UNIT 1: NURSES ROLE IN COLLECTING ASSESSMENT: COLLECTING & ANALYZING
DATA
HEALTH ASSESSMENT
oa systematic method of collecting
and analyzing data for the purpose
of planning patient-centered care.
The nurse:
ocollects data from patient
ocompare data to ideal state of health
otake into account the patient’s age,
gender, culture, ethnicity, & physical,
psychologic and socioeconomic status
Nursing Process is one approach to
develop plan of care.
Lesson 1: Overview of the Nursing
Process
PROCESS – series of steps or acts that
lead to accomplishment of goal/purpose
NURSING PROCESS
a. framework for providing
professional, quality nursing care.
b. Directs nursing activities for
health promotion, health protection,
disease prevention
c. Nurse’s systematic
method/approach in identifying,
diagnosing & treating human
responses to health & illness.
d. Purpose: to provide
individualized, holistic, effective,
& efficient care for clients
CHARACTERISTICS OF THE NURSING
PROCESS
1. CYCLIC & DYNAMIC
e. It is done in a sequential & repeated
manner until client’s need are met
f. It could be changed or altered
depending on the client’s pressing
needs
2. CLIENT-CENTERED
g. Developed in response to client’s
needs
h. Aimed primarily to meet needs
3. FOCUSED ON PROBLEM-SOLVING
i. nursing problem is formulated to
solve current problems of the client
that are within the scope of practice
and capabilities/knowledge and/or
skills of the professional nurse
4. INTERPERSONAL &
COLLABORATIVE
j. Interpersonal: it involves
communication bet. nurse & client
k. Collaborative: could be used to refer
the client’s condition to other
members of the health team
5. UNIVERSALLY APPLICABLE
l. Applicable to all patients
regardless of nationality/race,
culture, condition, etc.
6. INVOLVES CRITICAL THINKING
m. Involves analysis of various data
& formulation of plans/solutions
to meet client’s need.
PHASES OF THE NURSING PROCESS
A – assessment
D – diagnosis
P – planning
I – implementation
E – evaluation
1. ASSESSMENT
n. systematic collection of data to
determine the patient’s health status
and identify any actual or potential
health problems
Activities during the assessment phase:
oconduct health history
operform physical assessment
oInterview the patient’s family
and s/o
oStudy the patient’s health
record
