BASIC B.

Sc NURSING DEGREE COURSE

( I YEAR)
NURSING FOUNDATIONS

UNIT V
THE NURSING PROCESS
PART A - ASSESSMENT

Dr. (Mrs) M.SARAYU PRIYA

RN.,RM
PRINCIPAL
 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
 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
 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
 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.

 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.
 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
 THE NURSING PROCESS -FIVE STEP
PROCESS

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
ASSESSMENT
 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.
 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.
Sl. Type Time Purpose Eg.
No Performed

1. Initial Performed To establish a Nursing admission

assessment with specified complete data base for assessment.
time after problem identification,
admission to reference and future
a health care comparison
agency

2. Problem Ongoing To determine the status Hourly assessment

focused process of a specific problem of clients fluid intake
assessment integrated identified in an earlier and urinary output in
with nursing assessment an ICU.
care Assessment of clients
ability to perform self
care while assisting a
client to bathe
3. Emergency During any  To identify life Rapid assessment
assessment physiological threatening of an individual’s
crisis of the problems airway, breathing
client.  To identify new status & circulation
(or) over looked during a cardiac
problems arrest.
Assessment of
suicidal tendencies
(or) potential for
violence

4. Time-lapsed Several months To compare the Reassessment of a

assessment after initial clients current clients functional
assessment status to baseline health patterns in a
data previously home care (or)
obtained outpatient setting
(or) in a hospital at
shift change.
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.
 STEPS IN ASSESSMENT

• Collecting data
• Organizing data
• Validating data
• Documenting client data
 STEP I
DATA COLLECTION
Consider
– time
– needs of patient
– developmental stage
– physical surroundings
– past and present coping patterns
 CHARACTERISTICS OF DATA

• Complete
• Factual
• Accurate
• Relevant
 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
 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
Contd...
• Patient record
– History & Physical examination
– Laboratory
– Consultations
– X-ray, CT, PT/OT, other ancillary departments
 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
 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
 2.INTERVIEW
An interview is a planned communication
(or) a conversation with a purpose

i. Approaches in the interview:

• Directive interview
• Non directive interview
 ii.Types of interview questions

• Open ended questions

• Closed
• Neutral questions
• Leading questions
• Back Channeling questions
• Probing questions
Sl. Advantages OPEN-ENDED QUESTIONS
Disadvantages
No
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 Valuable information may be

important
4. They may reveal the interviewee’s lack of
information, misunderstanding of words, frame
of reference, prejudices (or) stereotypes
5. They can provide information the interviewer
may not ask for
withheld
They often elicit more
information than necessary
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 The interviewer requires skill is
freedom they provide controlling an open- ended
interview
 CLOSED QUESTIONS
Sl. Advantages Disadvantages
No.
1. Questions and answer can be controlled more They may provide too little
effectively 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 They do not allow the
require explanations(or) justifications 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 The interviewer may dominate
be volunteered the interview with questions
6. Responses are easily documented

7. Questions are easy to use and can be handled by

unskilled interviewers
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
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
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
•
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
 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
 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)
MASLOW’S BASIC HUMAN NEEDS MODEL
 STEP III
DATA VALIDATION

• Verifies understanding of information

• Comparison with another source:
a. patient or family member
b. record
c. health team member
 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
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”
 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