Nursing process comprise of 5 phases
That includes:
Assessment
Nursing diagnosis
Planning
Implementation
Evaluation
ASSESSMENT
- Is the systematic and continuous
collection, organization, validation,
and documentation of data
- It is the first step in nursing process
Purpose = To gather information, collect
data from different sources :
● Primary sources that are coming
from the client alone.
● Secondary sources that are coming
from the results of physical exam,
nursing health history, laboratory or
diagnostic test results.
Data can be classified as:
➔ Subjective Data : from the client,
complains of symptoms that needs
to be validated
➔ Objective data: can be observe from
the client’s signs of illness
Assessment is done to establish a patients
database which is a baseline data of the
client.
In doing assessment, we need to consider
what type of assessment we are going to
do.
Types of Assessment:
1. Initial Assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment
INITIAL ASSESSMENT
- It is performed within specified time
after admission
Purpose : is to complete database or
problem identification and reference
for future comparison
PROBLEM-FOCUSED ASSESSMENT
- It is an ongoing process integrated
with nursing care
Purpose: is to determine the status
of a specific problem identified in an
earlier assessment
EMERGENCY ASSESSMENT
- It is done during any physiologic or
physiologic crisis of the client
- Purpose : is to determine life-
threatening problems, identifying
new or overlooked problems
TIME-LAPSED REASSESSMENT
- It is done several months after initial
assessment
Purpose : is to compare the clients
status to baseline data previously
obtained
Assessment follows different process:
A. Data collection
B. Organization
C. Validation
D. Documentation
A. DATA COLLECTION - is the process of
gathering information about a client’s status.
Data is being defined as a set of information
or facts about a client.
- It focus on clients response to health
problems or information about
clients health status
*Data collected should be relevant to the
health problems.
- Consider the Time, Needs of client,
developmental stage of the client,
 physical surroundings, past and
present coping patterns that are
being used by our client.
★ Data to be collected includes:
○ Demographics
○ Medical history
○ Health habits
○ Education tikane
○ Allergies
○ Environmental and family
factors
○ Potential for injury
○ Ability to participate of care
○ Result of physical
assessment
★ Data Characteristics:
○ Complete
○ Factual
○ Accurate
○ Relevant
★ Types of Data:
○ Subjective - Symptoms or
covert data, which cannot be
readily observed by another
individual.
- This can be obtained:
Interview, sensation,
feelings, values, beliefs,
attitudes, perception of
personal health status, and
life situation
○ Objective - Signs or over
data. Can be observe, heard,
seen, felt or smelled, can be
measured or tested against
an acceptable standard
- Obtained : observation and
physical examination
★ Other description of data:
○ Variable
○ Constant
○ Variable - changes from day
to day or even our in needs
of updating from time to time
○ Constant - unchanging
★ Sources of Data:
○ Primary - patient; statement
made
- Primary source
- Usually best source
○ Secondary - coming from
other sources : Family or
Significant others, records or
reports of other healthcare
professionals and relevant
literature.
★ Data collection method:
1. Observation/Observing
2. Interview/Interviewing
3. Examination/Examining
OBSERVATION - process of gathering
data, using the senses.
INTERVIEW - gathering of data by asking
questions
❖ Types of interview:
➢ Open-ended - non directive
in nature, allows the clients
to express his feelings or
thoughts, freedom to share
their emotions.
➢ Closed - directive, requires
short or factual answers
➢ Neutral - can be answer by
the client without pressure
from nurse, open ended
questions and non directive
 ➢ Leading - usually close-
ended questions and
directive in nature, which
directs the clients to answer
the questions asked by the
nurse, gives the client less
opportunity to decide
whether the answer is true or
not.
❖ We should consider 2 approaches:
1. Directive approach - usually elicits
and specific information which the
nurse controls the subject matter,
the client has little opportunity to ask
question or discuss his/her concerns
2. Non-directive approach - the nurse
allows the client to control the
purpose, subject matter and phase
❖ Phases of interview:
1. Preparatory phase - the nurse
collects the background information
from previous charts,
- the nurse ensures that the
environment is conducive for
interview
- Seats are arranged 3-4 ft
apart
- interviewer is at 45 degree
angle to the patient
- And the client given an
adequate time to participate
in interview
2. Introductory phase - the nurse
introduces his/herself, identify its
purpose, ensures confidentiality,
provides patients need before
starting an interview
- During this phase the nurse
gathers info from client for
the subjective data
- The nurse should have an
excellent communication
skills, active listening, good
eye contact
- Open ended questions are
usually
3. Working phase
4. Termination phase - interview is
about to be end
- The gather information must
be kept confidential
EXAMINATION - physical examination/
assessment
- Systematic data collection method
that uses observation (sight,
hearing, smell, touch) to detect
health problems
❖ Approaches of Examination
Techniques
1. Body system - investigates each
system individually
2. Cephalocaudal - head to toe
❖ Also :
➢ Inspection - using sense
sight
➢ Palpation - using sense of
touch : finger pads because
their concentration of nerve
ending make them highly
sensitive to tactile
dicrimination
➢ Percussion - strikes the body
surface to elicits sound that
can be heard or vibration that
can be felt
➢ Auscultation - listens through
the use of stethoscope
B. ORGANIZATION - organizing related - Ask someone else to collect
cues into predetermined categories the same data to confirm
your findings

D. DOCUMENTATION - data should be

➔ Using 2 types of models: recorded in a factual manner & not as
◆ Nursing models: interpreted by the nurse
- Gordon’s 11 - Record Subjective data in the
Functional Health client’s own words, using quotation
Patterns marks
- NANDA Human - In documenting clients care, it
Response Pattern should be clear and concise --
◆ Non nursing model: - written in appropriate terminologies
Maslow’s Hierarchy of Needs - Avoid generalization, make it more
specific. Do not make summative
C. VALIDATION - “double checking” or statement regarding the client’s
verifying data status
*not all data should be validated especially
when the data is accepted, factual or
accurate
*validation process only done if there are
discrepancies
Purpose : to ensure its completeness,
accuracies and factual, Subjective and
Objective data may agrees, and to eliminate
errors, biases, and misperception, to avoid
jumping into conclusions

● Some ways to validate data:

1. Always compare S&O data to verify
the client’s statements with your
observations.
2. Be sure your data consist of cues,
not inferences. *inferences =
educated guesses
3. Double check data that are
extremely abnormal.
- Recheck your measurement
to be sure it is accurate
- Check to be sure your
measuring device is working
correctly, or use a different
piece of equipment.