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Unit 1
Contemporary concepts in nursing
Health history
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 nurse’s approach to the patient will
largely determine the amount and quality of the information
that is received. Achieving a relationship of mutual trust and
respect requires the ability to communicate a sincere interest
in the patient. Examples of effective therapeutic communica-
tion techniques that can be used to achieve this goal are found
in Table 2-1.
The use of a health history guide may help in obtaining
pertinent information and in directing the course of the inter-
view. A variety of health history formats designed to guide
the interview are available, but they must be adapted to the
responses, problems and needs of the person. See Chapter 4 for
further information about the health history.
Physical assessment
A physical assessment may be carried out before, during, or
after the health history, depending on the patient’s physical
and emotional state and the immediate priorities of the
situation.
The purpose of the health assessment is to identify those
aspects 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 inter-
view skills and techniques. Physical examination techniques as
NURSING
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Figure 2-4
The nursing process is depicted schematically
in this circle. Starting from the innermost circle, (nursing
assessment), the process moves outward through the formulation
of nursing diagnoses and collaborative problems; planning,
with setting of goals and priorities in the nursing plan of care;
implementation and documentation; and finally, the ongoing
process of evaluation and outcomes
Steps of the nursing process
Assessment
1. Conduct the health history.
2. Perform the physical assessment.
3. Interview the patient’s family or significant others.
4. Study the health record.
5. Organise, analyse, synthesise, and summarise the collected
data.
Diagnosis
1. Identify the patient’s nursing problems.
2. Identify the defining characteristics of the nursing
problems.
3. Identify the aetiology of the nursing problems.
4. State nursing diagnoses concisely and precisely.
Collaborative problems
1. Identify potential problems or complications that require
collaborative interventions.
2. Identify health team members with whom collaboration is
essential.
Planning
1. Assign priority to the nursing diagnoses.
2. Specify the goals.
a. Develop immediate, medium and long-term goals.
b. State the goals in realistic and measurable terms.
3. Identify nursing interventions appropriate for goal
attainment.
4. Establish expected outcomes.
a. Make sure that the outcomes are realistic and
measurable.
b. Identify critical times for the attainment of outcomes.
5. Develop the written plan of nursing care.
a. Include nursing diagnoses, goals, nursing interventions,
expected outcomes and critical times.
b. Ensure that all nursing diagnoses identified are addressed
in the critical pathway for the patient.
c. Write all entries precisely, concisely and systematically.
d. Keep the plan current and flexible to meet the patient’s
changing problems and needs.
6. Involve the patient, family or significant others, nursing team
members and other health team members in all aspects of
planning.
Implementation
1. Put the plan of nursing care into action.
2. Coordinate the activities of the patient, family or significant
others, nursing team members and other health team
members.
3. Record the patient’s responses to the nursing actions.
Evaluation
1. Collect data.
2. Compare the patient’s actual outcomes with the expected
outcomes. Determine the extent to which the expected
outcomes were achieved.
3. Include the patient, family or significant others, nursing
team members and other healthcare team members in the
evaluation.
4. Identify alterations that need to be made in the nursing
diagnoses, collaborative problems, goals, nursing
interventions and expected outcomes.
5. Continue all steps of the nursing process: assessment,
diagnosis, planning, implementation and evaluation.
CHART
2-7
