Nursing 109

N109: Foundations in Nursing Practice Study Guide

3.8 The Nursing Process Assessment In the assessment phase for an individual with chronic illness, the nurse must assess: • The individual’s physical condition: This should include the disabilities and impairments that may prevent the individual from being able to perform activities of daily living, the specific aids and equipment the individual requires or will require, and the assistance the individual can expect from friends and family. • Risk for injury: Assess the individual for any issues that would put them at risk for injury, such as a confused mental state, sensory deficit, chronic pain or fatigue, or a weakened physical state. • Trajectory model of chronic illness phase: The nurse must determine which phase the individual is in and how he is responding. • Environmental factors: This must include any physical hazards that may prevent the individual from being able to operate at home and specific alterations that must be made to increase safety at home. The assessment will also include available means of transportation and access to healthcare. • The individual’s capacity for self-efficacy: The nurse must assess the individual’s abilities for self-care and the psychological responses to the chronic illness, while making appropriate referrals. • Use of complementary/alternative and integrative therapies: The nursemust assess how these things impact the plan of care. Analysis Following assessment, the nurse, patient, family or caregiver, and other members of the healthcare team must analyze the data to identify actual and potential problems. Each nursing diagnosis that is selected should be related to specific issues associated with the chronic illness and prioritized accordingly. Nursing diagnoses that might be considered appropriate for an individual with chronic illness include: • Activity intolerance (or risk for) • Body image disturbance • Caregiver role strain related to the work involved with caring for the chronically ill • Ineffective coping • Risk for falls • Fatigue • Hopelessness • Impaired mobility • Noncompliance • Pain • Powerlessness • Impaired resilience • Self-care deficit • Impaired self-esteem • Ineffective health maintenance • Impaired home maintenance

©2018

Achieve

Page 53

of 154