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

Nursing Process

The steps of the Nursing process include

• Assess - Gather information about client's condition.
• Diagnose - Identify the client problem.
• Plan - Set goals of care and desired outcomes and identify appropriate action.
• Implement - Perform the nursing actions according to the planning.
• Evaluate - Determine the achieved goals and outcomes.

The Nursing assessment includes

• Collection of data
• Validation of data
• Documentation of data
• Analysis of data

Collection of data:

It is the gathering of information about client status which must be descriptive, concise, and complete. The nurse applies intellectual critical thinking to understand the client's problem. The nurse should gather information about the physical, psychological, social, and spiritual data, client's past medical history, current health status.

Types of Data:

Subjective data collection:

• Client's perception of his health condition.
• the client only can provide the kind of information.
• Also called as symptoms.
• Example: pain, feelings of anxiety, mental stress.

Objective data collection:

• It is the observation made by the data collector.
• Also called as signs.
• Examples: measuring temperature of the client, assess the skin for pallor.

Validation of data:

After gathering the assessment data, the nurse must verify the collected data for accuracy.

• Ensure that the data is collected completely.
• Validate the information by asking the family members.
• checking for any additional data required.
• Clustering of any data.

Documentation of Data:

A thorough, concise and accurate documentation of client information is necessary while documenting. The data recorded in a manner that it contains the original meaning of the client's status.

Analysis of Data:

The nurse has to analyze the data through the inferential reasoning and judgment. The nurse has to analyze the data to decide about the client's health status. The analyzation should be concise, accurate, and meaningful.

Types of assessment:

(a) Initial comprehensive assessment:

Initial assessment is based on the patient's nature of the problem and based on client's medical history, and physical examination and psychosocial assessment.

(b) Ongoing or partial assessment:

Once the treatment has started, the client is compared to the initial baseline status of the client prior to treatment and the progression of the patient condition. This also includes the laboratory and diagnostic findings.

(c) Focused assessment:

The assessment is done in the state when the health problem is identified and treated. The client should be monitored continuously. For example, the changing of vital signs, root-cause analysis of the problem and the relief of pain due to medication etc. Diagnosis and the laboratory tests also included in this assessment.

(d) Emergency Assessment:

The nurse must assess the airway, breathing, circulation. Once the emergency status of the client is stabilized, then the assessment is turned towards the initial or focused assessment.

The nurse's role in the assessment has met vast changes. In the past, the assessment was done in the outpatient settings, and during the subsequent visits of shift change. Today, the first step of the nursing process is the assessment. And also the abbreviated assessment is a less consuming of time for nurses. In the past, the assessment is focused only on the problem-oriented. Now, the complete head to foot detailed assessment of the client is done before admission and ongoing assessment is done till discharge.

In the future, the nurses become more strengthen in the field of assessment. The role of nurse in assessment pertaining to a large area. Proper assessment lead to a comprehensive care in the future. The nursing assessment includes all the areas and the nursing education and training improved a lot. The effective workforce planning will make better data collection and better health outcomes. Nurses role in health profession becomes great in the future.