MODULE 4: NURSING PROCESS AND ASSESMENT

Standards of Nursing Practice i.e. Scope and Standards

of Nursing Practice.
OUTLINE

I. Introduction
NURSING PROCESS
II. Overview of the Nursing Process
a. Definition of Nursing Process  A deliberate activity whereby the practice of nursing is
b. History performed in a systematic manner
c. Nursing Process  The foundation, the essential, enduring skill that has
d. Purpose of the Nursing Process characterized nursing from the beginning of the
e. Characteristics of The Nursing Process profession
That Promote Critical Thinking  A SYSTEMATIC & OUTCOME ORIENTED method that
f. Principles of Nursing Process
nurses use to expedite diagnosis and treatment of actual
(ACODE)
g. Steps of the Nursing Process and potential health problems
III. Assessment  Consists of 5 INTERRELATED STEPS;
a. Definition o Assessment, Diagnosis, Planning, Implementation &
b. Assessment Evaluation which serves as CRITICAL THINKING
c. Characteristics of an assessment that MODEL FOR NURSING
promotes critical thinking
d. Two Main Types of Assessment PURPOSE OF THE NURSING PROCESS
e. Assessment activities
f. Identifying Subjective and Objective  To provide a systematic methodology for nursing practice
Data
 It unifies, standardizes, and directs nursing practice
INTRODUCTION  Help the nurse continually assess & reassess the
patient’s response to illness & then plan appropriate care
 Nursing is described as both an art and a science; a in any setting for illness care or health promotion
heart and a mind. At its heart, lies primarily in respect for
human dignity and an understanding for human needs.
CHARACTERISTICS OF THE NURSING PROCESS
The practice and purpose of nursing is caring which is THAT PROMOTE CRITICAL THINKING
handled by the process the nurses view the client's health
 PURPOSEFUL & DELIBERATE
and the client’s environment.
o each step has specific principles and rules designed
 The use of the Nursing Process is essential in the
to achieve a specific purpose
Nursing practice. The Nursing Process, as a problem-
 HUMANISTIC
solving method, is used to develop evidence-based plans
o must consider unique interests, values, desires and
for patient care as they respond to actual or potential
culture
health problems. This incorporates assessment, nursing
o guides you to focus holistically on the body, mind &
diagnosis, planning, implementation and evaluation as
spirit
the five steps of the Nursing Process.
o pushes you to consider health problems in context of
OVERVIEW OF THE NURSING PROCESS how they impact on sense of well-being and ability to
DEFINITION OF NURSING PROCESS do desired activities
 SYSTEMATIC
 Nursing Process is a systematic problem-solving o five steps guide you to think systematically about
process that guides all nursing actions to help the nurse what’s
provide goal directed and client centered care. It has set o most important & to take deliberate steps to
of actions occur in sequence and are interrelated. The maximize efficiency
primary purpose of Nursing Process is to help the nurse  STEP-BY-STEP, YET DYNAMIC
manage patient care scientifically and with good o to ensure that nothing important is missed
judgement.  OUTCOME-FOCUSED & COST EFFECTIVE
o result oriented
HISTORY – DEVELOPMENT OF NURSING o designed to help you stay focused on getting the best
PROCESS results in the most efficient way
 PRO-ACTIVE
 Lydia Hall (1955) introduced the term nursing process. o emphasizes the need to not only treat problems, but
Lydia identified three aspects of nursing care: Care, Cure, also
and Core and the three steps of nursing process: o maximize health by managing risk factors & by
Observation, Ministration of Care, and Validation. encouraging healthy behaviors
 Johnson (1959), Orlando (1961), and Wiedenbach  EVIDENCE BASED
(1963): refers Nursing Process as series of phases o it mandates that judgments, decisions, & actions be
describing the practice of nursing. based on the best evidence than guesswork
 The use of the nursing process in the clinical practice o strict documentation requirements ensure that we
gained additional legitimacy in 1973 when the phases have the data we need to manage care & help
were included in the American Nurses Association (ANA) researchers study care practices & improve them

ANDREA DENISE SAMBRANO | BSNS1B

 INTUITIVE & LOGICAL o Making immediate changes as needed
o principles of nursing process push you to o Charting to monitor progress
acknowledge patterns & intuitive hunches, then
EVALUATION
to look for evidence that supports your intuition
 REFLECTIVE, CREATIVE & IMPROVEMENT-  Assess the patient to decide whether expected outcomes
ORIENTED have been met
o stresses the need for on-going evaluation, requiring  Then decide whether to discharge the patient or modify
to continually reflect on both patient responses the plan as appropriate, and you plan for ongoing
(outcomes) &practice (how we give care) so that continuous assessment and improvement
corrections can be immediately done
ASSESSMENT
o requires to work continually to improve nursing care,
encouraging one to think creatively about how to get DEFINITION OF ASSESSMENT
better results in easier, more efficient, less costly  Assessment is a key component of nursing practice,
ways
required for planning and provision of patient and family
Figure 1. The Nursing Process centered care. An RN uses a systematic, dynamic way to
collect and analyze data about a client, the first step in
delivering nursing care. Assessment includes not only
physiological data, but also psychological, sociocultural,
spiritual, economic, and life-style factors as well. (ANA,
2018).

Figure 2. The Nursing Process

PRINCIPLES OF NURSING PROCESS (ACODE):

 A cognitive process
 Client centered
 Outcome-directed;
o Systematic problem-solving approach
 Dynamic and cyclic
 Encourages medical diagnosis

STEPS OF THE NURSING PROCESS ASSESSMENT

ASSESSMENT  systematic, deliberate process

 continuous data collection
 Collect & Record all information needed to be able to:
 analyzes data about the patient, client’s human response,
o Predict, detect, prevent, manage, or eliminate health
problems health status, strengths and concerns
o Clarify expected outcomes (results?)  finding all the “necessary puzzle pieces” to get a picture
o Develop a comprehensive plan of your patient’s health status
 collecting, organizing and communicating / recording
DIAGNOSIS client data
 Analyze assessment data, draw conclusions, and  PURPOSE: to establish data base about the client’s
determine: response to health concerns or illness and the ability to
o Actual and potential health problems and their manage health care needs
cause(s)
o Presence of risk factors CHARACTERISTICS OF AN ASSESSMENT THAT
o Resources, strengths, use of healthy behaviors PROMOTES CRITICAL THINKING
o Health states that are satisfactory but could be
improved  PURPOSEFUL
o your aim is to gain all the information needed to
PLANNING ensure that your patients have “individualized plans”
 Clarify expected outcomes, set priorities, and determine  FOCUSED & RELEVANT
interventions. The interventions are designed to: o Must be focused to gain relevant information,
o detect, prevent, and manage health problems and depending on purpose and context
risk factors  SYSTEMATIC
o promote optimum function, independence, and o Helps pay attention to what’s important, learn how to
sense of well-being prioritize, be comprehensive, and avoid omission
o achieve the expected outcomes safely and efficiently errors
IMPLEMENTATION  COMPREHENSIVE & ACCURATE
o factual & complete
 Put the plan into action by:  RECORDED IN A STANDARDIZED WAY
o Assessing appropriateness of (and readiness for) o value the importance of completing a standardized
interventions tool designed to promote an assessment that’s
o Performing interventions, then reassessing to purposeful, relevant, systematic and complete
determine initial responses
 TWO MAIN TYPES OF ASSESSMENT o client communicates what he or she thinks, feels,
knows and perceives in response to questions from
 DATA BASE ASSESSMENT the nurse
o “start of care” assessment  CLOSING
o Comprehensive information gathered on initial o important in facilitating future interactions
contact with the person to assess all aspects of
health status
 FOCUS ASSESSMENT  Examination of Patient
o Data gathered to determine the status of a specific
condition PHYSICAL ASSESSMENT has to be:

ASSESSMENT ACTIVITIES  Thorough

 Systematic
 COLLECTING DATA  Skilled
o Data Collection Skills APPROACHES
 Observation of patient
 noting pieces of information or cues through  Head-to-toe Assessment/Cephalocaudal
the use of senses (sight, touch, hearing,  Body System Approach
smell and taste).
 What to observe? Characteristics of SKILLS USED IN PHYSICAL EXAM
appearance, content and process of  Inspection
interactions and relationships, and  Palpation
environment  Percussion
 Interview of patient, family & other nurses  Auscultation
 a structured form of communication that the
nurse uses to collect data face to face

KEYPOINTS FOR AN INTERVIEW  Medical Record Review

 ability to establish rapport PURPOSES

 ability to ask questions
 To relate the past health care history of the patient to the
 ability to listen is essential to successful interviews
present episode
 ability to observe
 To identify what medication the patient is taking so that
DIRECT INTERVIEW the assessment can include the effectiveness of the
medication & the occurrence of any side effects
 Highly structured and elicit specific information by asking  To understand interdisciplinary care planning
closed questions that call or a specific amount of data.  To understand other health team members’ evaluations
of the patient’s clinical progress
INDIRECT INTERVIEW  To clarify information found on the patient’s kardex or
medication administration record
 The nurse allows the client to control the purpose, subject
matter and pacing
Table 1. Kinds of Interview Questions o Data Collection Format
CLOSE ENDED OPEN-ENDED  Maslow’s Basic Need Frameworks
restrictive and generally lead or invite clients to  Henderson’s Components of Nursing Care
require only short answers explore their thoughts or  Gordon’s Functional Health Patterns
giving specific information; feelings  Nanda’s Human Response Patterns
often begin with when,  Nursing Theories
where, who, what, do, does,  Human Growth & Development
did

Table 2. Planning the interview and setting  IDENTIFYING CUES & MAKING INFERENCES
TIME Need to be scheduled when o Cues – the subjective and objective data identified
the client is comfortable and o Inference – how one interprets or perceive a cue
free of pain  VALIDATING / VERIFYING DATA
PLACE Must have adequate privacy o Advantages – it helps one to avoid:
to promote communication  Making assumptions
SEATING Most people feel  Missing key information
ARRANGEMENT: comfortable 3 to 4 ft. apart
 Misunderstanding situations
DISTANCE during an interview
 Jumping to conclusions or focusing in the wrong
direction
STAGES OF AN INTERVIEW  Making errors in problem identification
o Guidelines in Validating/Verifying Data
 OPENING  Data that can be measured accurately can be
o sets the tone of the remainder of the interview accepted as factual.
1. Establish rapport → process of creating good will and
 Data that someone else observes (indirect data)
trust
2. Orientation → explaining the purpose and nature of may or may not be true.
the interview
 BODY
VALIDATE QUESTIONABLE INFORMATION BY USING  Safety and security- energy level, presence of
THE FF. TECHNIQUES, AS APPROPRIATE: risk factors
 Love and belongingness - Family and
 Double check information that’s extremely abnormal or relationship
inconsistent with patient cues
 Self-esteem - honors, awards, recognitions
 Double check that your equipment is working correctly.
 Self- actualization - self-fulfilment, selfless
 Recheck own data
 Look for factors that may alter accuracy service
 Ask someone else, preferably an expert, to collect the o ABC (Airway Breathing Circulation)
same data  Used to set priorities
 Compare subjective & objective data to see if what the  I.E. Bleeding- circulation, Difficult of Breathing-
person is stating is congruent with what you observe Airway and Breathing
 Clarify statements and very your inferences with the o Body System
patient  Used to identify signs and symptoms of possible
 Compare your impressions with those of other key medical problems
members of the health care  I.E. body systems – cardiovascular, respiratory,
lymphatic systems
o Gordon’s Functional Health Problems
 ORGANIZING / CLUSTERING DATA  Used to identify nursing diagnosis and problems
o RULE: Cluster your data according to your  Psychological, elimination, rest and sleep,
purpose: oxygenation, nutrition, etc.
 to identify nursing diagnoses and problems  IDENTIFYING PATTERNS / TESTING FIRST
 to identify signs and symptoms of possible IMPRESSIONS
medical problems o involves deciding what’s relevant & irrelevant,
 to set priorities making tentative decisions about what the data
 clustering data one way, then clustering it suggests
another way helps you think critically o focusing assessment to gain more information to
better understand the situations at hand
o remember cause & effect; find out why or how the
pattern came to be
o
 REPORTING AND RECORDING DATA
o Report abnormal findings as soon as possible
o Before reporting, take a moment to be sure you have
all the necessary information readily at hand
o Jot down the facts in order of importance
o Give precise information, state the facts rather than
how you interpret the facts

 Data Gathering Resources

o Primary Source – Client/Patient
o Secondary Sources – Significant Others, Nursing &
 clustering of data according to a nursing model Medical Records, Verbal & Written Consultation, And
– helps to identify nursing diagnosis and Diagnostic / Laboratory Studies
problems
 The most up-to-date information comes from your direct
assessment of the patient

IDENTIFYING SUBJECTIVE AND OBJECTIVE DATA

 Subjective data - information given verbally by the

patient
 Objective data - factual data that are observed by the
nurse & could be noted by any other skilled observer

TYPES OF DATA

 SUBJECTIVE DATA
o symptoms or covert data
o e.g. – itching pain, feelings of worry includes client’s
sensations, feelings, values, beliefs, attitudes and
perception of personal health status and life
situations
o Problem: Fever → subjective cue: “Mainit ang
 clustering of data according to body systems – pakiramdam ko.”
helps to identify data that may indicate medical  OBJECTIVE DATA
problems o signs or overt data
o Maslow’s Hierarchy of Needs o detectable by an observer or can be tested against
 Used to set priorities an accepted standard
 Physiologic- vital signs, nutrition, sex, pain o e.g. discoloration of the skin
o Problem: Fever → Objective cues: skin is warm to
touch temperature is 38.9 C