Nursing Process

Insert Subject's name or Topic 3/24/22 | 1

 Nursing 101

Nursing Process
Assessment

Nursing Process 3/24/22 | 2

Definition of Assessment:

• An orderly and precise method of collecting

and analyzing information about the
physiological, psychosocial and socio-cultural
behavior of a client

Nursing Process | 3
1 Initial comprehensive

2 Focused

3 Emergency

4 Time-lapsed

Four Types of Nursing Assessments

Nursing Process | 4
1.Database Assessment: Initial
Assessment

• All the information about the client’s health

status will help in:
• Make a judgment about a patient’s health stat
• Refer the patient to a physician
• Plan and deliver individualized, holistic nursing
care.

Nursing Process 3/24/22 | 5

1.Database Assessment: Initial
Assessment (cont.)

• The initial • The nurse collect data

assessment is concerning all aspects
performed shortly of the patient’s health,
after the patient is establishing priorities
of ongoing focused
admitted .
assessments and
creating a reference
for future comparison.

Nursing Process 3/24/22 | 6

2. Focus Assessment:

• An in-depth assessment of a specific client

problem.
• It may be done during initial assess., but it is
routinely part of ongoing data collection.
• Another purpose of it is to identify new or
overlooked problems.

Nursing Process 3/24/22 | 7

 Example :

What are your

When did they start?
symptoms?

Are you taking any

What makes your
remedies (medical or
symptoms better?
natural) for your
Worse?
symptoms?
Nursing Process 3/24/22 | 8
3. Emergency Assessment:

• When a physiological or psychological crisis

present.

• The nurse perform an emergency assessment

to identify life-threatening problems.

Nursing Process 3/24/22 | 9

4. Time-lapsed Assessment:

• It is scheduled to compare a patient current

status to baseline data obtained earlier.

Nursing Process 3/24/22 | 10

assessments
Medical
• Target data pointing to
pathologic conditions

assessments
• Focus on the patient’s

Nursing
response to health
problems

Nursing Process 3/24/22 | 11

Example:

• Is there any interference with the patient’s

ability to meet basic human needs ?

• Can the patient perform the activity of daily

living ?

Nursing Process 3/24/22 | 12

1 Primary/Secondary

2 Objective/Subjective

3 Positive/Negative

4 Cues/Inferences

Types of Data
Nursing Process 3/24/22 | 13
 Types of Data

Primary Data Secondary Data

• Source of the data is • Source of the data is

the client everything and
everybody else that
contributes to the
Database Assessment.

Nursing Process 3/24/22 | 14

 Types of Data

Objective Data Subjective Data

• Measurable or • Data the client or the

observable significant others tell
information the nurse.
• It cannot be observed,
measured or validated
in any other way.

Nursing Process 3/24/22 | 15

 Types of Data

Positive Data Negative Data

• Data that indicates a • Data that indicates

deviation from normal there is no deviation
and suggests an from normal.
illness

Nursing Process 3/24/22 | 16

 Cues Inferences

• Data that comes to us • Judgments that are

via our senses. The made about the cues.
subjective and • It may be validated by:
objective data you physical examination,
identify is a cue that clarifying statements,
something may be checking your finding
wrong. with research reports,
textbooks, or journals
Nursing Process 3/24/22 | 17
Sources of Data

• Patient
• Family and significant others
• Patient record
• Other healthcare professionals
• Nursing and other healthcare literature

Nursing Process | 18
1 Observation

2 Examination

3 Interview

4 Research

Methods of Data Collection

Nursing Process 3/24/22 | 19
1. Observation

• A method of gathering data by using the

senses. The senses that are usually involved
are:
- sight
- touch
- smell
- hearing

Nursing Process 3/24/22 | 20

1. Observation
• Patient
How is the patient responding?
Are there signs of distress?
• Environment
Are there any safety concerns?
Are there other people in the room?
Is the equipment working properly? (IV therapy, O2 , drain…….)
• How to Observe:
Use your senses
Notice general appearance
Observe body language
Notice interaction patterns

Nursing Process 3/24/22 | 21

2. Examination: Physical assessment

• A method of gathering data that can involve the use

of an instrument or a more sophisticated technique.
The techniques involved are:

- Inspection - Auscultation

- Palpation

- Percussion
Nursing Process 3/24/22 | 22
Purpose of a Nursing Physical
Assessment

• Appraisal of health status

• Identification of health problems
• Establishment of a database for nursing
intervention

Nursing Process 3/24/22 | 23

3. Interview: Nursing History
• It is communicating with the client or significant other to obtain
data

• Successful Interview Techniques

• Focus on the patient during the interview.
• Listen to the patient attentively.
• Ask about patient’s main problem first.
• Pose questions and comments in appropriate manner.
• Avoid comments and questions that impede communication.
• Use silence and touch appropriately.

Nursing Process 3/24/22 | 24

4. Research:

• It is the process that gives us information

about:
- disease process
- diagnostic tests
- treatments
- expected client response

Nursing Process 3/24/22 | 25

Data Validation:

• Validation involves:
• verifying the client’s statements
• verifying client information with the documented
information
• measuring the data when possible
• examining the situation to see if there are any
interfering factors
• researching texts to insure that data is reasonable
Nursing Process 3/24/22 | 26
Data Documentation:

 Clustering Data

 Assessment Tool

 Scenarios

Nursing Process 3/24/22 | 27

 Thank you

Nursing Process 3/24/22 | 28