Kap Integrated Practice & Review
Phase 1 of Assessment – Assessment *Sets the stage for Diagnosis
o Collect Data
o Identify Cues and Making Inferences
o Validating Data
o Clustering Data/Identify Patterns
o Report/Record Data
Phase 2 of Assessment - Clinical Reasoning
o Analyzing, synthesizing, reflecting, making judgements and drawing conclusions
o Leads to Diagnosis
What is the nursing process?
o provides the framework in which nurses use their knowledge and skills to express human caring
ADPIE - Nursing Process
o Assessment
o Diagnosis
o Planning
o Implementation
o Evaluation
Nursing Assessment involves communication, collection of data, analysis of data
Nursing Diagnosis provides data used to determine client problems and strengths
Nursing Planning/outcomes/implementations
o Information helps you to plan realistic goals and effective interventions
Nursing Implementation
o As you perform nursing actions, you will continually assess and gain new information which can
lead to new diagnosis and goals
Nursing Evaluation
o Re-assessment of the patient's response to intervention will allow you to change care as needed
Comprehensive Data Collection (nursing)
o Risk for potential problems
o Desire for a higher level of wellness
o Patient and family desired outcomes
o Spiritual beliefs/cultural values
o Patient's lifestyle
Data collection
o Must be relevant to the current problem
o Must be organized
Tools for Nursing Data Collection
o Functional health patterns, medical history,
o Computer charting or agency assessment forms
Types of Health Assessments
o Initial (admission)
Admission when client enters healthcare system
Purpose to evaluate health status and identify health needs that are unmet
Must be documented by registered nurse
Parts may be delegated to non-licensed personnel
o Ongoing
performed as needed and conducted at regular intervals to continually collect data
o Focused or problem oriented
assessment conducted to assess a specific problem; focuses on pertinent history and body
regions
, o Emergency
rapid focused assessment conducted to determine potentially fatal situations
o Comprehensive
Provides holistic information about the client's overall health status
Special Needs Assessments
o Focused assessments that provide in-depth information about a particular area of client
functioning/often involves a special form
o Examples of special needs assessment
Braden Scale (risk for pressure ulcers)
Katz Index of ADL scale
Nutritional Assessment
Pain Assessment
Community Assessment
Components of a Nursing Health History
o biographic data
o chief complaint
o history of present illness
o past history
o family history of illness
o lifestyle
o social data
o psychological data
o patterns of health care
o medication history and device use, including herbs
o review of systems and functional abilities (ADLs)
Types of interviewing
o Directive interviewing is used to obtain factual, easily categorized information, or in an
emergency situation.
o Closed questions: yes or no questions
o Nondirective interviewing means that the patient controls the subject matter. The nurse facilitates
thought and communication, and clarifies data obtained.
o Open-ended questions specify a topic but are phrased to encourage the patient to elaborate. They
are used to find out what is important to the patient.
o Often times the patient will tell you what the problem is! (if you allow them to...be patient and
listen
Considerations when performing a health assessment
o Lifespan considerations
o Cultural considerations and sensitivity
o Body Language and Silence
o Patient preparation
o Environmental preparations
o Gender awareness/perception
Types of Data
o subjective and objective
o Objective Data
Vital Signs, lab values, radiology images/reports
Physical assessment findings
Information gathered using senses
(Observable and measurable data that can be seen, heard or felt by someone other than
the person experiencing them)
Phase 1 of Assessment – Assessment *Sets the stage for Diagnosis
o Collect Data
o Identify Cues and Making Inferences
o Validating Data
o Clustering Data/Identify Patterns
o Report/Record Data
Phase 2 of Assessment - Clinical Reasoning
o Analyzing, synthesizing, reflecting, making judgements and drawing conclusions
o Leads to Diagnosis
What is the nursing process?
o provides the framework in which nurses use their knowledge and skills to express human caring
ADPIE - Nursing Process
o Assessment
o Diagnosis
o Planning
o Implementation
o Evaluation
Nursing Assessment involves communication, collection of data, analysis of data
Nursing Diagnosis provides data used to determine client problems and strengths
Nursing Planning/outcomes/implementations
o Information helps you to plan realistic goals and effective interventions
Nursing Implementation
o As you perform nursing actions, you will continually assess and gain new information which can
lead to new diagnosis and goals
Nursing Evaluation
o Re-assessment of the patient's response to intervention will allow you to change care as needed
Comprehensive Data Collection (nursing)
o Risk for potential problems
o Desire for a higher level of wellness
o Patient and family desired outcomes
o Spiritual beliefs/cultural values
o Patient's lifestyle
Data collection
o Must be relevant to the current problem
o Must be organized
Tools for Nursing Data Collection
o Functional health patterns, medical history,
o Computer charting or agency assessment forms
Types of Health Assessments
o Initial (admission)
Admission when client enters healthcare system
Purpose to evaluate health status and identify health needs that are unmet
Must be documented by registered nurse
Parts may be delegated to non-licensed personnel
o Ongoing
performed as needed and conducted at regular intervals to continually collect data
o Focused or problem oriented
assessment conducted to assess a specific problem; focuses on pertinent history and body
regions
, o Emergency
rapid focused assessment conducted to determine potentially fatal situations
o Comprehensive
Provides holistic information about the client's overall health status
Special Needs Assessments
o Focused assessments that provide in-depth information about a particular area of client
functioning/often involves a special form
o Examples of special needs assessment
Braden Scale (risk for pressure ulcers)
Katz Index of ADL scale
Nutritional Assessment
Pain Assessment
Community Assessment
Components of a Nursing Health History
o biographic data
o chief complaint
o history of present illness
o past history
o family history of illness
o lifestyle
o social data
o psychological data
o patterns of health care
o medication history and device use, including herbs
o review of systems and functional abilities (ADLs)
Types of interviewing
o Directive interviewing is used to obtain factual, easily categorized information, or in an
emergency situation.
o Closed questions: yes or no questions
o Nondirective interviewing means that the patient controls the subject matter. The nurse facilitates
thought and communication, and clarifies data obtained.
o Open-ended questions specify a topic but are phrased to encourage the patient to elaborate. They
are used to find out what is important to the patient.
o Often times the patient will tell you what the problem is! (if you allow them to...be patient and
listen
Considerations when performing a health assessment
o Lifespan considerations
o Cultural considerations and sensitivity
o Body Language and Silence
o Patient preparation
o Environmental preparations
o Gender awareness/perception
Types of Data
o subjective and objective
o Objective Data
Vital Signs, lab values, radiology images/reports
Physical assessment findings
Information gathered using senses
(Observable and measurable data that can be seen, heard or felt by someone other than
the person experiencing them)
