Question

List and describe the steps of the nursing process: subjective data collection; objective data collection; validation of data, documentation of data, and analysis of data. . Describe the steps of the analysis phase of the nursing process. Compare and contrast the four basic types of nursing assessment:

(a) initial comprehensive

(b) ongoing or partial

(c) focused/problem-oriented

(d) emergency

Explain how the nurse’s role in assessment has changed over the past century. Discuss what the nurse’s role might be 25 years from now.

Answer 1

In healthcare, the effective and efficient nursing care plays a crucial role, as it safeguards the patient’s interest and helps them in a speedy recovery. Effective nursing care is contributed by the implementation of the nursing process. The nursing process is based on individualized care, it considers each patient’s and their needs as unique. The nursing process is the systematic method to solve the problems and decision making. It also helps the nurses to identify actual or potential health problems and plan to solve the problems.

It can always be evaluated and revised or modified if needed. The nursing process is always goal based and the goal is set in mutual understanding between nurses and patients. The entire process is always patient-centred and each phase or step in the nursing process needs accuracy and preceding steps.

The nursing process consists of five main phases:

1. Assessment phase:

Assessment is the beginning and foundation of the nursing process. In the assessment, phase nurse collects as much information about the patient. The assessment also involves critical thinking skills and data collection. Assessment helps to determine the present health status of the patient, coping abilities, patient’s strengths and limitations, maintain rapport with the patient and caregivers.

Assessment phase also includes the reviewing of client records,

collecting, organizing, validating, and documenting client data, collecting nursing health history.

The assessment phase is also used to establish a database about the client's response to health problems and the ability to cope with the needs.

It can be obtained as the subjective data and objective data.

Subjective data: it is the verbal statements from the patient. It can also be obtained from the primary caregiver. It exactly represents what the patient’s feels or experiences. Subjective data can be obtained by listening and talking to the patient.

Subjective data can be anything that is validated by the patient.

Objective data: It is the measurable and tangible data obtained by the nurses. Examples are vital signs, intake and output, height and weight. It can be obtained by the observation.

The data can also be collected with the help of Electronic health records (EHRs) and it can assist the assessment process.

Validation of data: Validation of data can be done by repeating client’s response back to the patient or with open-ended questions to clarify the statement. Obtain the holistic data to get a clear picture of the patient.

Documentation of data: The validated data obtained by the assessment should be documented carefully with accurate time and date.

Analysis of data:

The interpretation or analysis of the data is done in the second phase of the nursing process, the Diagnosis.

2. Diagnosis: the obtained data is analyzed and interpreted to form a problem statement or nursing diagnosis.

The data collected in the assessment is clustered, analyzed and synthesized in the diagnosis phase. The client’s strengths, risks and problems are determined and stated in the diagnosis.

In the diagnosis phase, the assessed data compared against standards.

3. Planning:

In the planning phase, the individualized care /interventions are planned to achieve the goals or desired outcomes. In the planning phase, the nurse makes patient-centred, realistic interventions in discussion with other team members.

4. Implementation

In the implementation phase, the planned interventions are put into action.

5. Evaluation

The evaluation phase determines the effectiveness of the interventions. In this phase, the nurse determines the efficiency of the plan and nurse can also modify or terminate the plan of care.

The achievement of goals are assessed and if needed re-planning can be done in the evaluation phase.

Reassessment and re-planning can be done in the nursing process.

(a) an initial comprehensive assessment

It can be done shortly after admission and must be done within 24 hours.

As it is the initial assessment it is a bit time consuming and can be used to establish a database. In the initial assessment data on all aspects of patient's health along with baseline data is collected. It also includes health history.

(b) ongoing or partial

In the ongoing or partial assessment of the assessment, reassessment and validation of past data are done.

(c) focused/problem-oriented

This type of assessment is done on specific health concerns. It focuses only on specific concerns. Example: focusing on breath sounds in a pneumonia patient.

(d) emergency

This type of assessment is done in a rapid way during life-threatening situations.

Mainly focusing on ABC's; Airway, Breathing, Circulation