Nursing Process::ASSESSMENT

ASSESSMENT

The nurse collects data about the health statis of the client. The data is subjective and objective.

Subjective data is usually documented in the clients own words. This data includes such things as previous experiences,and sensations or emotions that only the client can describe.

The Objective data is obtained by the health team, through observation, physical examination, or/and diagnosistic testing. Objective data can be seen or measured.
Sources of subjective data and objective data are the client, the family and significant others, medical records, and other health care team members.

Assessment includes, the "HEALTH HISTORY" and "physical assessment".

Physical assessment can be broken down into four components(2);

* Inspection,
* Palpation,
* Percussion,
* Auscultation.

CLICK on the above links to obtain further information.
Measurement Criteria(2)

1. The priority of data collection is determined by the client's immediate condition or need.
2. Pertinent data is collected using appropriate assessment techniques.
3. Data collection involves the client, significant others, and health care providers when appropriate.
4. The data collection is ongoing.
5. Relevant data is recorded according to standards.

source from www.http://home.cogeco.ca/~nursingprocess/

The Nursing Process: A Common Thread Amongst All Nurses

The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care.

Assessment

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. For example, a nurse’s assessment of a hospitalized patient in pain includes not only the physical causes and manifestations of pain, but the patient’s response—an inability to get out of bed, refusal to eat, withdrawal from family members, anger directed at hospital staff, fear, or request for more pain mediation.

Diagnosis

The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications—for example, respiratory infection is a potential hazard to an immobilized patient. The diagnosis is the basis for the nurse’s care plan.

Outcomes/Planning

Based on the assessment and diagnosis, the nurse sets measurable and achievable short- and long-range goals for this patient that might include moving from bed to chair at least three times per day; maintaining adequate nutrition by eating smaller, more frequent meals; resolving conflict through counseling, or managing pain through adequate medication. Assessment data, diagnosis, and goals are written in the patient’s care plan so that nurses as well as other health professionals caring for the patient have access to it.

Implementation

Nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured. Care is documented in the patient’s record.

Evaluation

Both the patient’s status and the effectiveness of the nursing care must be continuously evaluated, and the care plan modified as needed.

(taken from www.nursingworld.org)

Nursing Process

The nursing process is a process by which nurses deliver care to patients. It is often supported by nursing models or philosophies. The nursing process was originally an adapted form of problem-solving and is classified as a deductive theory.


The nursing process is a cyclical and ongoing process that can end at any stage if the problem is solved. The nursing process exists for every problem that the patient has, and for every element of patient care, rather than once for each patient. The nurse's evaluation of care will lead to changes in the implementation of the care and the patient's needs are likely to change during their stay in hospital as their health either improves or deteriorates. The nursing process not only focuses on ways to improve the patient's physical needs, but lon social and emotional needs as well.
The nursing process is not something foreign or unusually complex. On the contrary, we use the nursing process method on a daily basis without even realizing it. For example, a trip to the gas station to get fuel requires Assessing the various prices and the number of people waiting to get gas among other things. A subsequent decision, or Diagnosis, is made based on the former criteria. This may include pulling into the gas station to fuel up or going down the road for better prices and/or less of a crowd. The price is right and there's not much of a crowd, we're pulling in. Now the Planning can take place. This may include which pump to use, how much gas to put in the tank, whether or not to clean the windows along with other things. We're at the pump and ready to fuel up. We must now Implement what we planned prior to pulling up to the pump. We've pulled up on the passenger side because the gas tank resides on this side, part of our plan. We've also given ourselves enough room to exit without getting blocked in by another vehicle, part of our plan also. We now uscrew the gas cap and begin fueling or Implementing what we planned. Things went well. We are fueled up and have exited the gas station without complication. Our Evaluation of the trip to the gas station would be a good one. We may choose to use this method in the future. The Nursing process is that simple in theory. However, as a nurse, the nursing process tool will be used for more complex and difficult situations but is applied the same way as the gas station analogy. Taken from www.wikipedia.com