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Describe the phases of the nursing process.
Concepts for Lecture
2. Assessing includes collecting, organizing, validating, and document-
ing data in order to establish a database about the client’s response to
health concerns or illness and the ability to manage health care.
3. Diagnosing includes analyzing and synthesizing data in order to
4. Planning includes determining how to prevent, reduce, or resolve the
identified priority client problems; how to support client strengths;
5. Implementing includes carrying out (or delegating) and documenting
6.
Evaluating includes measuring the degree to which goals/outcomes have
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Identify major characteristics of the nursing process.
Concepts for Lecture
1. The nursing process has distinctive characteristics that enable the
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Identify the purpose of assessing.
Concepts for Lecture
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ASSESSING
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• Provide the students with a list of activities
representative of the various phases of the
nursing process and ask them to classify each
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Give examples of how inadequate or inaccurate
assessment data can affect the other phases of the
nursing process.
• Give examples of goals written as client goals
and goals written as nursing goals. Ask the
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• Have the students provide examples of prob-
lem solving, decision making, and critical
thinking that they employed or observed other
nurses employ while providing care using the
nursing process.
52 CHAPTER 11 / Assessing
health care needs and is a continuous process carried out during all
phases of the nursing process.
3. Initial assessment is performed within a specified time after admis-
sion to a health care agency for the purpose of establishing a com-
plete database for problem identification, reference, and future
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Identify the four major activities associated with the assessing phase.
Concepts for Lecture
1. The assessment process involves four closely related activities: col-
lecting, organizing, validating, and documenting data. Collecting da-
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Differentiate objective and subjective data and primary and secondary data.
Concepts for Lecture
1. Subjective data, also referred to as symptoms or covert data, are ap-
2.
Objective data, also referred to as signs or overt data, are detectable by
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Give the students a case study. Ask them to
identify subjective and objective data as well as
primary and secondary sources.
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port the findings to the group.
CHAPTER 11 / Assessing 53
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Concepts for Lecture
Observation is useful for gathering data such as skin color or le-
sions (vision), body or breath odors (smell), lung or heart sounds
(hearing), and skin temperature (touch).
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Compare directive and nondirective approaches to interviewing.
Concepts for Lecture
1. The interviewing approach can be directive or nondirective.
3.
During a nondirective interview, or rapport-building interview, the nurse
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Compare closed and open-ended questions, providing examples and listing
advantages and disadvantages of each.
Concepts for Lecture
1. Questioning techniques for interviewing include both closed and
open-ended questions.
2. Closed questions are restrictive and generally require only “yes” or
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hanging over the bed. Give the students 5
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Have the students develop a systematic assess-
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Role-play an admission interview with one stu-
dent playing the role of the client, another the
client’s family member, and another the nurse.
Ask the other students to identify directive and
nondirective components of the interview.
view was used. Discuss the outcomes of the
interviews and ask students how they would
modify the approach, if necessary, for future
interviews.
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Divide the students into groups. Assign each
group a client scenario (e.g., a client with an in-
54 CHAPTER 11 / Assessing
3.
Open-ended questions invite clients to discover and explore, elaborate,
clarify, or illustrate their thoughts or feelings. An open-ended question
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Describe important aspects of the interview setting.
Concepts for Lecture
2. Nurses need to plan interviews for when clients are physically com-
3. A well-lit, well–ventilated room that is relatively free of noise,
movements, and distractions encourages communication. A place
4. The distance between the interviewer and interviewee should be nei-
5.
Failure to communicate in a language the client can understand is a form
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Contrast various frameworks used for nursing assessment.
Concepts for Lecture
1. Most schools of nursing and health care agencies have developed
their own structured assessment format. Many are based on selected
nursing models or frameworks. Examples include Gordon’s func-
tional health patterns, Orem’s self–care model, and Roy’s adaptation
answers provided to the questions elicited the in-
formation needed and how the students would
modify the questions if necessary.
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Demonstrate various seating arrangements and
ask the students to identify the advantages and
disadvantages of each.
• Demonstrate distance and its influence on the
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Discuss the institution’s availability of interpret-
ers.
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• Discuss the nursing model or framework used
by the school and how this influences nursing
assessment.
CHAPTER 11 / Assessing 55
2.
Non-nursing models and frameworks from other disciplines may also be
helpful for organizing data and are narrower than the model required in