Republic of the Philippines

CAMARINES SUR POLYTECHNIC COLLEGES

Nabua, Camarines Sur

BACHELOR OF SCIENCE IN NURSING

College of Health Sciences
1ST SEMESTER S/Y 2021-2022
NURSING PROCESS
Module 1: ASSESSMENT
Learning Outcomes:
1. Describe the phases of the nursing process.
2. Identify major characteristics of the nursing process.
3. Identify the purpose of assessing.
4. Identify the four major activities associated with the assessing phase.
5. Differentiate objective and subjective data and primary and secondary data.
6. Identify three methods of data collection, and give examples of how each is useful.
7. Compare directive and nondirective approaches to interviewing.
8. Compare closed and open-ended questions, providing examples and listing advantages and disadvantages of
each.
9. Describe important aspects of the interview setting.
10. Contrast various frameworks used for nursing assessment.

Introduction
The nursing process is a systematic, rational method of planning and providing individualized nursing care. Its
purposes are to identify a client’s 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. The client may be an
individual, a family, a community, or a group.

Phases of Nursing Process

It includes six phases of the nursing process: assessment, diagnosis, outcomes identification, planning,
implementation, and evaluation

Characteristics of the Nursing Process

The nursing process is a systematic, rational method of planning and providing nursing care. Its purpose is to
identify a client’s health care status, and actual or potential health problems, to establish plans to meet the identified
needs, and to deliver specific nursing interventions to address those needs. The nursing process is cyclical; that is, its
components follow a logical sequence, but more than one component may be involved at one time. At the end of the
first cycle, care may be terminated if goals are achieved, or the cycle may continue with reassessment, or the plan of
care may be modified.
Assessing includes:
• Collect data
• Organize data
• Validate data
• Document data
Assessing
 Assessing is the systematic and continuous collection, organization, validation, and documentation of data
(information)
 assessing is a continuous process carried out during all phases of the nursing process. For example, in the
evaluation phase, the client is reassessed to determine the outcomes of the nursing strategies and to evaluate
goal achievement
 Nursing assessments focus on a client’s responses to a health problem.
 A nursing assessment should include the client’s perceived needs, health problems, related experience, health
practices, values, and lifestyles.

Collecting of Data
Data collection is the process of gathering information about a client’s health status. Data collection must be
both systematic and continuous to prevent the omission of significant data and reflect a client’s changing health
status.

Types of Data
Subjective data
 also referred to as symptoms or covert data
 are apparent only to the person affected and can be described or verified only by that person. Itching,
pain, and feelings of worry are examples of subjective data.
 include the client’s sensations, feelings, values, beliefs, attitudes, and perception of personal health status
and life situation.
Objective data
 also referred to as signs or overt data
 are detectable by an observer or can be measured or tested against an accepted standard.
 They can be seen, heard, felt, or smelled, and they frequently, or rarely and include such data as blood
pressure, level of pain, and age.

Sources of Data
Sources of data are primary or secondary. The client is the primary source of data. Family members or other
support persons, other health professionals, records and reports, laboratory and diagnostic analyses, and relevant
literature are secondary or indirect sources.
Client - The best source of data is usually the client, unless the client is too ill, young, or confused to
communicate clearly.
Support People - Family members, friends, and caregivers who know the client well often can supplement or
verify information provided by the client. They might convey information about the client’s response to illness,
the stresses the client was experiencing before the illness, family attitudes on illness and health, and the client’s
home environment.
Clients Record - Client records include information documented by various health care professionals.
 Medical records (e.g., medical history, physical examination, operative report, progress notes, and
consultations done by primary care providers)
 Records of therapies provided by other health professionals, such as social workers, nutritionists,
dietitians, or physical therapists, help the nurse obtain relevant data not expressed by the client.
 Laboratory records also provide pertinent health information. For example, the determination of
blood glucose level allows health professionals to monitor the administration of oral hypoglycemic
medications.
Health Care Professionals - health care professionals serve as other potential sources of information about a
client’s health. Nurses, social workers, primary care providers, and physiotherapists, for example, may have
information from either previous or current contact with the client.
Literature - The review of nursing and related literature, such as professional journals and reference texts, can
provide additional information for the database. A literature review includes but is not limited to the following
information:
• Standards or norms against which to compare findings (e.g., height and weight tables, normal developmental
tasks for an age group)
• Cultural and social health practices
• Spiritual beliefs
• Assessment data needed for specific client conditions
• Nursing interventions and evaluation criteria relevant to a client’s health problems
• Information about medical diagnoses, treatment, and prognoses
 • Current methodologies and research findings
Data Collection Method
 Observing
 To observe is to gather data by using the senses
 Observing has two aspects: (a) noticing the data and (b) selecting, organizing, and interpreting the
data.
For example, a nurse walks into a client’s room and observes, in the following order:
1. Clinical signs of client distress (e.g., pallor or flushing, labored breathing, and behavior indicating pain
or emotional distress)
2. Threats to the client’s safety, real or anticipated (e.g., a lowered side rail)
3. The presence and functioning of associated equipment (e.g., intravenous equipment and oxygen)
4. The immediate environment, including the people in it.
 Interviewing
An interview is a planned communication or a conversation with a purpose, for example, to get or give
information, identify problems of mutual concern, evaluate change, teach, provide support, or provide
counseling or therapy.
Focused interview - the nurse asks the client specific questions to collect information related to
the client’s problem. This allows the nurse to collect information that may have previously been
missed and yields more in-depth information
2 approaches
1. Directive - is highly structured and elicits specific information, the nurse controls the interview
2. Non-directive - or rapport building interview, the nurse allows the client to control the purpose,
subject matter, and pacing. Rapport is an understanding between two or more people.
 Examining
The physical examination or physical assessment is a systematic data collection method that uses
observation (i.e., the senses of sight, hearing, smell, and touch) to detect health problems.
 Cephalocaudal
 Screening Examination
 Review of system

Organizing of Data
The nurse uses a written (or electronic) format that organizes the assessment data systematically. This is
often referred to as a nursing health history, nursing assessment, or nursing database form. Many of these are
based on selected nursing models or frameworks
Examples:
 Wellness Model
 Body System Model
 Maslow’s Hierarchy of needs
 Developmental Theories

Validating of Data
 The information gathered during the assessment phase must be complete, factual, and accurate because
the nursing diagnoses and interventions are based on this information.
 Validation is the act of “double-checking” or verifying data to confirm that it is accurate and factual.
Documentation of Data
To complete the assessment phase, the nurse records client data. Accurate documentation is essential
and should include all data collected about the client’s health status. Data are recorded in a factual manner and
not interpreted by the nurse.
Prepared by:
Jocyl Darrel B. Abinal, R.M, R.N, MAN
Clinical Instructor

Source: Kozier and Erb’s FUNDAMENTALS OF NURSING, concept, process and practice 10th edition Unit 3, Chapter 11