ADL	Activities of daily living
CAA	Care Area Assessment
CMS	Centers for Medicare & Medicaid Services
MDS	Minimum Data Set
NANDA-I	North American Nursing Diagnosis Association International
OBRA	Omnibus Budget Reconciliation Act of 1987
RN	Registered nurse

Nurses communicate with each other about the person’s strengths, problems, needs, and care. This information is shared through the nursing process. The nursing process is the method nurses use to plan and deliver nursing care. It has five steps:

• Assessment

• Nursing diagnosis

• Planning

• Implementation

• Evaluation

The nursing process focuses on the person’s nursing needs. The person and nursing team need good communication.

Each step is important. If done in order with good communication, nursing care is organized and has purpose. All nursing team members do the same things for the person. They have the same goals. The person feels safe and secure with consistent care.

The nursing process is used for all age-groups. It is on-going. New information is gathered and the person’s needs may change. However, the steps are the same. You will see the continuous nature of the nursing process as each step is explained.

Assessment

Assessment involves collecting information about the person. Nurses use many sources. A health history is taken. This tells about current and past health problems. The family’s health history is important. Many diseases are genetic. That is, the risk for certain diseases is inherited from parents. For example, a mother had breast cancer. Her daughters are at risk. Information from the doctor is reviewed. So are test results and past medical records.

An RN (registered nurse) assesses the person’s body systems and mental status. You play a key role in assessment. You make many observations as you give care and talk to the person.

Observation is using the senses of sight, hearing, touch, and smell to collect information:

• You see how the person lies, sits, or walks. You see flushed or pale skin. You see red and swollen body areas.

• You listen to the person breathe, talk, and cough. You use a stethoscope to listen to the heartbeat and to measure blood pressure.

• Through touch, you feel if the skin is hot or cold, or moist or dry. You use touch to take the person’s pulse.

• Smell is used to detect body, wound, and breath odors. You also smell odors from urine and bowel movements.

Objective data (signs) are seen, heard, felt, or smelled by an observer. You can feel a pulse. You can see urine color. Subjective data (symptoms) are things a person tells you about that you cannot observe through your senses. You cannot feel or see the person’s pain, fear, or nausea.

Box 7-1, p. 76 lists the basic observations you need to make and report to the nurse. Box 7-2, p. 77 lists the observations that you must report at once. Make notes of your observations. Use them to report and record observations. Carry a note pad and pen in your pocket. Note your observations as you make them. The center may provide electronic devices for this purpose (Fig. 7-1, p. 77).

Box 7-1

Basic Observations

Ability to respond