Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide • The functional assessment: During the functional assessment, the nurse will assess for any difficulty experienced by the patient during activities of daily living (ADL). These activities may include shopping, food preparation, housekeeping, using the telephone, and self-care activities such as bathing, the ability to administer own medications, and the ability to handle finances. • Review all available health records, lab data, or radiology reports. When doing the assessment, the nurse may spend more time in one step than another. For example, in a comprehensive assessment, the nurse will spend a great deal of time doing all the steps of the assessment process. An ongoing assessment might focus more on the physical aspects. Once the nurse has completed the assessment, the process of analysis and diagnosis can begin. 1.2 Analysis and Diagnosis The second phase of the nursing process includes the analysis of the information collected in the assessment phase, the identification of actual and potential health problems, and the formulation of nursing diagnoses. Analysis of the Data Once the data has been collected in the assessment phase, the nurse is ready to begin the analysis of the data. It is helpful to cluster the data into related groups in order to recognize patterns more easily within the data. As the analysis continues, the nurse will begin to see that there may be gaps in the data that will require a focused assessment. For example, notes may suggest the patient being short of breath, but the respiratory rate is 16 and not labored. The astute nursewill go back and do a focused assessment of the respiratory system to validate the data. As the analysis continues, patterns will begin to emerge that will enable the nurse to identify actual and potential problems. Problem Identification Before a plan can be developed, it is critical to identify all of the patient’s problems. Patient problems can be classified as either potential or actual. A potential problem exists when a patient is at risk due to his present illness or some condition identified in the assessment. For example, a patient in traction for a fractured leg is at risk for skin breakdown because of the inactivity associated with being in traction. An actual problem exists when the problem is already present and creating issues for the patient. For example, an elderly patient who has been on bed rest is noted to have skin breakdown (altered skin integrity). Because the condition already exists, it is an actual problem. Any identified problem, whether actual or potential, should be validated with the patient and family (if the patient wants to include them). Nursing Diagnosis Overview Once the list of patient problems is complete, it is time to develop the list of nursing diagnoses. It is critical to understand the difference between medical diagnoses and nursing diagnoses. A medical diagnosis is focused on a disease process and is identified by a physician or advanced practitioner. A nursing diagnosis is focused on human responses to problems. For example, a patient with shortness

©2018

Achieve

Page 11

of 134