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Prelim Lec Health Assessment
Prelim Lec Health Assessment
WEEK 1: OVERVIEW OF THE NURSING • These theorists were among the 1st to
PROCESS (ADPIE) use the Nursing Process and refer to a
series of phases describing the practice of
nursing.
NURSING PROCESS (ADPIE)
• Since then, various nurses have
• Is a systematic, rational method of described the process of nursing &
planning and providing individualized organized the phases in different ways.
nursing care.
PHASES/STEPS OF THE NURSING
Purpose: PROCESS
1. To identify a client`s health status & • The most current Scope and Standards
actual or potential health care of Nursing Practice includes six (6) phases
problems or needs of nursing practice (ANA, 2010):
2. To establish plans to meet the
✓ Assessment
identified needs
✓ Diagnosis
3. To deliver specific nursing
✓ Outcome identification
interventions to meet those needs
✓ Planning
• The client maybe an individual, a family, ✓ Implementation
a community, or a group ✓ Evaluation
1. Primary sources Client is the Example: Blood Pressure, Level of Pain &
primary source of data Age
2. Secondary sources Family
DATA COLLECTION METHODS
members or other support persons,
other health professionals, records • Principal methods used to collect data:
& reports, laboratory & diagnostic
✓ Observing/observation
analysis, relevant literature are
✓ Interviewing/ interview
secondary or indirect sources.
✓ Examining/Examination
• All sources other than the client are
• Observing occurs when the nurse is in
considered secondary.
contact with the client or support persons
• All data from secondary sources should
• Interviewing is used mainly while taking
be validated if possible.
the nursing health history
• A complete Data Base provides a
• Examining is the major method used in
baseline for comparing the client`s
the physical health assessment
responses to nursing & medical
interventions. • Reality: nurses used all the three
methods simultaneously when assessing
TYPES OF DATA
clients
Subjective Data
OBSERVING
• Referred to as symptoms or covert data
• gather the patient`s data using the
senses
HEALTH ASSESSMENT LECTURE DOCTOR A. CORPUS
BURI, JADE B. BSN 1-9 PRELIMS
Definitions
• Is the second phase of the nursing
process ✓ Diagnosing: refers to the reasoning
process
• Is a pivotal step in the nursing process
✓ Diagnosis: is a statement or
• the nurse will use his/her critical conclusion regarding the nature of
thinking skills to interpret assessment the phenomenon
data & identify the client`s strength & ✓ Diagnostic Labels: is the
problems. standardized NANDA names for the
diagnosis
• The identification & development of
✓ Nursing diagnosis: is the client`s
nursing diagnosis began formally in 1973
problem statement consisting of
from the 2 faculty members of St. Louis
the diagnostic label plus the
University & the National Conference to
etiology (causal relationship
identify nursing diagnosis was sponsored
between a problem & its related or
by St. Louis University School of nursing &
risk factors)
Allied Health Professions in 1973.
✓ Nursing Diagnosis (official
• In 1982, the conference group accepted definition from NANDA): a clinical
the name “North American Nursing judgment concerning a human
Diagnosis Association (NANDA)”, response to health conditions/life
recognizing the participation & processes, or a vulnerability for that
contributions of nurses in the United response by an individual, family,
States & Canada group or community.
✓ Nursing Diagnosis (NANDA-I, 2009):
• In 2002, the organization changed its
A nursing diagnosis provides the
name to NANDA International to further
basis for selection of nursing
reflect the worldwide interest in nursing
interventions to achieve outcomes
diagnosis.
for which the nurse has • These diagnosis labels begin with the
accountability. phrase: “Readiness for Enhanced, as in
Readiness for enhanced Nutrition”
This definition is consistent with the
following: Risk Nursing Diagnosis:
• The nurse who performs the admission • The end product of the planning phase
assessment usually develops the initial of the nursing process is a “formal or
comprehensive plan of care. informal” plan of care.
• This nurse has the benefit to see the • Informal Nursing Care Plan: is a strategy
client`s body language & can also gather for actions that exists in the nurse`s mind.
some intuitive kinds of information that
Example: Mrs. Rex is very tired. As a
are not available solely from the written
nurse, I need to reinforce teaching
data base.
after she is rested”
• Planning should be initiated as soon as
• Formal Nursing Care Plan: is a written
possible after the initial assessment
guide that organizes information about
Ongoing Planning the client` care.
• All nurses who work with the client do • The most obvious benefit for a formal
the ongoing planning. written care plan is that it provides for a
continuity of care.
• As nurses obtain new information &
evaluate the client`s responses to care, • Standardized Care Plan: Is a formal plan
they can individualize the initial plan that specifies the nursing care for group of
further clients with common needs
• Ongoing planning also occurs at the Example: all clients with GERD
beginning of a shift as the nurse plans the problems
care to be given that day.
• Individualized Care Plan: Is tailored to
• Using of ongoing assessment data, the meet the unique needs of a specific client-
nurse carries out daily planning for the needs that are not addressed by the
following purposes: standardized plan of care
• In the process of developing client care • After choosing the appropriate nursing
plans, the nurse engages in the following interventions, the nurse writes them on
activities: the care plan.
• Actual or related problems to fluid • Sensory experiences like pain & altered
balance, tissue integrity & gastro- sensory maybe identified & further
intestinal system evaluated.
• E.g., asking on the condition of the skin, • E.g., orientation about time & place, any
scalp & nails, diet, any food restrictions difficulty in making a sentence & loss of
related to a disease condition, any food memory.
that the patient like or dislike
Sleep & Rest Pattern
Elimination Pattern
• Assessment is focused on the persons
• Data collection focused on the excretory sleep, rest & relaxation practices.
patterns (bowel, bladder, skin).
• Dysfunctional sleeping pattern, fatigue
• Excretory problems like incontinence, & responses to sleep deprivation maybe
constipation, diarrhea & urinary retention identified.
may be identified.
• The person`s level of self-esteem & • E.g., If you have stress then what is your
response to threat to his/her self-concept coping mechanism towards stress, asking
maybe identified. the client on their opinion on crying, angry
& violence
• E.g., asking the patient on their own self-
perception about themselves, satisfaction Values & Belief Pattern
of self-body image, asking if the patient
• Assessment is focused on the person`s
likes grooming.
values & beliefs including spiritual beliefs,
Roles & Relationship Pattern goals that guide his/her decisions.
• Assessment is focused on the person`s • E.g., asking on the religion of the patient,
roles in the world & relationships with & if always offering a prayer daily.
others.
ON-GOING OR PARTIAL ASSESSMENT
• Satisfaction with roles, role strain or
dysfunctional relationships maybe further Another type of assessment that takes
evaluated. place after the initial assessment to
evaluate any changes in the client's
• E.g., asking the patient on his/her role in functional health.
the family, does all family members are
cooperative with the patient, who is the Consist of mini-overview of the client`s
decision maker in the family. body systems & holistic health patterns of
follow-up on the client`s health status
Sexuality & Reproductive Pattern
Nurses performed this type of assessment
• Assessment is focused on the person`s when substantial periods of time have
satisfaction or dissatisfaction with elapsed between assessment (e.g.,
sexuality patterns & reproductive periodic output patient`s clinic visits,
functions. home health visits, health & development
• Concerns with sexuality maybe screenings)
identified FOCUS OR PROBLEM-ORIENTED
• E.g., when was the 1st menses ASSESSMENT
(menarche) noticed, any sexual problem, • Collects data about a problem that has
if sexual needs is active, if has problems already been identified
with infertility.
• The nurse must be able to communicate difficulties & focuses on the helping the
clearly & accurately in order for a client`s person develop new attitudes, feelings &
health care needs to be met behaviors by encouraging the client to
look at alternative behaviors, recognize
Teacher
the choices & develop a sense of control.
• The nurse helps clients learn about their
Change Agent
health & the health care procedures they
need to perform to restore or maintain • This can be happened when a nurse is
their health. assisting clients to make facial s in their
behavior.
• The nurse assists the clients' learning
needs & readiness to learn, sets specific • Nurses also often act to make change in
learning goals in conjunction with the a system, such as clinical care, if it is not
client, enacts teaching strategies & helping a client return to health.
measures learning.
• Nurses are continually dealing with
• Nurses also teaches unlicensed assistive change in the health care system
personnel to whom they delegate care &
Example: Technological change,
share their expertise with other nurses &
change in medications are just a
health professionals
few changes nurses deal with daily
Client Advocate
Leader
• Acts to protect the client
• influence others to work together to
• In this role, the nurse may represent the accomplish a specific goal.
client`s needs & wishes to other health
• The role can be employed at different
professionals, such as relaying the client`s
levels: individual, client, family, groups of
request for information to the health care
clients, colleagues or the community.
provider
• Effective leadership is a learned process
• They also assist clients in exercising their
requiring an understanding of the needs &
rights & help them speak up for
goals that motivate people, the
themselves.
knowledge to apply leadership skills & the
Counselor interpersonal skills to influence others
• In other agencies, the nurse case • The client`s birth date, PH/SSS number,
manager is the primary nurse that hospital number or similar identifying
provides some level of direct care to the data may be included in the biographic
client & the family data section.
• Regardless of the setting, nurse care • When students are collecting the
managers help ensure that care is information & share it with their
oriented to the client, while controlling instructors, address & phone numbers
costs. should be deleted & initials will be use on
the name of the patient to protect the
Research Consumer client`s privacy
• Nurses often use research to improve • The client`s culture, ethnicity or
client care subculture may be collected by asking the
• In a clinical area, nurses need to have: date & place of birth, nationality, marital
status, religion & languages spoken if
1. Some awareness on the process & foreign nationals
language of research
2. Be sensitive to issues related to ✓ This information helps the nurse
protecting the rights of human examine special needs & beliefs
subjects that may affect the client or
3. Participate in the identification of family`s health care.
significant research problems • Gathering information about the client`s
4. Be a discriminating consumer of educational level, occupation & working
research finding status will assist the nurse &examiner to
Expanded Care Roles tailor questions to the client`s level of
understanding.
• Nurses are fulfilling expanded career
roles such as those of NP (Nurse REASONS FOR SEEKING HEALTH CARE
Practitioner) clinical nurse specialist, Two questions included in this category:
nurse midwife, nurse educator, nurse
researcher & nurse anesthetist, all of 1. What is your current major health
which allow a greater independence & problem?
autonomy 2. How do you feel about having to
seek health care?
STEPS OF HEALTH ASSESSMENT
“Why are you here” “How can I help you” • The information gathered from these
questions assists the nurse to identify the
• The physicians call this as the “Client`s
risk factors to the client as well as the
chief complaint (CC), but a more holistic
significant others
approach for phrasing the question may
draw out concerns that reach beyond just FAMILY HEALTH HISTORY
a physical complaint & may address stress
• As researchers discover more & more
or lifestyle changes
health problems that seem to run in the
• The 2nd question, “how do you feel families & are genetically based, the
about having seeking health care?”, can family health history assumes greater
encourage the client to discuss fears or importance.
other feelings about having to see a health
• The family health history should include
care provider.
as many genetic relatives as the client can
• This question may also draw out recall.
descriptions of previous experiences–
• It includes the maternal & paternal,
both positive & negative
grandparents, aunts & uncles on both
HISTORY OF PRESENT ILLNESS sides, parents, siblings & the client`s
children
• This section of health history considers
several aspects of the health problem & CURRENT MEDICATIONS
ask questions whose answers can provide
• Gathering of information about the
a detailed description of the health
medications taken which can provide the
concern.
nurse with information concerning
• The nurse encourages the client to medications that the patient has taken.
explain the health problem or symptoms
LIFESTYLE
focusing on the onset, progression, &
duration of the problem; signs & • This is a very important section of the
symptoms & related problems & what the health history because it deals with the
client`s perceives as causing the problem client`s human responses which includes
nutritional habits, activity & exercise,
PAST HEALTH HISTORY
sleep & rest patterns, use of medications
• At this point, the nurse asks questions & substances, self-concept & self-care
related to the client`s past health history activities, social & community activities,
(from the earliest beginnings to the relationships, values & beliefs, education
present). & work, stress level & coping styles &
environment.
• Information covered in this section
includes questions about birth, growth, • Be sure to pay attention on the cues the
development, childhood diseases, client may provide that point to possibly
immunizations, allergies, previous health more significant content
HEALTH ASSESSMENT LECTURE DOCTOR A. CORPUS
BURI, JADE B. BSN 1-9 PRELIMS
• Take brief notes so that pertinent data A complete nursing assessment includes
are not lost & so that there can be a both the collection of subjective data and
follow-up if some information needs the objective data.
clarification.
OBJECTIVE DATA
DEVELOPMENTAL LEVEL
• Includes information about the client
• Determining the client`s developmental that the nurse directly observes during
level is essential to complete the client`s interaction with the client or information
portrait that is elicited through physical
examination (examination) techniques.
• The nurse will group & analyze the data
obtained during the health history & • To become proficient with physical
compare them with the normal assessment skills, the nurse must have
developmental parameters basic knowledge in the three areas:
more relax & facilitates palpation of the • It is important to consider the client`s
abdomen & pubic area. ability to assume a position
Watch with second hand: time the heart Tongue Depressor: depress tongue to
rate, pulse rate view throat, check looseness of teeth,
view cheeks & check strength of tongue
ANTHROPOMETRIC MEASUREMENT:
Piece of small gauze: grasp tongue &
Flexible Tape Measure: measure the mid-
examine the mouth
arm circumference
Otoscope w/ wide-tip attachment: view
Platform scale w/ height attachment:
the internal nose
measure the height & weight
• Other equipment needed during
SKIN, HAIR & NAIL EXAMINATION:
physical assessment
Ruler w/ cm. markings: measure the size
TECHNIQUES
of skin lesions
FOUR PRIMARY TECHNIQUES IN PHYSICAL
Magnifying glass: enlarge visibility of
EXAMINATION:
lesion
1. Inspection
HEAD & NECK EXAMINATION:
2. Palpation
Small cup of water: help client swallow
during examination of the thyroid gland 3. Percussion
Snellen Chart: test the distance vision • Is the visual examination, by assessing
using the sense of sight
Ophthalmoscope: examine the retina of
the eye • Should be deliberate, purposeful &
systematic
Cover card: test for strabismus (abnormal
alignment of the eyes) • The nurse inspect with the naked eye &
with a lighted instrument such as an
Newspaper/Rosenbaum Pocket Screener:
otoscope (to view the ear).
test the near vision
• In addition to visual observations,
EAR EXAMINATION:
olfactory (smell) and auditory (hearing)
Otoscope: view the ear canal & tympanic cues will not be noted
membrane
• Visual inspection are frequently use to
Tuning Fork: test for bone & air assess moisture, color & texture of body
conduction of sound surfaces as well as shape, position, size,
color & symmetry of the body.
MOUTH, THROAT, NOSE, SINUS
EXAMINATION: • Lighting must be sufficient for the nurse
to see clearly, either natural or artificial
light can be used
HEALTH ASSESSMENT LECTURE DOCTOR A. CORPUS
BURI, JADE B. BSN 1-9 PRELIMS
• If it is necessary to determine the details • The nurse hands should be clean &
of a mass, the nurse presses lightly several warm, & the finger nails short
times rather than holding the pressure.
• Areas of tenderness should be palpated
Deep palpation last
• Deep palpation should be done after hand (plexor, the nurse strikes the
superficial palpation. pleximeter, usually at the distal &
proximal joints.
• The effectiveness of palpation depends
largely on the client`s relaxation. • The striking motion comes from the
wrist, the forearm remains stationary. The
• Nurses can assist the client to relax by:
angle between the plexor & the
1. Gowning or draping the client pleximeter should be 90 ̊, & the blows
appropriately must be firm, rapid & short to obtain a
2. Positioning the client comfortably clear sound.
3. Ensuring that their own hands are
• Percussion Is used to determine the size
warm before beginning the
& shape of internal organs by establishing
palpation
their borders.
• During palpation, the nurse should be
PERCUSSION ELICIT 5 TYPLES OF SOUNDS
sensitive to the client`s verbal & facial
expressions indicating discomfort Flatness is an extremely dull sound
produced by very dense
PERCUSSION
Dullness is a thud like sound produced by
• Is the act of striking the body surface to
dense tissue such as liver, spleen or heart
elicit sounds that can be heard or
vibrations that can be felt Resonance is a hollow sound such as that
produced by lungs filled with air
2 TYPES OF PERCUSSION:
Hyperrensonance is not produced in the
Direct Percussion
normal body, prescribed as booming &
• The nurse strikes the area to be can be heard over an emphysematous
percussed directly with the pads of two, lung.
three or four fingers or with the pad of the
Tympany musical/ drum like sound
middle finger
produce from an air filled stomach
• The strikes are rapid & the movement is (distended bowel) lungs. (emphysema or
from the wrist. pneumothorax)
• Stethoscope is used primarily to listen to • The images shows part of the body in
sounds from within the body such as different shades of black and white.
bowel sound or valve sounds of the heart
• Used to evaluate the structure of bones
&the blood pressure.
& soft tissues
• Auscultated sounds are described
• The patient is placed between an x-ray
according to their pitch, intensity,
machine and specially treated film
duration & quality.
• Gamma rays created in the x-ray
1. PITCH
machine pass through the patient`s body
• is the frequency of the
vibrations (the number of • Different internal structures absorb the
vibrations per second). x-rays in varying amounts, which results in
• Low-pitch sounds such as heart shadows of varying shades of gray being
sounds- have fewer vibrations cast on the film.
per second than high-pitch
CHEST X-RAY
sounds such as bronchial
sounds. • Is a projection radiograph of the chest
2. INTENSITY used to diagnosed conditions affecting the
• (amplitude) refers to the chest, its contents, and nearby structures.
loudness or softness of a sound.
Purpose:
• Some body sound are loud (e.g.,
bronchial sound heard from ✓ Assess the lung fields
the trachea) ✓ cardiac borders
• Others are soft (e.g., normal ✓ large arteries,
breath sounds heard in the ✓ clavicle
lungs) ✓ ribs
3. DURATION ✓ diaphragm & mediastinum
• of a sound is it`s length (long or ✓ Diagnose pulmonary or cardiac
short) disorders including heart failure
4. QUALITY ✓ COPD
• of sound is a subjective ✓ Pneumonia
description of a sound (e.g., ✓ TB
whistling, gurgling or snapping ✓ neoplastic disease
sound). ✓ Evaluate placement of feeding
tubes
DIAGNOSTIC TEST AND ✓ chest tubes
PROCEDURES ✓ central venous catheters
pacemaker wires
X-RAY ✓ endotracheal tubes
• called electromagnetic waves. BASIC POSITIONS FOR CHEST X-RAY
AP (ANTERIOR-POSTERIOR)
HEALTH ASSESSMENT LECTURE DOCTOR A. CORPUS
BURI, JADE B. BSN 1-9 PRELIMS
BASIC POSITIONS FOR X-RAYS • Plain films of a joint or joints (hip, knee,
shoulder, elbow, ankle, wrist joints in the
LATERAL feet & hands)
• Patient is positioned on either side and Purpose:
so that the x-ray passes from one side of
the body through the other side (right ✓ Assess fracture, infection, cyst,
lateral or left lateral). tumor, degenerative diseases.
OBLIQUE Procedure:
• x-ray is angled between PA and lateral ✓ The patient lies on the x-ray table
positions. while various views of the joints are
taken.
ABDOMINAL X-RAY
COMPUTED TOMOGRAPHY (CT SCAN)
• A plain film of the abdomen
• A specialized x-ray that takes cross-
• Also called as “abdominal flat plate” or sectional pictures of all types of tissues.
“KUB for kidneys, ureter and bladder”
• Sometimes called as “CAT SCAN”. The
Purpose: “A” refers to the word AXIAL, which is a
✓ Assess the cause of abdominal pain particular orientation of the image.
✓ Evaluate liver or kidney size, shape • Axial: relating to an axis/main axis
and position
• It is used extensively in diagnosing
Procedure: disease & injury of the:
✓ Patient lies supine on the table. ✓ Brain, cerebral blood vessels, eyes,
✓ One AP (anterior-posterior) image inner ear & sinuses
is taken ✓ Neck, shoulders, cervical spine, and
BONE X-RAYS blood vessels
✓ Chest, heart, aorta and lungs
• CLAVICLE/ SCAPULA, FOOT, HAND, TOE, ✓ Thoracic and lumbar spine
FINGERS, MANDIBLE ✓ Upper abdomen, liver, kidney,
Purpose: spleen & pancreas
✓ Skeletal system including bones of
✓ Assess for fracture, tumor, infection, the hands, feet, ankles, legs and
structural abnormalities, arms and jaws
degenerative diseases. ✓ Pelvis & hips, reproductive system,
✓ Evaluate pain, loss of function, bladder & GI tract
deformity
administration of oral
hypoglycemic medications.
o Any laboratory data about
the client must be compared
to the agency or performing
laboratory`s norms for that
particular test & for the
client`s age, gender & other
characteristics.
Example: