NCM103j

CHAPTER 11 - ASSESSING o Determining how to implement nursing interventions

in an organized, individualized, and goal-directed
Learning Outcomes manner
1. Describe the phases of the nursing process. o Goals
2. Identify major characteristics of the nursing process. - Develop an individualized care plan that
3. Identify the purpose of assessing. specifies client goals/desired outcomes
4. Identify the four major activities associated with the - Related nursing interventions
assessing phase.
5. Differentiate objective and subjective data and primary IMPLEMENTATING
and secondary data. o Carrying out (or delegating) and documenting planned
6. Identify three methods of data collection, and give nursing interventions
examples of how each is useful. o Goals
7. Compare directive and nondirective approaches to - Assist the client to meet desired
interviewing. goals/outcomes
8. Compare closed and open-ended questions, providing - Promote wellness
examples and listing advantages and disadvantages of - Prevent illness and disease
each. - Restore health
9. Describe important aspects of the interview setting. - Facilitate coping with altered functioning
10. Contrast various frameworks used for nursing
assessment. EVALUATING
o Measuring the degree to which goals/outcomes have
THE NURSING PROCESS been achieved
o Identifying factors that positively or negatively
influence goal achievement
o Goal
- Determine whether to continue, modify, or
terminate the plan of care

CHARACTERISTICS OF THE NURSING PROCESS

o Cyclic and dynamic nature
o Client centeredness
o Focus on problem-solving and decision-making
o Interpersonal and collaborative style
o Universal applicability
o Use of critical thinking
o Proxemics - is the study of personal space and the
degree of separation that individuals maintain between
each other in social situations

ASSESSING
o Collecting data
o Organizing data
o Validating data
o Documenting data
o Goal
- Establish a database about the client’s
response to health concerns or illness

DIAGNOSING
o Analyzing and synthesizing data
o Goals
- Identify client strengths
- Identify health problems that can be TYPES OF ASSESSMENT
prevented or resolved 1. Initial
- Develop a list of nursing and collaborative o Performed within a specified time period
problems after admission
o Purpose- Establishes complete database
PLANNING o Ex: nursing admission
o Determining how to prevent, reduce, or resolve 2. Problem-Focused
identified priority client problems o Ongoing process integrated with care
o Determining how to support client strengths o Purpose-Determines status of a specific
problem

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NCM103j

o Ex: Hourly assessment of I and O • Evaluate change

3. Emergency • Teach
o Performed during physiologic or psychologic • Provide support
crises • Provide counseling or therapy
o Purpose- Identifies life-threatening problems
o Identifies new or overlooked problems 3. Examining (physical examination)
o Ex: Rapid Assessment - Systematic data-collection method
4. Time-lapsed - Uses observation and inspection,
o Occurs several months after initial auscultation, palpation, and percussion
o Purpose -Compares current status to • Blood pressure
baseline • Pulses
o Ex. Reassessment of client status • Heart and lungs sound
• Skin temperature and moisture
ASSESSMENT ACTIVITIES
• Muscle strength

DIRECTIVE APPROACH TO INTERVIEWEING

o Nurse establishes purpose
o Nurse controls the interview
• Collecting data
o Used to gather and give information when time is
• Organizing data limited, e.g., in an emergency
• Validating data
• Documenting data NONDIRECTIVE APPROACH TO INTERVIEWING
o Rapport-building
o Client controls the purpose, subject matter, and
pacing
o Combination of directive and nondirective approaches
usually appropriate during the information-gathering
interview
SUBJECTIVE DATA CLOSED & OPEN-ENDED QUESTIONS
o Symptoms or covert data 1. Closed Question(directive)
o Apparent only to the person affected • Restrictive
o Can be described only by person affected - Yes/no
o Includes sensations, feelings, values, beliefs, - Factual
attitudes, and perception of personal health status • Less effort and information from client
and life situations
• “What medications did you take?”
• “Are you having pain now?”
OBJECTIVE DATA
2. Open-ended Question (Nondirective)
o Signs or overt data
o Detectable by an observer • Specify broad topic to discuss
o Can be measured or tested against an accepted • Invite longer answers
standard • Get more information from client
o Can be seen, heard, felt, or smelled • Useful to change topics and elicit attitudes
o Obtained through observation or physical examination • “How have you been feeling lately?”

SOURCES OF DATA THE INTERVIEW SETTING

o Primary Source o Time
- The client - Client free of pain
o Secondary Sources - Limited interruptions
- All other sources of data o Place
- Should be validated, if possible - Private
- Comfortable environment
METHODS OF DATA COLLECTION - Limited distractions
1. Observing o Seating arrangements
- Gathering data using the senses - Hospital
- Used to obtain following types of data: - Office or clinic
• Skin color (vision) - Group
• Body or breath odors (smell) o Distance
• Lung or heart sounds (hearing) - Comfortable
• Skin temperature (touch) o Language
2. Interviewing - Use easily-understood terminology
- Planned communication or a conversation - Interpreter or translator
with a purpose
- Used to: FRAMEWORKS FOR NURSING ASSESSMENT
o Nursing Models Framework
• Identify problems of mutual concern
- Gordon’s functional health pattern framework

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• a nursing model that standardizes • the aim of nursing is to increase

data collection in practicing the compliance and life expectancy. Roy
nursing process, simplifies the Adaptation Model evaluates the
process of making a nursing patient in physiologic mode, self-
diagnosis and considers the concept mode, role function mode
individual holistically and interdependence mode aiming
• used to examine adults (bates – for to provide holistic care.
children) o Do not Stand and look at patient-intimidating
o Sit at 45 degrees angle
o Wellness Models
o Nonnursing Models
- Body systems model
- Maslow’s Hierarchy of Needs

- Developmental theories

• Erik Erikson's Psychosocial

Development Theory - emphasized
that the environment played a major
role in self-awareness, adjustment,
human development, and identity.
Each of Erikson's stages of
psychosocial development focus on
a central conflict.
• Bowen's Family Theory

POST TEST
1. Which of the following behaviors is most
representative of the nursing diagnosis phase of the
nursing process?
a) Identifying major problems or needs. (is
part of nursing diagnosis. For example, a
- Orem’s self-care model client with difficulty breathing would have
• focuses on each “individual's ability Impaired Gas Exchange related to
to perform self-care, defined as 'the constricted airways as manifested by
practice of activities that individuals shortness of breat (dyspnea) as a nursing
initiate and perform on their own diagnosis.)
behalf in maintaining life, health, and b) Organizing data in the client’s family history.
well-being (is part of the assessment phase.)
c) Establishing short term and long-term goals.
(a part of the planning phase.)
d) Administering an antibiotic. (part of the
implementation phase.)

2. Which of the following behaviors would indicate that

the nurse was utilizing the assessment phase of the
nursing process, to provide nursing care?
a) Propose hypotheses (generated during
diagnosing)
b) Generate desired outcomes. (Set during
planning)
c) Reviews results of laboratory tests.( data are
collected, organized, validated, and documented)
- Roy’s adaptation model

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d) Documents care. (occurs throughout the nursing RESOURCES

process) o Audio Glossary
o Nursing Assessment Guidelines
3. Which of the following elements is best categorized - Assessment guidelines for various health
as secondary subjective data? problems, such as chest pain and
a) The nurse measures a weight loss of 10 - gastrointestinal and respiratory issues
pounds since the last clinic visit. (Weight is o Seniors! Inc.
objective data that can be measured or - An Article and tips on talking with senior
validated.) citizens about tough issues
b) Spouse states the client has lost all o How to Recognize and Respond to Symptoms of
appetite. (Secondary data comes from and Acute Stroke
other source (chart, family) besides the - Data provided by nursing site on identifying
client. Subjective data are covert (reported or the signs and symptoms of a cerebral
an opinion). vascular accident
c) The nurse palpates edema in lower
extremities. (Edema is objective data that
can be measured or validated.)
d) Client states severe pain when walking up
stairs. (What the client reports is primary
data)

4. The nurse wishes to determine the client’s feelings

about a recent diagnosis. Which interview question is
most likely to elicit this information?
a) “What did the doctor tell you about your
diagnosis?” (Just seeks factual information.)
b) “Are you worried about how the diagnosis
will affect you in the future?” (Can be
answered with a single word)
c) “Tell me about your reactions to the
diagnosis.” (Eliciting feelings requires an
open-ended question that seeks more than
just factual information and cannot be
answered with a single word.)
d) “How is your family responding to the
diagnosis?” (The family can provide indirect
information about the client but is not most
likely to provide the most accurate
information)

5. The use of a conceptual or theoretical framework for

collecting and organizing assessment data ensures
which of the following?
a) Correlation of the data with other members of the
health care team. (other members of the health
care team may use very different conceptual
organizing frameworks so data may not
correlate.)
b) Demonstration of cost-effective care. (more likely
to occur with systematic application of the
nursing process, but use of a framework for
assessment alone may not accomplish this goal)
c) Utilization of creativity and intuition in creating a
plan of care. (Because the framework is
structured and because of the nature of client
needs/problems, creativity and intuition in care
planning are not assured.)
d) Collection of all necessary information for a
thorough appraisal. (Frameworks help the
nurse be systematic in data collection.)

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