THE NURSING PROCESS Chapter 2 The Nursing Process

THE NURSING PROCESS Chapter 2 The Nursing Process: Assessment Step: Developing the Client Database

Competencies for Chapter 2: The Assessment Step By the end of this unit the student will: n 1. 2. 3. 4. 5. 6. 7. 8. 9. Define assessment Describe the 3 parts to developing a client database Differentiate between subjective and objective data and list examples of each Briefly describe 3 characteristics of data List 4 sources of data List 4 methods of data gathering Describe proper patient interviewing technique Define Initial, Focused, Emergency, and Time-lapse assessments Describe the purpose of data validation

Assessment Step: n Assessing ¡ n Data ¡ n Systematic and continuous collection, validation, and communication of client data Client information that reflects or pertains to health functioning Database ¡ All pertinent client information collected by the nurse and other healthcare professionals

Assessment Step: Developing a client database involves: 1. 2. 3. Systematic gathering of data Sorting and organizing data Documenting data

Assessment Step: Types of data n n Subjective: What client reports, believes, or feels Objective: What can be observed Characteristics of data n Complete n Factual and accurate n Relevant ¡

Sources of Data: n n Client, client’s family, friends, caregivers Medical record-laboratory/diagnostic studies Other healthcare professionals Nursing/healthcare literature

Data Gathering Methods: n n Observation Interview Nursing physical assessment Nursing History

Interviews: 1. 2. 3. 4. 5. Know your purpose Research the records Request an interview Conduct the interview Conclude the interview

Interviewing Techniques: n n n n Establish rapport Be sensitive to client’s needs Use active listening Ask open-ended questions Avoid closed-ended, leading, or probing questions Avoid agreeing or disagreeing Remain objective

Planning Data Collection: n n Initial assessment Focused assessment Emergency assessment Time-lapse assessment

Assessment Priorities: n n Health orientation Developmental stage Need for nursing Practical considerations

Data Validation: n n n The act of confirming or verifying Keeps the data free from error, bias, and misinterpretation Invalid information can lead to inappropriate nursing care

Data Communication: n n Immediately report critical findings verbally Documentation ¡ ¡ ¡ Use designated forms Record in a timely fashion Record in computer or in ink

Chapter 2 - Summary n Systematic gathering of data n Interviewing n Sorting and organizing data n Documenting Data

Chapter 2 – Summary n Assessment Step should provide: ¡ ¡ A holistic view of the client Data on the client’s state of wellness, response to health problems, and risk factors