Nursing: is a unique and complex science, and caring art, combined with the scien-
tific sciences such as chemistry, anatomy, physiology, biology, pharmacology…etc.
Nurses are increasing responsibilities that involve not only caring but also assessment , diagnosis, and implementation with patients to treat, prevent, educate and assist patients.
The Nursing Process: It is a logical plan that helps nurses give good care to the patient and avoid mistakes,
involves
1. Assessment (collect information)
2. Diagnosis (analysis information, know problem)
3. Planning (manage the problem)
4. Implementation (putting plan into action)
5. Evaluation (check output)
Nursing Assessment : Is the systematic and continuous
collection, organization, validation,
documentation of data.
documentation of data.
*First step of the Nursing Process
*Gather Information/Collect Data
Types of assessment
1-Initial
• Shortly after contact with patient
• Most facilities have specific time-frames
• Establishes database for development of plan
2-Focused
• Gathers data about specific problem
• May be part of initial assessment, but more often is not
3-Emergency
• Identifies life-threatening problems
4-Time-Lapse
• Compares current to previous data
Assessment collect data
-Nursing Interview (history)
-Physical Examination
-Lab results.
-Review records and literature
Nursing health history:
Biographic data:
- Client name, address, age, sex, marital satus, occupation,
religious, assurance, Date and time of history.
Chief complain:
- The answer given to question "what brought you to the
hospital?
- The chief complain should record in own patient word.
Ex: my stomach hurts or I have come for my regular check up
History of present pain:
a-Location.
b-Radiation.
c-frequency
d-Timing and duration.
e-Quality and quantity.
f-Factors aggravated or alleviated.
g-Associated symptoms
Past History:
a-Immunization.
b-Childhood illness( measles, mumps,
streptococcal infection and rheumatic fever).
c-Allergy ( drug, egg, animals and insect).
d-Surgeries
e-Hospitalization.
f-Medication ( aspirin, laxatives, antihypertensive)
Family history:
a-Risk factor certain disease
b-Cancer, hypertension. Angina, bleeding tendency.
Life style:
a-Personal habits: tobacco, alcohol, coffee, tea.
b-Diet description: high fat diet. High salt.
c-sleep pattern.
d-Hoppies.
Family relation ship, friends, support system.
Level of education.
Occupation history (number of days are missed,occupied hazard).
Economic status, how pay in medical care.
Home (safety measurement)
psychological data:
Major stressor, usual coping pattern, communications tyle.
Data collection method:
1. Observing: is the conscious use of the five
senses to gather information.
l Example: flushed face.
2. Interview:
Is a planned communication or conversation with purpose for example to get or to give
information or to identify problem.
There are two approaches to interview:
1-The directive interview: is highly structured
and elicit specific information.
2-Non directive interview: the nurse allow the client to control the purpose.
Phases of interview:
- Preparatory phase.
- Introduction phase.
- Working phase.
- Termination phase.
organizing data:
the nurse uses an organized assessment
framework, nursing health history, nursing
assessment etc.
validating data:
is the act double checking to confirm that they are
accurate and actual.
-Example: compare subjective and objective data
to verify the client statement with your observation.
-Feeling hot need with comparing body temperature.
Documentation data.
Biographic data:
- Client name, address, age, sex, marital satus, occupation,
religious, assurance, Date and time of history.
Chief complain:
- The answer given to question "what brought you to the
hospital?
- The chief complain should record in own patient word.
Ex: my stomach hurts or I have come for my regular check up
History of present pain:
a-Location.
b-Radiation.
c-frequency
d-Timing and duration.
e-Quality and quantity.
f-Factors aggravated or alleviated.
g-Associated symptoms
Past History:
a-Immunization.
b-Childhood illness( measles, mumps,
streptococcal infection and rheumatic fever).
c-Allergy ( drug, egg, animals and insect).
d-Surgeries
e-Hospitalization.
f-Medication ( aspirin, laxatives, antihypertensive)
Family history:
a-Risk factor certain disease
b-Cancer, hypertension. Angina, bleeding tendency.
Life style:
a-Personal habits: tobacco, alcohol, coffee, tea.
b-Diet description: high fat diet. High salt.
c-sleep pattern.
d-Hoppies.
Types of Data
Subjective data: (symptoms, covert data), the client
only client can be described. Such as itching, pain,
feeling, I feel weak all over.
Objective data: referred to as (signs or overt data)
are detectable by observe or can be measured, it can be seen, heard.
l Example Blood pressure reading, pulse, redness,
cyanosis.
l Blood pressure: 90/ 50 mmHg.
feeling, I feel weak all over.
Objective data: referred to as (signs or overt data)
are detectable by observe or can be measured, it can be seen, heard.
l Example Blood pressure reading, pulse, redness,
cyanosis.
l Blood pressure: 90/ 50 mmHg.
Type of Sources
Social data
-Primary Source : always the patient
-Secondary Source: family, other health care personnel, medical records, lab reports.
-Secondary Source: family, other health care personnel, medical records, lab reports.
Family relation ship, friends, support system.
Level of education.
Occupation history (number of days are missed,occupied hazard).
Economic status, how pay in medical care.
Home (safety measurement)
psychological data:
Major stressor, usual coping pattern, communications tyle.
Data collection method:
1. Observing: is the conscious use of the five
senses to gather information.
l Example: flushed face.
2. Interview:
Is a planned communication or conversation with purpose for example to get or to give
information or to identify problem.
There are two approaches to interview:
1-The directive interview: is highly structured
and elicit specific information.
2-Non directive interview: the nurse allow the client to control the purpose.
Phases of interview:
- Preparatory phase.
- Introduction phase.
- Working phase.
- Termination phase.
organizing data:
the nurse uses an organized assessment
framework, nursing health history, nursing
assessment etc.
validating data:
is the act double checking to confirm that they are
accurate and actual.
-Example: compare subjective and objective data
to verify the client statement with your observation.
-Feeling hot need with comparing body temperature.
Documentation data.
physical examination:
Techniques of Physical Assessment:
1) Inspection :
Deliberate visual exam e.g.: flush, cyanosis.
2) Palpation:
gather data with hands via sense of touch feel skin and
underlying tissue to detect/describe: temp, texture,
vibration, pulsation, mass, size, tenderness.
3) Percussion:
Tap body surfaces to produce vibration and sound
4) Auscultation
Listen to sounds produced by body heart, lung , bowel sounds, BP
Techniques of Physical Assessment:
1) Inspection :
Deliberate visual exam e.g.: flush, cyanosis.
2) Palpation:
gather data with hands via sense of touch feel skin and
underlying tissue to detect/describe: temp, texture,
vibration, pulsation, mass, size, tenderness.
3) Percussion:
Tap body surfaces to produce vibration and sound
4) Auscultation
Listen to sounds produced by body heart, lung , bowel sounds, BP
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