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NBHS 1104 Topic 1

This document discusses nursing assessment and the nursing process. It defines nursing and describes the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. The nursing process is a problem-solving tool used to identify client strengths and health problems, develop a care plan, and evaluate outcomes. Assessment involves 5 phases - data collection, validating data, organizing data, identifying patterns, and reporting/recording. The goal of nursing assessment and the nursing process is to provide high-quality nursing care.

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224 views16 pages

NBHS 1104 Topic 1

This document discusses nursing assessment and the nursing process. It defines nursing and describes the nursing process, which includes assessment, nursing diagnosis, planning, implementation, and evaluation. The nursing process is a problem-solving tool used to identify client strengths and health problems, develop a care plan, and evaluate outcomes. Assessment involves 5 phases - data collection, validating data, organizing data, identifying patterns, and reporting/recording. The goal of nursing assessment and the nursing process is to provide high-quality nursing care.

Uploaded by

hema angle
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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NBHS 1104

NURSING HEALTH ASSESSMENT


Topic 1
Nursing Assessment-Part I
DR Tan Beng Geok
Learning Outcomes
• Define nursing and the nursing process;
• Identify components of the nursing process
and phases of assessment;
• Classify the different types of data; and
• Prepare a comprehensive nursing assessment
using appropriate skills.
Introduction
Many changes are occurring in healthcare,
so it is not surprising that the role of
professional nurses continues to evolve.
One of the goals of most nurses is to
provide high quality nursing care. Therefore,
the utilisation of nursing process is to ensure
the quality of nursing care.
Florence Nightingale
• The first nurse theorist, known as “The
Lady With the Lamp,” best known as the
founder of modern nursing.
• She said that what nurses do “is to put
the patient in the best condition for
nature to act upon him”.
• The nurse's role is to nurture and support
these abilities. Thus, the art of nursing is
special and unique because it blends art
(caring) and science (knowledge and
problem-solving processes) within
person-to-person relationships.
Nursing
• Nursing is the diagnosis and treatment of
human responses to actual or potential health
problems.
• Diagnosis and treatment are achieved through
a process, called the nursing process, that
guides nursing practice.
Nursing Process
• Nursing process is a framework or problem-solving
tool for nursing.
• Nursing process gathering and analyzing data in
order to identify client's strengths and potential or
actual health problems and developing and
continually reviewing a plan of nursing
interventions to achieve mutually agreed outcomes
• The goal of the nursing process is to alleviate,
minimise or prevent actual or potential health
problems.
Components of the Nursing process
Assessmen
t

Nursing
Diagnoses

Planning

Implementatio
n

Evaluatio
n
5 Phases of Assessment

Data
collection

Reporting
and Validating
recording Data
data Phases
Assessment

Identifying Clustering
patterns the data
1. Data Collection
• Direct data
• Indirect data
• Assessment : Initial Assessment
• Focus Assessment
• Nursing history form
• Subjective data
– not measurable or observable.
– obtained from what the patient or significant others.
• Objective data
– obtained by observing and examining t
2. Validating (Verifying) Data

1. This second phase is an essential step as it


helps you to avoid:
– Making assumptions;
– Missing pertinent information;
– Misunderstanding situations;
– Jumping to conclusions; and
– Making errors in problem identification.
2. You can verify by directly observing and
interviewing the patient yourself.
3. Organising (Clustering) Data
• Clustering related data
requires critical thinking that
will help you to see various
aspects of health status.
• Organisation of Patient Data
– Data organised according to
body system
– Data organised according to
functional health pattern
4. Identifying Patterns/Testing First Impression

• Get some initial impressions of patterns.


• Test these first impressions and decide if the
patterns really are as they appear.
• Determine what is relevant and irrelevant
• Identify the cause for each information
5. Reporting and Recording
• This is the final phase of assessment.
• Reporting abnormal data will expedite diagnosis and
treatment
• Recording data will ensure continuity and accuracy of
data and enhances critical thinking.
• Report and record anything that you suspect might be
abnormal;
• Compare the data with accepted standards of normality
or the normal limits; and
• Remember the normal limits may vary from person to
person and from situation to situation.

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