3-2. ASSESSMENT

a. In order to provide nursing care, one must first determine the needs of the patient. Patient needs vary in relation to the illness or injury, the age and overall physical condition of the patient, the support or nonsupport of the patient's family and friends, the mental status of the patient, and the length of time expected for recovery. These are the most significant of the many variables involved. All the information and medical data obtained will be applied to a general assessment of the patient's needs. The practical nurse supports the professional nursing staff in the assessment of nursing care needs by:

(1) Using basic communication skills in the patient care setting, interacting with the patient and his family to obtain subjective information relative to the patient's condition.

(2) Obtaining objective data from the patient through observation and goal-directed interviews.

(3) Participating in the identification of physical, emotional, spiritual, cultural, and learning needs of the patient through data collection.

(4) Determining the significance of the data collected in relation to the patient's pathophysiology.

b. Once the specific needs of the patient have been identified, the health care team members go to the next step, which is the planning phase.