it includes first step of nursing process - ASSESSMENT

1. NURSING
PROCESS
PREPARED AND PRESENTED BY
MRS.BABITHA K DEVU,
ASSTT. PROFESSOR,
SMVDCoN

2. Objectives
 Introduce the history of nursing process.
 Describe each steps of the nursing
process.
 Discuss and differentiate types of nursing
assessment.
 List the steps of nursing diagnostic
process.
 Describe goal setting.
 Develop a plan of care from assessment.
 Discuss the process of selecting

4. NURSING PROCESS -
INTRODUCTION
 Foundation of nursing profession.
 Serves as a guide for professional
nursing practice
 Identifies, discovers health care needs
of the patient/family/community.
 Helps in the clinical application of
theory

5.  It is a dynamic continuous process as the
clients need change.
 The use of Nursing Process promotes
individualized nursing care
 And assists the nurse in responding to client
needs in a timely and reasonable manner to
improve or maintain the client’s level of
health.
NURSING PROCESS -
INTRODUCTION

6. NURSING PROCESS -
INTRODUCTION
 For the successful application of Nursing
Process,
◦ the nurse integrates elements of critical thinking to
make judgments
◦ and take actions based on reason.
 The nursing process is used to
◦ identify, diagnose and treat human responses to
health and illness.

7. EVOLUTION
The term nursing process is synonymous to
problem solving approach (for discovering the
health care needs of the client or family).
 Widespread use of the term nursing process
came in late 1960’s.
Before that nurses cared for people based on a
medical model (loosely structure framework).
Since then several nursing leaders were
instrumental in developing a model of nursing
process

8. NURSE LEADERS
CONTRIBUTION
 Florence Nightingale helped to establish
nursing as a separate
body of knowledge
from medicine.
 1952--Hildegard Peplau Identified stages of
nurse client
Relationship-
orientation, identification,
exploitation
and resolution.
 1955-- Lydia Hall First person who
introduced the term
nursing process (not
used in nursing
publications until
1960’s)

9. Contin..
 Referring to the “nursing process” as a series
of steps, Johnson (1959), Orlando (1961), and
Wiedenbach (1963) further developed this
description of nursing. At this time, the nursing
process involved only three steps:
assessment, planning, and evaluation.
 1959 -- Dorothea Orlando theorized that
nurses must be intrinsically involved not
passively in the nursing process. (specifies the
unique role of nurses)
 1967-- Yura And Walsh devised 4 steps
of nursing process (assessment, planning,
implementation and evaluation) which is the
basis for widely accepted 5 step nursing
process.
 1967 - first comprehensive book on nursing
process was published

10. Contin. 1971 -- Dorothea Orem identified 3 levels of
client involvement in nursing care. (supportive,
educative, partly compensatory and wholly
compensatory) - helps in establishing focus for
decision making.
 1973 -- ANA introduced diagnosis as a separate
step of nursing process in standards of nursing
practice. (standards are formulated based on the 5
steps of nursing process).
 1953 - Fry first used the term nursing diagnosis,
but it was not until 1974, after the first meeting of
the group now called the North American Nursing
Diagnosis Association (NANDA), that Gebbie and
Lavin added nursing diagnosis as a separate and
distinct step in the nursing process. Prior to this,
nursing diagnosis had been included as a natural

11. Contin.
 1980 -- ANA identified diagnosis of
actual and potential health problems
as an integral part of nursing practice.
 1991 -- newest development in
nursing process is 6 step nursing
process introduced by ANA in
standards of clinical nursing practice.
In this model “outcome identification”
was distinguished as 3rd step of
nursing process.

12. Contin.
 Format of nursing care plan as per
INC. it has seven steps in nursing
process, namely:
Assessment
Diagnosis
Goal/outcome identification
Planning
Rationale
Implementation
Evaluation

13. Critical
thinking
ASSESSMENT
DIAGNOSING
PLANNINGIMPLEMENTING
EVALUATING

14. 1. Definition
 Nursing process is orderly, systematic
manner of determining the clients health
status,/ specifies the problems defined as
“alterations in human need fulfillment”,/
making plans to solve them, /initiating and
implementing the plans, /and evaluating
the extent to which plan was effective in
promoting the optimum wellness and
resolving the problems identified. - Yura

15. The Nursing Process is:
A systematic, rational method of planning
and
providing individualized nursing care.

16. Definition
 The nursing process is cyclical, that is,
its components follow a logical
sequence, but more than one
component may be involved at one time.
At the end of the first cycle, care may be
terminated if goals are achieved, or
cycle may continue with reassessment
or plan of care may be modified.

17.  It is synonymous with the PROBLEM
SOLVING APPROACH that directs the nurse
and the client to determine the need for
nursing care, to plan and implement the care
and evaluate the result.
 It is a G O S H approach (goal-oriented,
organized, systematic and humanistic care)
for efficient and effective provision of nursing
care.

18. PURPOSE OF THE NURSING
PROCESS
1. Identify a client’s health status and actual
or
Potential health problems or needs.
2. To establish plans to meet the identified
needs.
3. Deliver specific nursing interventions to
meet

19. PURPOSE OF THE NURSING PROCESS
4. To Achieve Scientifically-
Based, Holistic, Individualized
Care For The Client.
5. To Achieve The Opportunity To
Work Collaboratively With
Clients, Others.
6. To Achieve Continuity Of Care.

20. Benefits of Nursing Process
1. Provides an orderly & systematic method for planning
& providing care
2. Enhances nursing efficiency by standardizing nursing
practice
3. Facilitates documentation of care
4. Provides a unity of language for the nursing
profession
5. Is economical
6. Stresses the independent function of nurses
7. Increases care quality through the use of deliberate

21. Benefits of Nursing Process
1. Continuity of care
2. Prevention of duplication
3. Individualized care
4. Standards of care
5. Increased client participation
6. Collaboration of care
7. Provides personal satisfaction as you see client
achieve goals
8. Professional growth as you evaluate effectiveness of
your interventions

22. Characteristics of the Nursing
Process
1] Cyclic & dynamic in nature
2] Client centered
3] Focus on problem solving & Decision making
4] Interpersonal & Collaborative style
5] Universal applicability
6] Use of critical thinking.
7] Data from each phase provide input into the next
phase.
8]Decision making involved in every phase of nursing
process.

23. CHARACTERISTICS:
a. Systematic:
 The nursing process has an ordered sequence of
activities and each activity depends on the accuracy
of the activity that precedes it and influences the
activity following it.

24. b. Cyclic & Dynamic:
 The nursing process has great interaction and
overlapping among the activities and each activity
is fluid and flows into the next activity

25. c. Interpersonal:
 The nursing process ensures that nurses are client-
centered rather than task-centered and encourages
them to work to enhance client’s strengths and meet
human needs.

26. d. Goal-directed:
 The nursing process is a means for nurses and
clients to work together to identify specific goals
(wellness promotion, disease and illness prevention,
health restoration, coping and altered functioning)
that are most important to the client, and to match
them with the appropriate nursing actions

27. e. Universally applicable:
 The nursing process allows nurses to practice
nursing with well or ill people, young or old, in any
type of practice setting

28. Phases/Steps/Components of
Nursing Process
a. Assessing
b. Diagnosing
c. Planning
d. Implementing
e. Evaluating

29. 5. EVALUATION
a. Collect data related to outcomes
b. Compare data with outcomes
c. Relate nursing actions to client goals/outcomes
d. Draw conclusions about problem status
e. Continue, modify, or terminate the client’s care plan
4. IMPLEMENTATION
a. Reassess the client
b. Determine the nurse’s need for
assistance
c. Implement the nursing interventions
d. Supervise delegated case
e. Document nursing activities
3. PLANNING
a. Prioritize problems/diagnoses
b. Formulate goals/desired outcome
c. Select nursing interventions
d. Write nursing orders
2. DIAGNOSING
a. Analyze data
b. Identify health problems, risk, and
strengths
c. Formulate diagnostic statements
1. ASSESSING
a. Collect data
b. Organize data
c. Validate data
d. Analyze data
e. Document data
O
V
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R
V
I
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30. Assessment

31. Assessing - Definition
 It is the systematic and continuous collection,
organization, validation, and documentation of data
(information) as compared to what is standard /
norm .
 It is continuous process carried out during all
phases of the nursing process.
 For Eg. In evaluation phase assessment is done
to determine the outcomes of the nursing strategies
and to evaluate goal achievement.
 All phases of nursing process depend on the
accurate and complete collection of data.

32. Purpose of Assessment
1. To establish a data base (all the information about
the client):
o Nursing health history
o Physical assessment
o The physician’s history & physical examination
o Results of laboratory & diagnostic tests
o Material from other health personnel
2. To identify health promoting behavior.
3. To identify actual and/or potential health problems.
4. It promote holistic & innovative nursing care.
5. To collecting data for nursing research
6. To evaluation of nursing care

33. Types of assessment
There are 4 different types of
assessment:-
1] Initial assessment
2] Problem focused assessment
3] Emergency assessment
4] Time lapsed reassessment

34. Initial comprehensive
assessmentAn initial assessment, also called an admission
assessment, is performed when the client enters a
health care from a health care agency. The purposes
are to evaluate the client’s health status, to identify
functional health patterns that are problematic, and
to provide an in-depth, comprehensive database,
which is critical for evaluating changes in the
client’s health status in subsequent assessments.
Eg: Nursing admission assessment

35. Problem-focused assessment
A problem focus assessment collects data about a problem that
has already been identified. This type of assessment has a
narrower scope and a shorter time frame than the initial
assessment. In focus assessments, nurse determine whether
the problems still exists and whether the status of the
problem has changed (i.e. improved, worsened, or resolved).
This assessment also includes the appraisal of any new,
overlooked, or misdiagnosed problems. In intensive care
units, may perform focus assessment every few minute.
Eg: Hourly assessment of client’s fluid intake and urinary
output in an ICU
Assessment of client’s ability to perform self care while
assisting a client to bathe.

36. Emergency assessment
Emergency assessment takes place in life-threatening situations in which
the preservation of life is the top priority. Time is of the essence rapid
identification of and intervention for the client’s health problems. Often
the client’s difficulties involve airway, breathing and circulatory
problems (the ABCs). Abrupt changes in self-concept (suicidal thoughts)
or roles or relationships (social conflict leading to violent acts) can also
initiate an emergency. Emergency assessment focuses on few essential
health patterns and is not comprehensive.
Eg: Rapid assessment of a person’s airway, breathing status, and circulation
during a cardiac arrest
Assessment of suicidal tendencies or potential for violence.

37. Time-lapsed assessment or
Ongoing assessment
Time lapsed reassessment, another type of assessment, takes
place after the initial assessment to evaluate any changes in
the clients functional health. Nurses perform time-lapsed
reassessment when substantial periods of time have elapsed
between assessments (e.g., periodic output patient clinic
visits, home health visits, health and development
screenings)
Eg: Reassessment of a client’s functional health patterns in a
home care or outpatient setting or, in a hospital, at shift
change.

38.  Assessment varies according to
◦ purpose,
◦ timing,
◦ time available &
◦ client status.
 Nursing assessments focus on a client response to
a health problem.
 A Nursing assessment include the clients perceived
needs, health problems, related experience , health
practices, values and life styles.
 Data should be relevant to a particular health
problem.

40. Activities/Steps in Assessment
phase
Assessment
Collect data Organize data Validate data
Documenting
data

41. Collecting Data
 Is the process of gathering information
about a client’s health status.
 It must be both systematic & continuous
 To prevent the omission of significant
data
 It reflect a client’s changing health status.
 To collect data clearly both the client & nurse
must actively participate.

42.  includes physical, psychological, emotion,
socio-cultural, spiritual factors that may affect
client’s health status
 includes past health history of client (allergies,
past surgeries, chronic diseases, use of folk
healing methods)
 includes current/present problems of client
(pain, nausea, sleep pattern, religious practices,
medication or treatment the client is taking
now)

43. Types of data
Subjective Data
 Also referred to as symptoms or
covert data
 Are the verbal statements
provided by the Patient.
 Can be verified or described by
only the person who affected.
 Eg. Itching, pain, feelings of
worry.
 It includes the client’s
sensations, feelings values,
beliefs, attitudes and perception
of personal health status and
Objective data
 Also referred to as signs or overt
data,
 Are detectable by an observer or
Can be measured or tested
against an accepted standard.
 They can be seen, heard, felt or
smelled and
 They are obtained by observation
or physical examination
 For eg. Discoloration of skin, BP
reading.

44.  During Physical Examination, the nurse obtains
objective data to validate subjective data.
 Information supplied by family members, significant
others or health professionals are considered
subjective if it is not based on fact.
 A complete data base of both subjective & objective
data provides a base line for comparing the client’s
responses to nursing & medical intervention.

45. Eg. Of subjective & objective
data.
Sl.
No.
Subjective Data Objective Data
1 I have fever Body tem – 1000F
Tachycardia – 100 bt/mt
Dull & tired
Dried lips
2 I feel sick to my stomach Vomited 100ml of green tinged fluid
Abdomen firm
Slightly distended
Active bowel sounds in all 4 quadrants
3 I am short of breath RR – 28br/mt
Tachypnoea
Lung sound diminished in ® lower lobe.

46. Sources of Data
 Sources of data are primary or secondary.
 The client is the primary source of data. The alert and oriented
patient can provide information about past illness and surgeries
and present signs, symptoms, and lifestyle.
 When the patient is unable to supply information because of
deterioration of mental status, age, or seriousness of illness,
secondary sources are used.
 Secondary or indirect sources are family members or other
support persons, other health professionals, records & reports
laboratory and diagnostic analyses, and relevant literature.
 All sources other than the client are considered secondary
sources.

47. Client/ Patient
 The best source of data unless the
client is too ill, young or confused to
communicate clearly.
 The client can provide subjective data
that no one else can offer.

48. Support people
 Family members, friends and care givers who know
the client well often can supplement or verify
information provided by the client.
◦ They might convey information about the client’s
response to illness
◦ the stresses client was experiencing before the
illness,
◦ family attitudes on illness and health,
◦ and the clients home environment.
 Support people data are very important in case of a
client who is very young unconscious or confused.

49. Client Medical Records
 It includes information documented by various health
care professionals.
 Client records also contain data regarding the client’s
occupation, religion, and marital status.
 By reviewing the records the nurse can avoid asking
questions for which answers have already been
supplied.
 Medical records (Medical history, physical
examination, operative report, progress notes &
consultations by Physicians.)
 Records of therapies – Social workers, nutritionists,
dietitians or physical therapists

50.  Laboratory records & Other Literature
The various lab investigation done for the
client. Reviewing nursing, medical, and
pharmacological literature about patient’s
illness completes your assessment database.
This will improve your knowledge & only a
knowledgeable nurse obtains pertinent,
accurate and complete information for the
assessment database.
 Health care professionals.
The other members of the health team is also
able to give information regarding client.
Every member of the health care team is a
source of information for identifying and
verifying information about the patient.

51. Data Collection Methods
 The primary methods of data collection
are
◦ I. Observing – Occurs whenever the nurse is
in contact with the client or support persons.
◦ II. Interviewing/ History Collection – is
used while taking the nursing health History
◦ III. Examining – Major method used in the
physical health assessment.

52.  In reality, the nurse uses all three
methods simultaneously when
assessing clients.
 for Eg. During the client interview the
nurse observes, listens, asks
questions, and mentally retains
information to explore in the physical
examination.

53. Observation of patient’s
behavior
 It is a deliberate search carried out with care
and forethought. (Virginia Henderson)
During an interview
& physical assessment
it is important for you
to closely observe a
patient’s verbal &
nonverbal behaviors.

54. Contin..
 Is to gather data by using the senses.
 Observation is a conscious, deliberate
skill that is developed through effort &
with an organized approach.
Eg. Using the senses to observe client
data.

55. Methods of Observation
◦ Vision :- overall appearance (body size ,
general weight, signs of distress or posture
& grooming) discomfort, facial & body
gestures, skin colour & lesions
◦ Smell: - Body or Breath odors.
◦ Hearing: - lung, heart sounds, bowel
sounds, ability to communicate, language
spoken.
◦ Touch :- Skin temperature, moisture,

56. Aspects of Observation
 1] Noticing the data
 2] Selecting, organizing & interpreting the
data
 Eg : - A nurse who observes that a client’s
face is flushed, must relate that observation
to body temperature, activity, environmental
temperature, and blood pressure.
 Errors can occur in selecting, organizing &
interpreting data.

57.  Nursing observations must be organized so that nothing
significant is missed.
 Most nurses develop a particular sequence for observing
events, usually focusing on the client first.
 For Eg. A nurse walks into a client’s room and observes, in
the following order.
1]Clinical signs of client distress (Eg. pallor or flushing, labored
breathing, and behavior indicating pain or emotional distress)
2] Threats to clients safety, real or anticipated (Eg. a lowered side rail)
3]The presence and functioning of associated equipment (Eg.
Equipment & oxygen)
4] The immediate environment, including the people in it.

58. Interviewing
 An interview is a
planned communication
or a conversation with a
purpose
For Eg. to get or give
information, identify
problems of mutual
concern, evaluate
change, teach

59. Contin..
 There are 2 approaches in interview
Direct Indirect or nondirective

60. Direct Indirect or nondirective
Highly structured & elicits
specific informations
Rapport- building interview
(understanding between two
or more people)
Nurse establishes purpose of
interview and controls the
interview
Nurse allows the client to
control the purpose, subject
matter and pacing
Clients who responds may
have limited opportunity to
ask question or Discuss
concerns

61. Types of interview
questions
There are 4 types of interview questions
 Closed question
 Open ended question
 Neutral questions
 Leading question

62.  OPEN-ENDED: broad questions, often specifying only the topic
 highly open-ended: virtually no restrictions
◦ Tell me about yourself.
◦ What is photography like?
◦ How is life in Brazil?
 moderately open-ended: restrict interviewees to a narrower response and greater focus
◦ Tell me about your first internship at a radio station.
◦ What led you to leave your career in advertising and return to school to pursue your interest in photography?
◦ What are the main ways that life in Brazil is different from life in the United States?
 CLOSED-ENDED: limit answer options; specific response required
 highly closed-ended: interviewees select answers from specified choices
◦ How would you describe the performance of your new car?
 excellent
 good
 fair
 poor
◦ What is your class standing?
 Freshman
 Sophomore
 Junior
 Senior
 Graduate
 Other
 bipolar: a special type of closed-ended questions having only two options that are at opposite ends of a continuum
◦ Have you finished your assignment?
here the implied possible answers are "yes" or "no"
◦ Is the electricity on or off?
◦ Do you like or dislike your new computer?
 moderately closed-ended: asks for specific information
◦ How old are you?
◦ In what languages are you fluent?
◦ When did you move to Chile?

63.  NEUTRAL: seek straight-forward answer; typically, the
questions you ask in the information interview are
neutral
 What is your favourite colour?
 How would you describe the music you play?
 Where were you born?
 LEADING: imply or state expected answer in question;
generally, you will want to avoid these questions in the
information interview
 Wouldn't you agree that older home have more charm
than modern ones?
 Don't you think essay exams are easier than multiple
choice?
 Aren't you a big fan of the Indigo Girls?

64. Closed question Open ended
question
Neutral questions Leading question
1. Used in direct
interview,
2. Are restrictive
3. Generally requires
yes of No or short
factual answers
4. Often begin with
when, where, who,
what, do, did or
does, or is, are, was.
Eg.
a. Are you having pain
now?
b. What medication did
you take?
1. Associated with
nondirective
interview
2. Invite clients to
discover & explore,
elaborate, clarify or
illustrate their
thoughts or feelings.
3. It specifies only the
broad topic to be
discussed & invites
longer that one or
two words.
4. An open ended
question begins with
what or how?
Eg.
a. What brought you to
hospital?
b. How did you feel in
that?
1. Is a question the
client can answer
without direction or
pressure from the
nurse.
2. Used in non directive
that question.
Eg.
a. How do you feel
about that?
b. Why do you think
you had the
operation?
1. Used in directive
interview &
2. Thus directs client
answer.
Eg.
a. You’re stressed about
surgery tomorrow,
aren’t you?
b. You’ll take medicine
won’t you?
Types of interview questions

65. Planning the interview and
setting
 Before beginning an interview, the nurse
reviews available information.
Eg. Operative report, information about
the current illness.
 Each interview is influenced by time,
place, seating arrangement or distance,
and language.

66.  Time: -
Nurse need to plan for an interview with hospitalized clients
◦ physically comfortable,
◦ free of pain,
◦ when interruptions by friends, family, and other health
professionals are minimal.
The client should be made to feel comfortable & unhurried.
 Place: - Well lighted, well ventilated, moderate sized room,
free of nurse, movements, interruptions encourages the
communication.
 Seating arrangements: -
 Distance:-

67. Interviewing
 A nurse generally performs two types of
interview:
Initial Interview: it involves assessing the
patient’s health history and obtaining
information about the current illness. During the
initial interview nurse will:
 introduce
Establish a therapeutic relationship
Gain insight about patient’s worries &
concern
Determine the patient’s goal
Cues for in – depth investigation

68. Contin..
 Later interviews: allows you to assess
more about a patient’s situation and to
focus on specific problem areas. It
helps the patients to explain their own
interpretation and understandings of
their conditions.

69. Phases of Interview

70. Orientation Phase
It begins with introducing yourself and your
position and explaining the purpose of
the interview. During orientation you
establish trust and confidence with a
patient.
Goal:
1. To lay the groundwork for understanding the
patient’s needs.
2. To begin a relationship that allows a patient to
become an active partner in decisions about
care.
Initially you may gather demographic data
as this is least personal and eases

71. Working Phase
During working phase you gather
information about the patient’s health
status. Remember to stay focused,
orderly and unhurried.
Use a variety of communication
strategies such as active listening,
summarizing to promote clear
interaction.
The use of open ended questions in
particular encourages patient’s to tell
their stories.

72. Termination phase
Give your patient a clue that the interview
is coming to an end.
Eg: there are just two more questions.
This helps the patient maintains direct
attention without being distracted. This
approach also give patient a chance to
ask questions.
When ending summarize the important
points and ask your patients whether it is
correct.
End the interview in a friendly manner.

73. History Collection

74. Physical assessment

75. Examining
 Physical examination or physical assessment is
a systematic data collection method that uses
observation to detect health problems.
It includes the systematic collection of
information about the body systems through
the techniques of physical assessment.
 To conduct examination the nurse uses
techniques of 1) Inspection 2) auscultation, 3)
palpation, 4) percussion.

76. Inspection
Inspection is seeking physical signs by observing
the patient. Of the several methods of examination
inspection is the least mechanical the hardest to
learn, but it yields most physical signs.

77. Palpation
Palpation is the process of using one's hands to
examine the body, especially while
perceiving/diagnosing a disease or illness.

78. Auscultation
 Auscultation or listening with a stethoscope:
During auscultation, the physician listens to the
patient's heart beat, lungs and blood vessels of the
neck and groin.

79. Percussion
Percussion is a method of tapping body parts with
fingers, hands, or small instruments as part of a
physical examination. It is done to determine: The
size, consistency, and borders of body organs. The
presence or absence of fluid in body areas.

80.  Inspection: - Process of checking that
things are in the correct condition.
 Auscultation: - Examining the internal
organs by listening to the sounds that they
give out
 Palpation: - Examination of organ by
touches or pressure of the hand over the
part.
 Percussion: - Tapping with the fingers or

81.  The physical examination is carried our
systematically.
 It may be organized according to the
examiner’s preference,
 Head to toe approach (Cephalo caudal approach)
 System wise approach – examine all the body
system
 Review of system approach – examine only
particular area affected

82. A Body System Format For
Physical Assessment
General assessment
Integumentary system
Head, ears, eyes, nose & throat
Breast & axillae
Thorax & lungs
Cardiovascular system
Nervous system
Abdomen & gastrointestinal system
Anus & rectum
Genitourinary system
Reproductive system
Musculoskeletal system

83. Diagnostic & Lab Data
 The results identify or verify
alterations questioned or identified
during the nursing health history or
physical examination.
 Compare lab data with the
established norms for a particular
test, age-group and gender.

84. Organization of data
 Uses a written or
computerized format that
organizes assessment data
systematically.
 Maslow’s basic needs
 Body system model
 Gordon’s functional health
patterns

86. BODY SYSTEM MODEL
1)THE INTEGUMENTARY SYSTEM
2)THE SKELETAL SYSTEM
3)THE MUSCULAR SYSTEM
4)THE NERVOUS SYSTEM
5)THE ENDOCRINE SYSTEM
6)THE CIRCULATORY SYSTEM
7)THE LYMPHATIC SYSTEM
8)THE RESPIRATORY SYSTEM
9)THE DIGESTIVE SYSTEM
10)THE URINARY SYSTEM
11)THE REPRODUCTIVE SYSTEM

87. GORDAN’S FUNCTIONAL
HEALTH PATTERNS
 The clients strengths, talents and functional
health patterns are an integral part of the
assessment data.
 An assessment of functional health focuses not
only on the clients normal function but on his /
her altered function or risk for altered function.
 Because the information gathered using the 11
functional health patterns is basic to nursing, it is
applicable for all conceptual models of nursing

88.  Gordon’s Functional Health Patterns:
i. Health perception-health management pattern.
ii. Nutritional-metabolic pattern
iii. Elimination pattern
iv. Activity-exercise pattern
v. Sleep-rest pattern
vi. Cognitive-perceptual pattern
vii. Self-perception-concept pattern
viii. Role-relationship pattern
ix. Sexuality-reproductive pattern
x. Coping-stress tolerance pattern
xi. Value-belief pattern

89. Validating Data
 The information gathered during assessment
phase must be complete, factual, and accurate
because the nursing diagnoses and interventions
are based on this information.
 Validation is double checking or verifying the
data is accurate and factual or complete.

90. Purposes of data validation
1. Ensure that data collection is complete
2. Ensure that objective and subjective data
agree
3. Obtain additional data that may have
been overlooked
4. Avoid jumping to conclusion
5. Differentiate cues and inferences

91.  Cues - subjective and objective data that can be
directly observed by the nurse.
(What client can say, what the nurse can see, hear,
feel, smell or measure)
 Inferences - Nurses interpretation or conclusions
made based on the cues
Example:
1. Red, swollen wound = infected wound
2. Dry skin = dehydrated

92. Methods of validation
 Recheck your own data through a repeat assessment. For
example, take the client’s temperature again with a different
thermometer.
 Clarify data with the client by asking additional questions. For
example: if a client is holding his abdomen the nurse may
assume he is having abdominal pain, when actually the
client is very upset about his diagnosis and is feeling.
 Verify the data with another health care professional. For
example, ask a more experienced nurse to listen to the
abnormal heart sounds you think you have just heard.
 Compare you objective findings with your subjective findings
to uncover discrepancies.

93. Analyze data
 Compare data against standard and identify
significant cues.
 Standard/norm are generally accepted
measurements, model, pattern:
Ex:
1. Normal vital signs,
2. Standard weight and height,
3. Normal laboratory/diagnostic values,
4. Normal growth and development pattern

94. Documenting data
 To complete the assessment phase, the nurse records client
data.
 record in a factual manner
 It includes all data collected about client status.
 Eg. Data in factual manner Wrong manner
 Slice of toast – I Appetite is good”
 Egg - I “normal appetite”
 Juice - 250ml.
 Coffee- 240ml.
- Record subjective data in client’s own words (more
accuracy)

95. Contin..
 Communication of assessment findings,
either verbally or through
documentation, is the last step of
complete assessment. The timely and
accurate communication of facts is
necessary in order to ensure continuity
and appropriateness of patient care.
 It is legal and professional responsibility.

96. Conclusion
 Assessment is the first and most
critical step of nursing process.
Accuracy of assessment data affects
all other phases of the nursing
process. A complete data base of both
subjective and objective data allows
the nurse to formulate nursing
diagnosis, develop client goals, and
intervenes to promote heath and
prevent disease.