Assessment
Assessment is the foundation step of nursing process. It consists of systematic and orderly collection of information pertaining to and about the health status of the client. The information obtained helps to make nursing diagnosis and to develop a plan of care. Informations are obtained by data collection.
Data Collection
Data collection includes accumulation of comprehensive information about the client on initial assessment. The initial assessment provides baseline data. The data involves information about clients health problem, specific factors that contribute to the problem. The client has health problem (s) with which hes/he gets admitted and may also develop additional problem during his stay in the hospital, because of this course of illness, and the treatment modalities.
The data collected by the nurse during assessment are:
Assessment is the foundation step of nursing process. It consists of systematic and orderly collection of information pertaining to and about the health status of the client. The information obtained helps to make nursing diagnosis and to develop a plan of care. Informations are obtained by data collection.
Data Collection
Data collection includes accumulation of comprehensive information about the client on initial assessment. The initial assessment provides baseline data. The data involves information about clients health problem, specific factors that contribute to the problem. The client has health problem (s) with which hes/he gets admitted and may also develop additional problem during his stay in the hospital, because of this course of illness, and the treatment modalities.
The data collected by the nurse during assessment are:
- Subjective Data
- Objective Data
Subjective Data
Subjective data includes client’s description of his personal health status, problem e.g. feeling,description pain, weakness, nausea. This data also include information supplied by client’s family members. The data are not observable and are difficult to measure objectively.
Objective Data
Objective data are usually the one that is obtained through senses --sight, smell, hearing, touch and during physical examination of the client. Objective data are observable and measurable.For example: rate of pulse, weight, presence of oedema. The data collected by the nurse can be historical data and current data.Historical data has information related to the events that have occurred prior to the present.The event might be previous hospitalization, presence of chronic disease, pattern of bowel movement in the past, childhood illness in an adult patient. Current data refer to the events that are occurring at present e.g. pain, vomiting, inability to pass urine and present illness.
It is always necessary to validate subjective with objective data, historical with current data. For example, subjective data of feeling of pain is validated by objective findings of pallor, increasednsweating and hypotension. Similarly, historical data e.g. passing stool once every day and bowels not moved for two days (current) may initiate a strategy to help patient move his bowels. But when substantiated with historical data the client may inform that movement of bowel on every alternate day is his routine at home. Thus the information obtained earlier becomes valid. Therefore, validation of the data is necessary before planning care.
Nursing Diagnosis
The diagnostic process involves processing the data by classification interpretation and validation. Writing nursing diagnostic statement is the basis of identifying client’s problems and strengths. The health problem and the etiological factor are reflected in the formulation of diagnostic statement. The diagnosis is verified with the client and documented. Planning
Planning includes setting priorities and writing outcomes. The different problems of the client identified in the nursing diagnosis needs to be prioritized. The nurse can determine priority problems related to needs of client. Outcomes/goals are written from the diagnostic statement in terms of client’s behaviour that are desired to be achieved by the nurse in the limited time. The characteristic features of outcomes are:
client centered
observable and measurable
time limited and realistic.
The areas in which outcomes are written include:
appearance and functioning of the body,
specific symptoms,
knowledge,
psychomotor skills and emotional status.
Implementation
Implementation involves preparation for executing the plan and carrying the interventions to resolve client’s problem. The interventions include all those independent, dependent and interdependent nursing actions carried out by the nurse to restore health, prevent illness,promote wellness and facilitate copying with altered functioning. The implementation of nursing action is followed by complete and accurate documentation of events.
Evaluation is used to judge each component of nursing process. It measures the effectiveness of nursing interventions. It consists of comparing and judging the data about client’s progress.The client’s response to the nursing interventions will guide the nurse to continue with the plan care, modify it or terminate. In case the plan of care needs modification the nurse will reassess and carryout the remaining steps of nursing process. When the care is continued the ongoing process of assessment and evaluation is continued.
Subjective data includes client’s description of his personal health status, problem e.g. feeling,description pain, weakness, nausea. This data also include information supplied by client’s family members. The data are not observable and are difficult to measure objectively.
Objective Data
Objective data are usually the one that is obtained through senses --sight, smell, hearing, touch and during physical examination of the client. Objective data are observable and measurable.For example: rate of pulse, weight, presence of oedema. The data collected by the nurse can be historical data and current data.Historical data has information related to the events that have occurred prior to the present.The event might be previous hospitalization, presence of chronic disease, pattern of bowel movement in the past, childhood illness in an adult patient. Current data refer to the events that are occurring at present e.g. pain, vomiting, inability to pass urine and present illness.
It is always necessary to validate subjective with objective data, historical with current data. For example, subjective data of feeling of pain is validated by objective findings of pallor, increasednsweating and hypotension. Similarly, historical data e.g. passing stool once every day and bowels not moved for two days (current) may initiate a strategy to help patient move his bowels. But when substantiated with historical data the client may inform that movement of bowel on every alternate day is his routine at home. Thus the information obtained earlier becomes valid. Therefore, validation of the data is necessary before planning care.
Nursing Diagnosis
The diagnostic process involves processing the data by classification interpretation and validation. Writing nursing diagnostic statement is the basis of identifying client’s problems and strengths. The health problem and the etiological factor are reflected in the formulation of diagnostic statement. The diagnosis is verified with the client and documented. Planning
Planning includes setting priorities and writing outcomes. The different problems of the client identified in the nursing diagnosis needs to be prioritized. The nurse can determine priority problems related to needs of client. Outcomes/goals are written from the diagnostic statement in terms of client’s behaviour that are desired to be achieved by the nurse in the limited time. The characteristic features of outcomes are:
client centered
observable and measurable
time limited and realistic.
The areas in which outcomes are written include:
appearance and functioning of the body,
specific symptoms,
knowledge,
psychomotor skills and emotional status.
Implementation
Implementation involves preparation for executing the plan and carrying the interventions to resolve client’s problem. The interventions include all those independent, dependent and interdependent nursing actions carried out by the nurse to restore health, prevent illness,promote wellness and facilitate copying with altered functioning. The implementation of nursing action is followed by complete and accurate documentation of events.
Evaluation is used to judge each component of nursing process. It measures the effectiveness of nursing interventions. It consists of comparing and judging the data about client’s progress.The client’s response to the nursing interventions will guide the nurse to continue with the plan care, modify it or terminate. In case the plan of care needs modification the nurse will reassess and carryout the remaining steps of nursing process. When the care is continued the ongoing process of assessment and evaluation is continued.
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