Nursing Dx

The Nursing: Scope & Standard of Practice addresses the assessment process. The standard stipulates that the data-collection process is systematic and ongoing. The nurse collects client health data from the client, significant others, and healthcare providers when appropriate. The priority of the data-collection activities is determined by the client’s immediate condition or needs. Pertinent data are collected using appropriate assessment techniques and instruments. Relevant data are documented in a retrievable form.

The assessment step of the nursing process is focused on eliciting a profile of the client that allows the nurse to identify client problems or needs and corresponding nursing diagnoses, to plan care, to implement interventions, and to evaluate outcomes. This profile, or client database, supplies a sense of the client’s overall health status, providing a picture of the client’s physical, psychological, sociocultural, spiritual, cognitive, and developmental levels; economic status; functional abilities; and lifestyle. It is a combination of data gathered from the history-taking interview (a method of obtaining SUBJECTIVE information by talking with the client or significant other(s) and listening to their responses), from the physical examination (a “hands-on” means of obtaining OBJECTIVE information), and from the results of laboratory/diagnostic studies. To be more specific, subjective data are what the client/significant others perceive and report, and objective data are what the nurse observes and gathers from other sources.

Assessment involves three basic activities:
• Systematically gathering data
• Organizing or clustering the data collected
• Documenting the data in a retrievable format

The assessment step of the nursing process emphasizes and should provide a holistic view of the client. The generalized assessment done during the overall data-gathering creates a profile of the client. A focused, or more detailed, assessment may be warranted given the client’s condition or emergent time constraints, or it may be done to obtain more information about a specific issue that needs expansion or clarification. Both types of assessments provide important data that complement each other. A successfully completed assessment creates a picture of clients’ states of wellness, their response to health concerns or problems, and individual risk factors—this is the foundation for identifying appropriate nursing diagnoses, developing client outcomes, and choosing relevant interventions necessary for providing individualized care.