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NURSING PROCESS:
ASSESSMENT
Steps
Assessment – gather information
Nursing diagnosis – identify client’s
problem
Planning – set goals
Assessment
Critical
thinking
approach
Deliberate & systematic
approach
Mosby items and derived items © 2005 by Mosby, Inc.
Assessment - Steps
Analysis of data
Norms
Cluster cues
Sources of data
Primary - client
Secondary- family, health care team,
medical/other records, literature, experience
Physical examination
Diagnostic and laboratory results-identify/verify problems
Nursing judgments
Data validation and interpretation-
compare with another source
Data clustering- Signs/symptoms
grouped together logically