Using the Nursing Process
Assessment data are gathered through the health history and the physical assessment. In addition, ongoing monitoring is crucial to remain aware of patient needs and the effectiveness of the nurs-ing care that the patient receives.
The health history is conducted to determine the individual’s state of wellness or illness and is best accomplished as part of a planned interview. The interview is a personal dialogue between the patient and the nurse that is conducted in order to obtain in-formation. The nurse’s approach to the patient will largely de-termine the amount and quality of the information that is received. Achieving a relationship of mutual trust and respect re-quires the ability to communicate a sincere interest in the patient. Examples of effective therapeutic communication techniques that can be used to achieve this goal are found in Table 3-1.
The use of a health history guide may help in obtaining perti-nent information and in directing the course of the interview. A variety of health history formats designed to guide the interview are available, but they must be adapted to the responses, prob-lems and needs of the individual. If a previous history is available, it should be used to reduce the need for the patient to repeat in-formation. An experienced interviewer will develop a comfortable style and format for conducting an interview and will be flexible in adapting the format to suit the individual situation, while still obtaining the essential information. Various frameworks are available for acquiring the assessment data, such as functional health patterns, Maslow’s hierarchy of needs, and Erikson’s “eight stages of man.” The information gathered will relate to the patient’s physical, psychological, social, emotional, intellectual, developmental, cultural, and spiritual needs.
In some instances, it may be appropriate for the patient to fill out a health history form. When a form is used, the nurse verifies and clarifies the information provided by the patient and seeks any additional information necessary to identify the individual’s nursing needs.
A physical assessment may be carried out before, during, or after the health history, depending on the patient’s physical and emo-tional state and the immediate priorities of the situation.
The purpose of the health assessment is to identify those as-pects of the patient’s physical, psychological, and emotional state that indicate a need for nursing care. It requires the use of sight, hearing, touch, and smell as well as the appropriate interview skills and techniques. Physical examination techniques as well as techniques and strategies for assessing behaviors and role changes.
Additional relevant information should be obtained from the pa-tient’s family or significant others, from other members of the health team, and from the patient’s health record or chart. De-pending on the patient’s immediate needs, this information may have been obtained before the health history and the physical as-sessment were done. Whatever the sequence of events, it is im-portant to use all available sources of pertinent data to complete the nursing assessment.
After the health history and physical assessment are completed, the information obtained is recorded in the patient’s permanent record. This record provides a means of communication among members of the health care team and facilitates coordinated planning and continuity of care. The record fulfills other functions as well:
· It serves as the business and legal record for the health care agency and for the professional staff members who are re-sponsible for the patient’s care.
· It serves as a basis for evaluating the quality and appropri-ateness of care and for reviewing the effective use of patient care services.
· It provides data that are useful in research, education, and short- and long-range planning.
A variety of systems are used for documenting patient care, and each health care agency selects the system that best meets its needs. The types of systems available include the problem-oriented health record system, focus charting, patient outcome charting, problem intervention evaluation (PIE) charting, and charting by exception (CBE). In addition, many health care agencies have moved toward computerized documentation systems; these ap-pear to save time, improve the monitoring of quality improvement issues, and make it easier to gain access to patient information.