4.7:
Role of Communication in the Nursing Process I: Assessment and Diagnosis
The nursing process relies on the structured and systematic application of both verbal and non-verbal communication to provide high-quality and efficient care.
Each method provides direction for effective therapeutic communication.
The assessment stage of the nursing process determines and analyzes a patient's health-related information.
Nurses use verbal communication, such as asking questions and active listening, to collect information about health history from patients and families.
Non-verbal communication skills, such as inspection and touch, allow nurses to perform physical examinations to gather more patient data.
For example, nurses may identify and document symptoms such as frequent urination and weakness from verbal communication with a diabetic patient and weight loss via non-verbal data collection.
This information can then be shared with a healthcare team. Such a nursing diagnosis could be reported as: "Imbalanced nutrition less than body requirement related to insulin deficiency, as evidenced by weight loss and weakness."
Overall, a nursing diagnosis is the systematic categorization of assessment data to identify existing health problems and select appropriate interventions to achieve optimum outcomes.
4.7:
Role of Communication in the Nursing Process I: Assessment and Diagnosis
The nursing process uses scientific reasoning, problem-solving, and critical thinking to guide nurses in providing patients with appropriate care. This process is a systematic approach to recognize, avoid, and treat current or potential health issues while promoting the patient's well-being.
The nursing process considers the patient's emotional and physical well-being. The process can be repeated or stopped at any point if judged essential. Assessment is the first step in the nursing process. It entails gathering, compiling, verifying, and documenting the patient's health status. There are numerous ways to collect this information. For example, when a nurse first meets a patient, they are typically expected to assess the patient to determine the patient's physical, mental, and emotional state. They are also likely to create a database about the patient's attitude to health issues or illness and their capacity to manage their healthcare needs.
During the assessment, verbal information includes spoken or written statements from a client or another source. A nurse's listening skills are required to evaluate verbal data challenges, such as slurring, tone of voice, aggressiveness, anxiousness, difficulty locating the necessary word, and flight of ideas.
Nonverbal data are observable behaviors that provide information without the use of words. Examples include the patient's body language, general appearance, facial expressions, gestures, eye contact, proxemics (distance), body language, touch, posture, and clothing. Moreover, when a client's body language seems inconsistent with what they say, think, or feel, nonverbal information might be more insightful than verbal information.
In the nursing process, the second step is the nursing diagnosis. The nurse will review all the data gathered to determine the condition and requirements of the client. To make a nursing diagnosis, the nurse must analyze a patient's data, health issues, risks, and strengths, which will help make diagnostic statements about a patient's potential or current health issues.