CHAPTER 15

NURSING PROCESS:
ASSESSMENT

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New ANA Standards (2004)
Nursing process is:
A critical thinking model used to
promote a competent level of care
Encompasses all significant actions
taken by registered nurses, and
forms the foundation for decision-
making.

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Critical Thinking: Picture This

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Critical Thinking Indicators ™
(Alfaro-LeFevre, 2004, 2005)

Behaviors that evidence suggests

promote critical thinking in clinical
practice.
 Give concrete descriptions and examples.
 Listed in context of what’s likely to be
observed when a nurse is thinking
critically in the clinical setting.

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 Examples of CTIs™ Demonstrating
CT Characteristics / Attitudes
Self-aware: Clarifies biases,
inclinations, strengths, and limitations.
Curious and inquisitive: Looks for
reasons, explanations, and meaning;
seeks new information to broaden
understanding.

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 Examples of Knowledge CTIs
Clarifies:
nursing vs. medical and other
models, roles, and responsibilities.
signs and symptoms of common
problems
and related potential complications.

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Examples of CTIs Demonstrating
Intellectual Skills/Competencies

Assesses systematically &

comprehensively
Identifiesassumptions
Detects bias; determines credibility of
information sources

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Nursing Process

 Steps
 Assessment – gather information
 Nursing diagnosis – identify client’s
problem
 Planning – set goals

 Implementation- perform nursing

actions
 Evaluation- determine if goals met

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Nursing Process (cont'd)

Assessment
Critical
thinking
approach
Deliberate & systematic
approach
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Assessment - Steps

Collection and verification of

data
Cues– not inferences
Moves from general to specific

Analysis of data
Norms

Cluster cues

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Assessment - Approaches

 Use of a structured database format

 Functional Health Patterns
 Problem oriented
 Focus on client’s present situation

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Assessment – Data Collection

 Datamust be descriptive, concise,

complete
 Types of data
 Objective- can be measured
 Subjective- client’s perceptions

 Sources of data
 Primary - client
 Secondary- family, health care team,
medical/other records, literature, experience

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EXAMPLES
 SUBJECTIVE  OBJECTIVE
 “My back really  Lying rigidly in bed.
hurts” Facial grimace
 “I’m not sure I observed
should have this  Tearful, facial
surgery, I’m scared” muscles tense,
pulse 100, hands
trembling

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Assessment –
Methods of Data Collection
 Interview-obtain health hx. &
current problem
 Orientation phase-
introduction/explanation
 Working phase- gather information
 Termination phase-end/summarize

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DATA COLLECTION (cont)
 Nursing health history
 Components
 Biographical
 Reason for apptm.
 Client expectations
 Present illness/health concern
 Health history-drugs, allergies,etc
 Family Hx.
 Environmental Hx.
 Psychosocial Hx.- cultural
 Spiritual health

 Physical examination
 Diagnostic and laboratory results-identify/verify problems

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Assessment Process

 Nursing judgments
 Data validation and interpretation-
compare with another source
 Data clustering- Signs/symptoms
grouped together logically

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DOCUMENTATION

 Documentation- thorough, precise,

accurate, ex, p. 295-296.

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