
goal of the focused assessment is to diagnose and treat
the patient in order to stabilize her condition. Focused
assessments may also include X-rays or other types of
tests.

13. 3- Time-Lapsed Assessment
Once treatment has been implemented, a time-lapsed
assessment must be conducted to ensure that the patient
is recovering from his malady and his condition has
stabilized.
Depending on the nature of the malady, the time-lapsed
assessment may span the length of one or two hours or a
couple of months. During the time-lapsed assessment,
the current status of the patient is compared to the
previous baseline during and prior to treatment. Similar
to the focused assessment, the time-lapsed assessment
may also include lab work, X-rays or other diagnostic
medical testing.

14. 4-Emergency Assessments
During emergency procedures, a nurse is focused on
rapidly identifying the root causes of concern for the
patient and assessing the airway, breathing and
circulation (ABCs) of the patient. Once the ABCs are
stabilized, the emergency assessment may turn into an
initial or focused assessment, depending on the
situation. If the nurse is not in a health care setting,
emergency assessments must also include an assessment
for scene safety so that no other individuals, including
the nurse himself, are hurt during the rescue and
emergency response process

15. Steps of assessment:
1-collection of data
-subjective data collection
-objective data collection
2-validation of data
3-organaization of data
4-recording / documenting of data

16. Collection of data
-gathering of information about the client
-includes physical , psychological , emotion , socio-
cultural , spiritual factors that may affect client’s health
status
-includes past health history of client ( allergies ,past
surgeries ,chronic disease , use of folk healing methods )
-includes current/present problems of client ( pain ,
nausea , sleep , pattern , religion practices , medication ,
or treatment the client is taking now )

17. Types of data:
when performing data an assessment the nurse gathers
subjective and objective data
subjective data(symptoms or convert data) :
are the verbal statements provided by the patient .
statements about nausea and descriptions of pain and fatigue
are examples of subjective data.
Objective data:
Are detectable by an observer or can be measured or tested
against an accepted standard . they can be seen , heard , felt ,
or smelt , and they are obtained by observation or physical
examination . for example : discoloration of skin