NCMA 111 Health Assessment: Nursing Process Overview

• NCMA 111: Health Assessment Course Unit 1 provides an overview of the Nursing Process, Health Assessment in Nursing Practice, & Nurse's Role in Health Assessment

Learning Objectives

• Discuss how needed nursing assessment skills apply to all nurse encounters
• Differentiate between holistic and physical medical assessments
• Describe which phases of the nursing process involve nurse assessments
• List and describe the steps of the nursing process, including how some steps may overlap and/or be repeated
• Describe the steps of the analysis phase of the nursing process
• Explain how the nurse's role in assessment changed over the past century
• Inculcate the importance of the nursing process in the nursing profession
• Listen during class discussions
• Demonstrate tact and respect when challenging other people's opinions and ideas
• Accept classmates' comments and reactions to one's opinions openly and graciously
• Participate actively during class discussions
• Confidently express personal opinions and thoughts in front of the class

Outline of Discussion

• The outline includes these topics:
  • Overview of the Nursing Process (ADPIE)
  • Health Assessment in Nursing Practice
  • Types of Health Assessment
  • Nurse's Role in Health Assessment

Overview of the Nursing Process (ADPIE)

• "The very elements of nursing are all but unknown" - Florence Nightingale, 1859

Definition of Nursing

• Nursing, as defined by the ANA in 1995, involves diagnosing and treating human responses to health and illness.
• Nursing is both a science and an art
• Nursing concentrates on the individual's physical, psychological, sociological, cultural, and spiritual needs

Essential features of Nursing Practice

• Considers the full range of human experiences and responses to health and illness without restricting focus
• Understanding and integrating objective data based on a client's subjective experience
• Requires a caring relationship to facilitate health and healing
• Requires scientific knowledge for diagnosis and treatment

Diagnosis

• It is a clinical judgement concerning a human response to health conditions/ life processes, or vulnerability for that response by individual, family, or community the nurse is licensed and competent to treat
• Data analysis to identify the problem
• It involves identifying and prioritizing actual or potential health problems or responses
  • Actual Nursing Diagnosis identifies existing health problems in patients
  • Potential Nursing Diagnosis identifies high-risk health problems likely to occur without preventive measures
  • Possible Nursing Diagnosis needs further data to support

Types of Nursing Diagnosis

• Problem-Focused Nursing Diagnosis includes:

  • Problem + Etiology + S/Sx
  • Diagnoses include acute pain related to trauma and ineffective breathing patterns

• Risk Nursing Diagnosis includes:

  • Problem + Etiology
  • Diagnoses include risk for infection and risk for bleeding

• Health Promotion Nursing Diagnosis includes:

  • Readiness for enhanced decision-making including problem resolution, grieving, and hopefulness.

• Syndrome Nursing Diagnosis includes:

  • Conditions occur together and require similar nursing interventions to resolve the situations.
  • Examples include chronic pain syndrome manifested by anxiety and disturbed sleep patterns.

Key Factors Regarding Diagnosis

• Defining Characteristics (Signs and Symptoms)
  • Observable assessment cues, such as patient behavior and physical signs
• Related Factor (Etiology)
  • Etiological or causative factor for diagnosis

Planning

• Involves establishing desired outcomes and appropriate interventions
• Includes setting goals and outcomes
• Requires an individualized care plan
• Includes priority setting:
  • Involves ordering nursing diagnoses or patient problems based on urgency and importance to determine a preferential order for nursing interventions

Types of Goals

• Long-term goals include:
  • Objective behaviors/responses expected over a longer period (days, weeks, or months)
  • Ex: achieving a normal and healthy body weight.
• Short-term goals include:
  • Objective behaviors/responses expected quickly (within hours or a week)
  • Ex: resolving a high body temperature or resolving acute pain after surgery.
• Planning should be SMART:
  • Specific
  • Measurable
  • Attainable
  • Realistic
  • Time-bound

Interventions

• Involves treatments based on clinical judgment and knowledge to enhance patient outcomes
• Putting plan of care into action
• It is also called IMPLEMENTATION.
• The "doing" phase involves carrying out a designed plan to meet goals and outcomes

Approaches to Intervention

• Direct Care:
  • Direct interventions are treatments through interaction with the patient.
  • Medication administration or insertion of a urinary catheter are considered direct interventions.
• Indirect Care:
  • Interventions performed away from a patient but on their behalf.
  • Safety and infection control and delegating nursing care are indirect.

Types of Intervention

• Independent: Actions the nurse initiates without supervision or direction from others
• Dependent: Actions requiring a healthcare provider's order
• Collaborative: Interdependent interventions requiring combined knowledge, skills, and expertise from multiple healthcare providers

Evaluation

• Final step of the nursing process
• Crucial to know if the patient's condition improved or worsened after application of the first four steps of the nursing process
• Involves monitoring the client's progress and altering the plan as indicated
• Involves assessing the patient's response based on set outcome criteria

Things to Note in the Nursing Process

• The steps of the nursing process are interrelated, forming a continuous, dynamic, and cyclic circle of thought and action
• Nurses must apply basic abilities using scientific and theoretical knowledge
• Creativity and adaptability are vital

Characteristics of the Nursing Process

• It is dynamic and cyclical
• Is patient-centered
• Goal-directed
• Flexible
• Problem-oriented
• Cognitive
• Action oriented
• Interpersonal
• Holistic
• Systematic

Purpose of the Nursing Process

• To identify a client's health status: actual, present, and potential health problems or needs
• To establish a care plan to meet identified needs
• To provide nursing interventions to meet those needs
• To provide individualized, holistic, effective, and efficient nursing care

Health Assessment in Nursing Practice

• Health assessment is defined as collection of data to determine a client's current and past health status and to determine the client's present and coping patterns. (Carpenito)
• Atkinson and Murray stated that assessment is part of each activity a nurse does for and with the patient (1991)

Types of Assessment

• Initial comprehensive assessment
• Ongoing or partial assessment
• Focused or problem-oriented assessment
• Emergency assessment