Chapter 3: Nursing Process : Assessment
I. ASSESSMENT : the first step in the nursing process
1. Assessment : the systematic gathering of information related to the
physical, mental, spiritual, socioeconomic, and cultural status of an
individual, group, or community.
2. Patient database: (all pertinent patient data obtained by nurses and other
health professionals).
B. How is Assessment Related to Other steps of the nursing process?
1. Diagnosis—Assessment provides the data necessary for identifying the
client’s health problems and strengths.
2. ■ Planning outcomes—Data about the patient’s motivation, family, and
available resources help you formulate realistic goals.
3. ■ Planning interventions—Assessment data help you to choose the
interventions most likely to be acceptable to and effective for the client.
4. ■ Implementation—As you perform nursing actions, you will also gather
data by observing the client’s responses.
5. Evaluation—After performing interventions for existing diagnoses, you
assess the client’s responses. This reassessment provides the basis for
changes in the care plan.
C. How Does Nursing Assessment Fit into Collaborative Care?
1. Assess response to illness and also identify ways to prevent disease
2. Nurse can look at database and delegate or make referrals to other
professionals
D. What do Professional Standards Say about Assessment?
1. ANA standards:
a) Collects comprehensive data pertinent to health care consumer’s
health and/or situation
b) Prioritize data based on immediate condition
c) Use evidence based practice
d) Applies legal, ethical and privacy guidelines
e) Patient has authority of his or her own health
2. Joint Commission
a) Assessments are written, comprehensive (physical,
psychological, and social status), and used to identify and assign
priorities for care.
b) ■ Agency policy designates (1) when each patient is to be
reassessed and (2) which disciplines can make which
assessments.
c) ■ All patients are assessed for pain.
E. Can I Delegate Assessments
1. Nurse aides or other nursing assistive personnel (NAP) may collect
information such as temperature, height, and weight. However, as a
nurse, it is your responsibility to assign those tasks, validate the data
collected, conduct the interview, and complete the physical assessment.
I. ASSESSMENT : the first step in the nursing process
1. Assessment : the systematic gathering of information related to the
physical, mental, spiritual, socioeconomic, and cultural status of an
individual, group, or community.
2. Patient database: (all pertinent patient data obtained by nurses and other
health professionals).
B. How is Assessment Related to Other steps of the nursing process?
1. Diagnosis—Assessment provides the data necessary for identifying the
client’s health problems and strengths.
2. ■ Planning outcomes—Data about the patient’s motivation, family, and
available resources help you formulate realistic goals.
3. ■ Planning interventions—Assessment data help you to choose the
interventions most likely to be acceptable to and effective for the client.
4. ■ Implementation—As you perform nursing actions, you will also gather
data by observing the client’s responses.
5. Evaluation—After performing interventions for existing diagnoses, you
assess the client’s responses. This reassessment provides the basis for
changes in the care plan.
C. How Does Nursing Assessment Fit into Collaborative Care?
1. Assess response to illness and also identify ways to prevent disease
2. Nurse can look at database and delegate or make referrals to other
professionals
D. What do Professional Standards Say about Assessment?
1. ANA standards:
a) Collects comprehensive data pertinent to health care consumer’s
health and/or situation
b) Prioritize data based on immediate condition
c) Use evidence based practice
d) Applies legal, ethical and privacy guidelines
e) Patient has authority of his or her own health
2. Joint Commission
a) Assessments are written, comprehensive (physical,
psychological, and social status), and used to identify and assign
priorities for care.
b) ■ Agency policy designates (1) when each patient is to be
reassessed and (2) which disciplines can make which
assessments.
c) ■ All patients are assessed for pain.
E. Can I Delegate Assessments
1. Nurse aides or other nursing assistive personnel (NAP) may collect
information such as temperature, height, and weight. However, as a
nurse, it is your responsibility to assign those tasks, validate the data
collected, conduct the interview, and complete the physical assessment.
