Online Companion: Fundamentals of Nursing Standards and Practice 2E

Chapter Summary


This chapter begins the study of the steps nurses take when solving problems in clinical situations. The process begins by collecting, verifying, organizing, interpreting and documenting information about a problem that is presented to the nurse. The type of problem may vary from a client who presents with an acute, emergency situation to the client who comes for a health screening clinic visit. The type of data collected will vary with each situation. There are two types of data: subjective and objective. The nurse uses a variety of sources of data to get complete and accurate information. The nurse has skill in observation, interviewing, taking a health history, symptom analysis, physical examination, and analysis of laboratory and diagnostic data. These methods are needed to make the assessment valid and complete. The interview has three stages from introduction to working stage and ending with closure stage. Each of these has specific purpose and focus that is guided by the nurse. The nurse selects the type of question to use to elicit pertinent information in an interview. A closed question is easily answered in one or two words. An open-ended question allows the client flexibility in responding and is especially useful for getting the patient to discuss a particular concern. The health history data is gathered in the interview is a valuable source when the nurse is preparing a plan of care that is individualized to the client. Sometimes the client is sensitive about or reluctant to share data; the nurse is sensitive to the client's responses and uses communication skills to reflect a non-judgmental and accepting manner. The physical examination is another important method of data collection. The nurse uses visual, auditory and tactile senses during the exam. These senses correspond to the special skills of inspection, auscultation, palpation and percussion that are used during the exam. After the data is collected, the nurse then starts the next phase of assessment, that of verifying the accuracy and consistency of the data. The data are organized using a type of assessment model. The organized data are then interpreted so that nursing diagnoses can be established. The nursing diagnoses will form the basis for the plan of care. The final stage of assessment is documenting the results of the process. Different types of forms have been developed for use in clinical situations.