Sources
This discussion summarizes five presentations produced by Ma’am Tuiza.
The Nursing Process, a systematic scientific method of formulating and providing nursing care generally consists of five core steps, summarized by the mnemonic ADPIE. In order, they are Assessment, Diagnosis, Planning, Intervention/Implementation, and Evaluation.
Assessment
Assessment is the first step of the nursing process. There are four major activities to do during the assessment phase: collection, organization, validation, and documentation of data. Assessment aims to determine client health status prior to, during, and after nursing and medical interventions. Assessment can be done in various settings, and can by typed as such:
| Based on Timing | Function |
|---|---|
| Initial Assessment | Done after admission to establish a complete database for problem identification, reference, and future comparison. |
| Problem-Focused Assessment | Ongoing process integrated with nursing care to determine the status of a specific problem identified in an earlier assessment. |
| Emergency Assessment | Done during any physiologic or psychologic crisis of the client to identify life-threatening, new, or overlooked problems. |
| Time-Lapsed Reassessment | Done several months after initial assessment to compare the client’s status to baseline data previously obtained. |
| Based on Focus | Function |
|---|---|
| Comprehensive Assessment | A complete assessment and health history performed upon admission. |
| Focused Assessment | Assessment focused on a particular need or healthcare problem. |
| Ongoing Assessment | Systematic monitoring and observation related to specific problems. |
Data Collection
This function of assessment aims to gather information about a client’s health status. The end goal product of this step is to produce a database, which contains all the information about a client. This process aims to be systematic and continuous to prevent the omission of significant data and to reflect a client’s changing health status. There are various categories of data collected:
- Nursing Health History
- Biographic Data
- Chief Complaint
- Past History: illness, immunization, allergies
- Family History of Illness
- Lifestyle: personal habits, diet, sleep pattern
- Social Data: ethnic affiliation, educational and occupational history
- Psychologic Data: stressors, coping pattern
- Patterns of Healthcare: ophthalmologist, gynecologist, dentist
- Physical Assessment
- Primary Care Provider’s History
- Physical Examination
- Results of Laboratory and Diagnostic Tests
- Material Contributed by Other Health Personnel
Data Types
| Data Type | Description |
|---|---|
| Subjective Data | Symptoms felt by the patient, which can only be described or verified solely by the patient. These are covert data such as itching, pain, feelings of worry, feelings, values, beliefs, and attitudes. |
| Objective Data | Signs observed or measured by the examiner, often tested against accepted standards. These are overt data such as discoloration of the skin, blood pressure, vital signs, etc. |
| Constant Data | Data that do not change over time such as ethnicity and blood type. |
| Variable Data | Data that is subject to change over time, even acutely, such as that of pain, blood pressure, and height. |
| Primary Data | Data obtained directly from the client or source. This is often the most reliable source. |
| Secondary Data | Data obtained anywhere other than from the client. All secondary sources should be validated when possible. This includes family members or other support persons, health professionals, records, and reports. |
Data Sources and Collection Methods
- Client: usually the best source of data except in cases of illness, young patients, or patients too confused to communicate clearly. Some clients cannot or do not with to provide accurate data. In these cases, family members or significant others can be sources of secondary data.
R.A. 10173: Data Privacy Act of 2012
You can remind the client of Data Privacy if they are hesitant about the safety of their information. The Data Privacy Act mandates the protection of all privileged client information from those not involved in their care. Additionally, the Nurses Code of Ethics and Patients’ Bill of Rights place privacy and confidentiality as important aspects of data handling.
- Support People: family members, friends, and caregivers who can give information on the client’s response to illness, the client’s stressors, family attitudes on illness and health, and the client’s home environment. As mentioned, they are especially important for very young, unconscious, or confused clients. Information, if obtained from support systems, should be notated as such.
- Client Records: documented information by various healthcare professionals, including medical records, records of therapies, and laboratory records.
- Healthcare Professionals: nurses, social workers, and primary care providers can share information to ensure the continuity of care when clients are transferred to and from home and healthcare agencies.
- Literature: professional journals and reference texts can be used as basis for care. Literature needs to be reviewed when used, including the comparison of findings to the current standards, comparison to cultural and social health practices, spiritual beliefs, and the assessment data needed for specific client conditions.
The nurse is able to obtain data with three main methods:
- Observing: the nurse utilizes their senses and specialized knowledge to obtain data about the patient. The process of observation is systematic to avoid oversights:
- Clinical Signs are checked, particularly of distress. This includes pallor, labored breathing, and behaviors indicating pain.
- Threats to Safety are determined, including both present and foreseeable risks. A common example of this is a lowered siderail.
- Equipment are also maintained and checked if they are properly functioning and configured. Examples include IV sets, oxygen tanks, monitors, and ventilators.
- Environment: many environmental factors can affect health and quality of life. Even minor, non-lethal factors such as lighting, cleanliness, and the people in the client’s immediate environment are considered.
| Sense Used | Client Data Obtained |
|---|---|
| Vision | Overall appearance (body size, posture, grooming) Signs of distress or discomfort Facial and body gestures Skin color and lesions Religious or cultural artifacts (books, icons, candles, beads) |
| Smell | Body or breath odors, especially in discharges and wounds. |
| Hearing | Lung and heart sounds Bowel sounds Ability to communicate Language spoken Orientation to time, person and place |
| Touch | Skin temperature and moisture Muscle strength (via hand grip) Pulse rate, rhythm, and volume Palpable lesions (lumps, masses, nodules) |
- Interviewing: communication planned and carried out with a purpose, such as for a nursing health history. Two common approaches are used: direct (highly structured, specific) and non-directive (rapport-building, the client is allowed to control the purpose, subject matter, and pacing).
- Closed Questions: short, direct questions seeking factual answers. “What medications have you taken today?” “Are you having pain now?”
- Open-ended Questions: questions that elaborate, clarify, or illustrate their thoughts or feelings. Non-directive. “How have you been feeling lately?” “What brought you to the hospital?”
- Neutral Questions: open-ended, non-pressuring questions. Non-directive. “How did you feel about that?” “What do you think led to the operation?”
- Leading Questions: questions that direct client answers. Directive. “You will take your medicine, won’t you?” “You’re stressed for the upcoming surgery, aren’t you?”
Planning an Interview
An interview should be planned according to:
- Time: the client should be comfortable and free of pain, with little opportunity for interruptions.
- Place: well-lit, well-ventilated rooms that are free of noise and distractions should be used as much as possible.
- Seating Arrangement: the nurse positions themselves at a 45° angle to the bed. This makes it more familiar than sitting behind a table or standing at the foot of the bed, while maintaining a professional distance.
- Distance: an appropriate distance of 2 to 3 feet is used during an interview.
- Language: the nurse takes care to convert medical terms to common language; at the level of the client’s educational attainment.
- Flow: the interview consists of an opening (introduction, rapport, orientation), body (questioning, answering), and closing (clarifications, conclusions/summary, termination, and future planning if necessary).
- Physical Examination: the application of inspection, palpation, percussion, and auscultation (mn. IPPA), carried out systematically, often in an organized (head-to-toe; cephalocaudal, and body systems approach).
Organizing Data
Nurses organize data in a written or electronic format to systematically organize assessment data. A common framework for organization was made by Marjory Gordon as Gordon’s 11 Functional Health Patterns:
| Functional Health Pattern | Contents |
|---|---|
| Health Perception and Health Management | General health, health promotion activities, general health appearance, attitudes toward medical advice. |
| Nutritional-Metabolic Pattern | Typical intake, changes in weight, appetite, wound healing (well or poor), skin lesions, dental problems. |
| Elimination | Excretion patterns that need to be evaluated, such as constipation, incontinence, and diarrhea. The excretion itself should also be examined for color and consistency. |
| Activity-Exercise | Whether one is able to perform daily activities normally without any problem. This includes feeding, bathing, toileting, dressing, grooming, etc. There are generally four levels of functionality: - Level I: requires equipment/device use. - Level II: requires assistance or supervision from another person. - Level III: both I and II - Level IV: is dependent and does not participate. |
| Cognitive-Perceptual | Neurological function; the person’s ability to comprehend information. This includes hearing, vision, memory, decision-making, learning, etc. |
| Roles-Relationships | Family conditions, problems, dependencies, etc. Only obtained if necessary for the patient’s age and specific situation. |
| Self-Perception/Self-Concept | How does the patient describe themself? Self-image, satisfaction with the self and/or body (esp. after illness or disability), etc. |
| Coping-Stress | Any stressors, persistent stress/anxiety levels, the use of medications, drugs, or alcohol. Commonly used coping mechanisms and their success are recorded. |
| Value-Belief | Religion, spirituality, future plans, etc. The most important consideration is if religious practices may interfere with healthcare or vice versa. |
| Medication and History | The patient’s health history, medication history, and current medication regimen. |
| Nursing Physical Assessment | Biophysical data, vital signs, etc. |
Validating Data
Data, as much as possible, and especially secondary data, is validated to ensure accuracy; basically, double-checking the data to ensure accuracy. Generally, data can be considered as cues which are signs and symptoms, and inferences, which are further interpretations and conclusions based on the cues.
Faulty inferences can result from jumping to conclusions or focusing in the wrong direction.
There are some types of data that do not require validation. These include things such as height, weight, birth dates, and most laboratory studies. However, those that do require validation are data that need to be correlated with the client’s physical or emotional behavior, and data found to have discrepancies obtained in the nursing interview (subjective data) and the physical examination (objective data), or when the client’s statements shift between assessments. The following are examples of validating data:
- Comparing subjective and objective data: the statement of “I’m feeling hot” warrants the nurse to check the patient’s body temperature.
- Clarify statements: statements are clarified if they are ambiguous or vague. “I felt sick on and off for six weeks” warrants the nurse to clarify: “Describe what your sickness is life. What does on and off mean?”
- Cues, not inferences: data is based on cues and not inferences. For example, the observation of dry skin and poor skin turgor (tenting) produces an inference of dehydration. Furthermore, additional data is obtained to support any inferences made, if necessary. In the previous example, the nurse would then obtain data on the client’s fluid intake, amount and appearance of urine, and blood pressure. If these also correlate as signs of dehydration, the inference is strengthened.
- Double-check abnormal data: all abnormal, especially those of extreme abnormality, is double checked. For example, an abnormal blood pressure reading of 210/95 mm Hg is double-checked with another sphygmomanometer and/or by another nurse.
- Check for interference: many factors can interfere with accurate measurement. The nurse checks for potential sources of abnormality before measuring. For example, a crying infant will often display an abnormal respiratory rate. In this case, the finding is not representative of the infant’s actual respiratory status, and quieting of the infant is required before an accurate assessment can be made.
- Use references: phenomena may be explained using information from reputable textbooks, journals, and research reports. For example, a geriatric patient with a tiny purple/blue-black swollen area under the tongue is normal according to literature stating such physical changes (sublingual varices) are normal with aging.
Documenting Data
The nurse completes assessment by recording client data. All data are recorded factually rather than interpretatively. This data can be used for the following steps of the nursing process, and should not change in meaning when written down. For example, a client’s morning meal is recorded literally: “Client consumed 240 mL coffee, 120 mL juice, 1 egg, and 1 slide of toast” rather than “Client appetite is good.” (a judgement)