PART A - ASSESSMENT Nursing foundation I sem

1. BASIC B.Sc NURSING DEGREE COURSE
( I YEAR)
NURSING FOUNDATIONS
UNIT V
THE NURSING PROCESS
PART A - ASSESSMENT

2. OBJECTIVES
At the end of the class, students will be able to:
• define nursing process
• list down the characteristics of Nursing Process
• understand the benefits of Nursing Process
• identify subjective and objective data gathered
• state and define interrelated phases of nursing
process
• formulate nursing diagnosis according to
NANDA using the nursing process
• apply the nursing process to a clinical situation

3. INTRODUCTION
Nursing is the protection, promotion
and optimization of health and abilities,
prevention of illness and injury, alleviation of
sufferings through the diagnosis and treatment
of the human response & advocacy in the care
of individual , family, community and population.
Nursing Process is a systematic way
of determining a client health status, isolating
health concern and problems, developing the
plans to remediate them, initiating actions to
implement the plan and finally evaluating the
adequacy of the plan in promoting wellness and
problem resolution

4. HISTORICAL PERSPECTIVE
1955- Hall- originated the term nursing process.
1960-Delineated the specific steps in a process.
1967-Yura and Walsh published book on Nursing
process.
1974- (Gebbie and lavin) –Nursing diagnosis as a
separate step in the process

5. STANDARDS OF NURSING
 Provision of a caring relationship that facilitates health and healing.
 Attention to the range of human experiences and responses to
health and illness within the physical and social environments
 Integration of objective data with knowledge gained from an
appreciation of the patient or group’s subjective experience.
 Application of scientific knowledge to the processes of diagnosis
and treatment through the use of judgment and critical thinking
 Advancement of professional nursing knowledge through scholarly
inquiry.
 Influence on social and public policy to promote social justice.

6. DEFINITION
Nursing process is a systematic, rational method of
planning and providing individualized nursing care. Its
purpose are to identify a clients health status and actual
(or) potential health care problems (or) needs, to establish
plans to meet the identified needs & to deliver specific
nursing interventions to meet these needs. The client may
be an individual, a family, a community (or) a group.

7. CHARACTERISTICS OF THE NURSING
PROCESS
• Systematic, cyclic and dynamic
• Client centered
• Focus on problem solving and decision making
• Interpersonal and collaborative style
• Universal applicability
• Use of critical thinking and clinical reasoning

8. THE NURSING PROCESS -FIVE STEP
PROCESS
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

9. ASSESSMENT

10. STEP I
DEFINITION - ASSESSSMENT
Assessing is the systematic and continuous
collection, organization, validation and
documentation of data
(or)
It is the deliberate and systematic
collection of the patients current and past health
and functional status and his (or) her present
and past coping patterns.

11. CASE SCENARIO
Mr. Jones complains his throat and
mouth are dry. He is allowed fluids, but has had
almost nothing to drink all evening.
He tells you he would like to drink, but
doesn’t like water, especially the warm water in
the pitcher.
He also hates to bother the nurse.The nurse
notes his oral mucosa is dry and cracked and his
urine output for the last shift is low.

13. Sl.
No
Type Time
Performed
Purpose Eg.
1. Initial
assessment
Performed
with specified
time after
admission to
a health care
agency
To establish a complete
data base for problem
identification, reference
and future comparison
Nursing admission
assessment.
2. Problem
focused
assessment
Ongoing
process
integrated
with nursing
care
To determine the status
of a specific problem
identified in an earlier
assessment
Hourly assessment
of clients fluid intake
and urinary output in
an ICU.
Assessment of clients
ability to perform self
care while assisting a
client to bathe

14. 3. Emergency
assessment
During any
physiological
crisis of the
client.
 To identify life
threatening
problems
 To identify new
(or) over looked
problems
Rapid assessment
of an individual’s
airway, breathing
status & circulation
during a cardiac
arrest.
Assessment of
suicidal tendencies
(or) potential for
violence
4. Time-lapsed
assessment
Several months
after initial
assessment
To compare the
clients current
status to baseline
data previously
obtained
Reassessment of a
clients functional
health patterns in a
home care (or)
outpatient setting
(or) in a hospital at
shift change.

15. ASSESSMENT – CRITICAL THINKING
• Making reliable observations.
• Distinguishing relevant from irrelevant data.
• Distinguishing important from unimportant
data.
• Validating data
• Organizing data.
• Categorizing data according to a framework
• Recognizing assumptions
• Identifying gaps in the data.

16. STEPS IN ASSESSMENT
• Collecting data
• Organizing data
• Validating data
• Documenting client data

17. STEP I
DATA COLLECTION
Consider
– time
– needs of patient
– developmental stage
– physical surroundings
– past and present coping patterns

18. CHARACTERISTICS OF DATA
• Complete
• Factual
• Accurate
• Relevant

19. TYPES OF DATA
• Subjective Data
– Patient
• Primary source
• Usually BEST source
Eg: Itching, pains and feelings of worry, client’s
sensations, feeling, values, beliefs, attitudes and
perception of personal health status and life
situation.
– Family & significant others
• When patient is a child or impaired adult
• Spouses
• Consider confidentiality when including
friends

20. TYPES OF DATA
Objective Data
– Observed data (What is not spoken)
Eg:
• Discoloration of the skin (or) a B.P
• Constant data that does not change over time
such as race (or) blood type
• Variable data can change quickly frequently (or)
rarely and include such data as B.P, level of pain
and age.
– Findings from physical examination
– Results from diagnostic or lab tests
– Information from pertinent nursing or medical
literature

21. Contd...
• Patient record
– History & Physical examination
– Laboratory
– Consultations
– X-ray, CT, PT/OT, other ancillary departments

22. SOURCES OF DATA
 Primary Data: Client/Patient
 Secondary Data:
I. Family members or significant others
II. Health care Team
III. Medical Record
IV. Laboratory and Diagnostic analysis
V. Other Records and the Scientific Literature
VI. Nurse’s Experience

23. Methods of Data Collection
1.OBSERVATION
It is a conscious deliberate skill ie.,
developed through effort and with an organized
approach.
Sense
• Vision
• Smell
• Hearing
• Touch
Two aspects in observing:
• Noticing the data
• Selecting, organizing and interpreting the data

24. 2.INTERVIEW
An interview is a planned communication (or)
a conversation with a purpose
i. Approaches in the interview:
• Directive interview
• Non directive interview

25. ii.Types of interview questions
• Open ended questions
• Closed
• Neutral questions
• Leading questions
• Back Channeling questions
• Probing questions

26. OPEN-ENDED
QUESTIONS
Sl.
No
Advantages Disadvantages
1. They let the interviewee do the talking They take more time
2. The interviewer is able to listen and observe Only brief answers may be given
3. They reveal what the interviewee thinks is
important
Valuable information may be
withheld
4. They may reveal the interviewee’s lack of
information, misunderstanding of words, frame
of reference, prejudices (or) stereotypes
They often elicit more
information than necessary
5. They can provide information the interviewer
may not ask for
Responses are difficult to
document and require skill
6. They can reveal the interviewee’s degree of
feeling about an issue
7. They can convey interest and trust because of the
freedom they provide
The interviewer requires skill is
controlling an open- ended
interview

27. CLOSED QUESTIONS
Sl.
No.
Advantages Disadvantages
1. Questions and answer can be controlled more
effectively
They may provide too little
information and require follow-
up questions
2. They require less effort from the interviewee They may not reveal how the
interviewee feels
3. They may be less threatening since they do not
require explanations(or) justifications
They do not allow the
interviewee to volunteer
possibly valuable information
4. They take less time They may inhibit
communication and convey lack
of interest by the interviewer
5. Information can be asked for sooner than it would
be volunteered
The interviewer may dominate
the interview with questions
6. Responses are easily documented
7. Questions are easy to use and can be handled by
unskilled interviewers

28. iii. Planning the interview and setting
a. Review available information
b. Review agency data collection form or prepare
interview guide
c. Both Nurse and client is made comfortable
Influential Factors during interview:
 Time
 Place
 Seating Arrangement
 Distance
 Language

29. iv. Phases of interview
• Preparatory Phase
– Nurse collects background information from
previous charts
– Ensure environment is conducive
– Arrange seating
• 2-3 ft apart
• Interviewer at 45° angle to patient
– Allow adequate time

30. Phases cont’d.
• Introduction
– Nurse introduces self
– Identifies purpose of interview
– Ensure confidentiality of information
– Provide for patient needs before starting
• Working
– Nurse gathers information for subjective data
– Excellent communication skills are needed
• Active listening
• Eye contact
• Open-ended questions

31. Phases cont’d.
• Termination
– Inform patient when nearing end of interview
– Ensure patient knows what will happen with
information
– Offer patient chance to add anything

32. 3.PHYSICAL EXAMINATION
 Is a systematic data collection method that uses
observation to detect health problems.
 Carried out systematically - head to toe
 May focus on a specific problem area noted from
assessment
 Screening examination/review of systems

33. STEP II
ORGANIZING DATA
• Cluster data into groups according to a nursing or
medical model (Maslow’s Basic Human Needs
Model)
• It helps to maintain a nursing focus and allows
patterns to be recognized
• Cluster by body system or need deficit
• Helps to identify nursing diagnosis pertinent to
your client
(eg., All information gathered regarding nutritional status
may help to identify nutritional alterations)

34. MASLOW’S BASIC HUMAN NEEDS MODEL

35. STEP III
DATA VALIDATION
• Verifies understanding of information
• Comparison with another source:
a. patient or family member
b. record
c. health team member

36. STEP IV
DATA DOCUMENTATION
• Clear and concise
• Appropriate terminology
– Usually on a designated form
• Physical assessment
– Usually by Review of Systems
• Overview of symptoms
• Diet
• Each body system

37. Documentation contd.,
• Record in permanent record
• Use patient’s own words in subjective data –
enclose in “ ___” (quotation marks)
• Avoid generalizations – be specific
• Don’t make summative statements – describe -
e.g. patient is being irritable should be patient
resists instruction or patient states “Don’t talk to
me, I don’t care about that”

38. REFERENCES
1. Kozier and erb’s, (2009).Fundamentals of
Nursing,(10th ed.).New Delhi:Pearson.
2. Potter,P.,Perry,A.,Stockert,P.,&Hall,A.(2013).
Fundamentals of Nursing(8th
ed.)St.Louis.:Mosby,USA.
3. Taylor, C., Lillis, C., Lynn, P., & LeMone, P. (2015).
Fundamentals of nursing the art and science of
person-centered nursing care(8th ed.). PA: Wolters
Kluwer. Philadelphia
4. TNAI,(2005).Fundamentals of Nursing(1sted.).India