Nursing Process: Assessment
Supplies
Gloves
Stethoscope
Blood pressure cuff
Quick Sheet
ALERT
If the patient is in acute distress, immediately assess the affected body
system(s). Assessment findings may change the direction of the
examination.
Report a pattern of findings that indicates abuse to a social service center
(refer to state guidelines). Obtain immediate consultation with the
practitioner, social worker, and other support staff to facilitate placement
of the patient in a safer environment.
Identify patients at high risk for adverse opioid-related outcomes (e.g.,
patients with sleep apnea, receiving continuous IV opioids, or on
supplemental oxygen).
1. Provide patient privacy and perform hand hygiene.
2. Introduce yourself to the patient.
3. Identify the patient using two identifiers.
4. Explain the procedure to the patient and ensure that he or she agrees to it.
5. Describe how you will conduct the interview.
6. During the interview:
a. Listen to the patient’s concerns.
b. Validate the patient’s information.
c. Determine the patient’s goals and expectations.
d. Apply critical thinking to identify topics that require additional
investigation.
e. Observe the patient’s verbal and nonverbal behavior.
f. Conduct a comprehensive or focused physical examination, as needed, to
gather objective data.
i. Don gloves if likely to come into contact with body fluids or
secretions.
, ii. Observe droplet precautions (i.e., wear a mask) in addition to hand
hygiene when examining and caring for a patient with signs and
symptoms of a respiratory infection.
iii. If treating a patient with suspected or confirmed diagnosis of
infectious disease, follow transmission-based precautions specific to
the organization’s practice.
g. Conduct relevant laboratory or diagnostic tests.
7. Discard supplies, remove personal protective equipment (PPE) if worn, and
perform hand hygiene.
8. Document assessment findings in the patient’s electronic health record.
9. Begin the concept map.
Extended Text
ALERT
If the patient is in acute distress, immediately assess the affected body
system(s). Assessment findings may change the direction of the
examination.
Report a pattern of findings that indicates abuse to a social service center
(refer to state guidelines). Obtain immediate consultation with the
practitioner, social worker, and other support staff to facilitate placement
of the patient in a safer environment.
Identify patients at high risk for adverse opioid-related outcomes (e.g.,
patients with sleep apnea, receiving continuous IV opioids, or on
supplemental oxygen).1
OVERVIEW
The nursing process has five steps: assessment, diagnosis, planning, implementation,
and evaluation. Critical thinking applies to every part of the nursing process. Although
the steps of the nursing process are learned and initially applied in sequence, as you
become proficient you will learn to move back and forth through the steps of the
process using clinical judgement to individualize care. You apply the nursing process
every time you meet a patient.
The first step of the nursing process is assessment. During assessment, you acquire and
analyze information about the patient's health. Establishing a positive nurse-patient
therapeutic relationship helps you to know a patient as a person, promotes trust, and
gives you context that aids in understanding a patient's health concerns.
Types of assessment vary and include: a patient-centered interview during a nursing
health history, physical focused or comprehensive examinations, and periodic
,assessments. Patient histories may be comprehensive or problem-focused. A
comprehensive history may involve the use of a comprehensive database, or may be
based on a theoretical framework, such as Gordon's model of 11 functional health
patterns. These comprehensive histories move from the general to the specific. 2 A
problem-oriented history begins with the patient's presenting situation. You ask the
patient questions about the problem, any precipitating factors, and the problem's
severity in order to understand the nature of the problem.
Using critical thinking, you differentiate important data from the total data you
accumulate. A cue is information you obtain using your senses. An inference is your
interpretation of a cue. For instance, while gathering data, you may see a patient
grimace, infer that she is in pain, and ask her focused questions about her pain. There
are two types of data: subjective and objective. Subjective data is the patient's account
of her feelings, perceptions or health problem, in her own words. Objective data include
verifiable, concrete observations and measurements of a patient's health status. Data
can be acquired from the patient, the patient's family or close friends, other health care
providers, medical records, scientific literature, and your own past clinical experiences.
An interview is an organized conversation used to gather detailed information about a
patient. Prepare for an interview by reviewing the available data, including the patient's
record. An interview has three phases: orientation, working, and termination. In the
orientation phase, you introduce yourself, explain the purpose of the interview, and ask
the patient for his or her concerns or problems. During the working phase, you gather
information about the patient's concerns and complete the nursing health history. In the
termination phase, you summarize your discussion and verify the accuracy of your
information. Apply interview techniques including observation, open-ended questions,
leading questions, back channeling, probing and direct close-ended questions. Clarify or
validate information as needed.
The components of a nursing health history include the patient's biographical
information, chief concern (reason for seeking health care), expectations, present
illness or health concerns, health history, family history, psychosocial history, spiritual
health, and review of systems. Some health histories are focused, and some are
comprehensive. You decide on the necessary information in response to the patient's
needs, answers to your questions, and changing health status during the interview.
When the assessment is complete, document your assessment in the patient's electronic
health record concisely and factually, using appropriate terminology. Record all
observations. Place the patient's subjective statements in quotation marks. Students
may also complete concept maps in order to form connections among a patient's
multiple health problems. A concept map begins by clustering data to form patterns
that lead you to the next step in the nursing process: diagnosis.
SUPPLIES
See Supplies tab at the top of the page.
, PATIENT AND FAMILY EDUCATION
When conducting the physical examination, inform the patient about normal
ranges of vital signs for age and physical condition and normal weight for height
and body frame.
Discuss the patient's goal for pain management.
Identify the patient's preferences for nonpharmacologic pain treatment
modalities.
Encourage questions and answer them as they arise.
ASSESSMENT AND PREPARATION
Review the patient's medical record.
Identify the patient's general perceptions about personal health.
Ask if the patient has a latex allergy.
Ask if the patient has any known food allergies or drug allergies.
Assess the patient for recent travel outside of the United States.
Screen for history of opioid dependence.
Assess for signs of abuse.
DELEGATION
The skill of patient assessment cannot be delegated.
MONITORING AND CARE
Observe the patient for evidence of physical or emotional distress throughout the
assessment.
Compare assessment findings with previous observations.
Ask if there is information about the patient's physical condition that has not been
discussed.
Assess, treat, and reassess pain.
EXPECTED OUTCOMES
Patient is alert and cooperative and provides appropriate subjective data related
to his or her physical condition.
Patient does not display evidence of physical or emotional distress during
assessment.
UNEXPECTED OUTCOMES
Patient demonstrates acute distress.
Supplies
Gloves
Stethoscope
Blood pressure cuff
Quick Sheet
ALERT
If the patient is in acute distress, immediately assess the affected body
system(s). Assessment findings may change the direction of the
examination.
Report a pattern of findings that indicates abuse to a social service center
(refer to state guidelines). Obtain immediate consultation with the
practitioner, social worker, and other support staff to facilitate placement
of the patient in a safer environment.
Identify patients at high risk for adverse opioid-related outcomes (e.g.,
patients with sleep apnea, receiving continuous IV opioids, or on
supplemental oxygen).
1. Provide patient privacy and perform hand hygiene.
2. Introduce yourself to the patient.
3. Identify the patient using two identifiers.
4. Explain the procedure to the patient and ensure that he or she agrees to it.
5. Describe how you will conduct the interview.
6. During the interview:
a. Listen to the patient’s concerns.
b. Validate the patient’s information.
c. Determine the patient’s goals and expectations.
d. Apply critical thinking to identify topics that require additional
investigation.
e. Observe the patient’s verbal and nonverbal behavior.
f. Conduct a comprehensive or focused physical examination, as needed, to
gather objective data.
i. Don gloves if likely to come into contact with body fluids or
secretions.
, ii. Observe droplet precautions (i.e., wear a mask) in addition to hand
hygiene when examining and caring for a patient with signs and
symptoms of a respiratory infection.
iii. If treating a patient with suspected or confirmed diagnosis of
infectious disease, follow transmission-based precautions specific to
the organization’s practice.
g. Conduct relevant laboratory or diagnostic tests.
7. Discard supplies, remove personal protective equipment (PPE) if worn, and
perform hand hygiene.
8. Document assessment findings in the patient’s electronic health record.
9. Begin the concept map.
Extended Text
ALERT
If the patient is in acute distress, immediately assess the affected body
system(s). Assessment findings may change the direction of the
examination.
Report a pattern of findings that indicates abuse to a social service center
(refer to state guidelines). Obtain immediate consultation with the
practitioner, social worker, and other support staff to facilitate placement
of the patient in a safer environment.
Identify patients at high risk for adverse opioid-related outcomes (e.g.,
patients with sleep apnea, receiving continuous IV opioids, or on
supplemental oxygen).1
OVERVIEW
The nursing process has five steps: assessment, diagnosis, planning, implementation,
and evaluation. Critical thinking applies to every part of the nursing process. Although
the steps of the nursing process are learned and initially applied in sequence, as you
become proficient you will learn to move back and forth through the steps of the
process using clinical judgement to individualize care. You apply the nursing process
every time you meet a patient.
The first step of the nursing process is assessment. During assessment, you acquire and
analyze information about the patient's health. Establishing a positive nurse-patient
therapeutic relationship helps you to know a patient as a person, promotes trust, and
gives you context that aids in understanding a patient's health concerns.
Types of assessment vary and include: a patient-centered interview during a nursing
health history, physical focused or comprehensive examinations, and periodic
,assessments. Patient histories may be comprehensive or problem-focused. A
comprehensive history may involve the use of a comprehensive database, or may be
based on a theoretical framework, such as Gordon's model of 11 functional health
patterns. These comprehensive histories move from the general to the specific. 2 A
problem-oriented history begins with the patient's presenting situation. You ask the
patient questions about the problem, any precipitating factors, and the problem's
severity in order to understand the nature of the problem.
Using critical thinking, you differentiate important data from the total data you
accumulate. A cue is information you obtain using your senses. An inference is your
interpretation of a cue. For instance, while gathering data, you may see a patient
grimace, infer that she is in pain, and ask her focused questions about her pain. There
are two types of data: subjective and objective. Subjective data is the patient's account
of her feelings, perceptions or health problem, in her own words. Objective data include
verifiable, concrete observations and measurements of a patient's health status. Data
can be acquired from the patient, the patient's family or close friends, other health care
providers, medical records, scientific literature, and your own past clinical experiences.
An interview is an organized conversation used to gather detailed information about a
patient. Prepare for an interview by reviewing the available data, including the patient's
record. An interview has three phases: orientation, working, and termination. In the
orientation phase, you introduce yourself, explain the purpose of the interview, and ask
the patient for his or her concerns or problems. During the working phase, you gather
information about the patient's concerns and complete the nursing health history. In the
termination phase, you summarize your discussion and verify the accuracy of your
information. Apply interview techniques including observation, open-ended questions,
leading questions, back channeling, probing and direct close-ended questions. Clarify or
validate information as needed.
The components of a nursing health history include the patient's biographical
information, chief concern (reason for seeking health care), expectations, present
illness or health concerns, health history, family history, psychosocial history, spiritual
health, and review of systems. Some health histories are focused, and some are
comprehensive. You decide on the necessary information in response to the patient's
needs, answers to your questions, and changing health status during the interview.
When the assessment is complete, document your assessment in the patient's electronic
health record concisely and factually, using appropriate terminology. Record all
observations. Place the patient's subjective statements in quotation marks. Students
may also complete concept maps in order to form connections among a patient's
multiple health problems. A concept map begins by clustering data to form patterns
that lead you to the next step in the nursing process: diagnosis.
SUPPLIES
See Supplies tab at the top of the page.
, PATIENT AND FAMILY EDUCATION
When conducting the physical examination, inform the patient about normal
ranges of vital signs for age and physical condition and normal weight for height
and body frame.
Discuss the patient's goal for pain management.
Identify the patient's preferences for nonpharmacologic pain treatment
modalities.
Encourage questions and answer them as they arise.
ASSESSMENT AND PREPARATION
Review the patient's medical record.
Identify the patient's general perceptions about personal health.
Ask if the patient has a latex allergy.
Ask if the patient has any known food allergies or drug allergies.
Assess the patient for recent travel outside of the United States.
Screen for history of opioid dependence.
Assess for signs of abuse.
DELEGATION
The skill of patient assessment cannot be delegated.
MONITORING AND CARE
Observe the patient for evidence of physical or emotional distress throughout the
assessment.
Compare assessment findings with previous observations.
Ask if there is information about the patient's physical condition that has not been
discussed.
Assess, treat, and reassess pain.
EXPECTED OUTCOMES
Patient is alert and cooperative and provides appropriate subjective data related
to his or her physical condition.
Patient does not display evidence of physical or emotional distress during
assessment.
UNEXPECTED OUTCOMES
Patient demonstrates acute distress.
