Components of nursing process:

The nursing process consists of five dynamic

and interrelated phases:
1. Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation.
Steps Of Assessment
1. Collection of data
• Subjective data collection
• Objective data collection
2. Validation of data
3. Organization of data
4. Recording/documentation of data
 Collection of data
 Gathering of information about the client
 Physical
 Psychological
 Emotion
 Socio-cultural
 Spiritual
 Factors that may affect client’s health status
Factors that may affect client’s
health status
 past health history of client
 allergies, past surgeries, chronic diseases, use of
folk healing methods

 current/present problems of client

 pain, nausea, sleep pattern, religious practices,
medication or treatment the client is taking now
 Complete Health History
 Biographical data
 Reason for Seeking Care
 History of Present Illness
 Past Health
 Accidents and Injuries
 Hospitalizations and Operations
 Family History
 Review of Systems
 Functional Assessment ( Activities of Daily
Living)
 Perception of Health
Types of data:

When performing an assessment the nurse

gathers
 Subjective data
 Objective data.
Subjective data
(symptoms or covert data)
 the verbal statements
 nausea
 descriptions of pain
 fatigue
 Objective data (signs or overt data):

 Detectable (an observer, be measured, tested

against an accepted standard.
 Seen
 Heard
 Felt
 Smelt
 Observation or physical examination
 Discoloration of the skin
 Vital signs
 Data collection methods
1. Observing
2. Interviewing
3. Examining : Physical assessment
Physical assessment
Assessment Sequencing

 Head – to - Toe Assessment

 Body Systems Assessment

 Sources of data:
 Primary
 patient
 Secondary .
 When the patient is unable to supply
information
 deterioration of mental status
 Age
 seriousness of illness,
The Secondary sources of data
 Family members
 Significant others (physicians, other nurses)
 Medical records
 Diagnostic procedures
Validating data:
The information gathered during the
assessment phase must be complete,
factual, and accurate because the nursing
diagnosis and interventions are based on
this information.
Validation is the act of "double-checking"
or verifying data to confirm that it is
accurate and factual.
 Purposes of data validation:
 ensure that data collection is complete
 ensure that objective and subjective data agree
 obtain additional data that may have been
overlooked
 avoid jumping to conclusion
Data Requiring Validation
 Not every data must be verified
 pulse, temperature, or blood pressure (unless
certain conditions)
 Requiring Validation
 Discrepancies or gaps between the subjective and
objective data.
 a male client tells you that he is very happy
 that he has terminal cancer
 Methods of validation
 Recheck (with a different thermometer)
 Clarify data (with asking additional questions)
 Verify the data (with another health care
professional)
 Compare objective findings with subjective
findings to uncover discrepancies
Organizing data
 Written
 Computerized

The format may be modified according to the

client's physical status.
 Gordon’s Functional Health Patterns
1. Health perception-health management pattern.
2. Nutritional-metabolic pattern
3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
10. Coping-stress tolerance pattern
11. Value-belief pattern