PAMANTASAN NG CABUYAO

Bachelor of Science in Nursing

COURSE TITLE: HEALTH ASSESSMENT – LECTURE

COURSE CODE: RLENCM101
LEVEL OFFERING: First Year, Second Semester AY 2021
NUMBER OF UNITS: 2

COURSE DESCRIPTION:
This course deals with concepts, principles and techniques of history taking head to toe physical
examination and psychosocial assessment using various tools and interpretation of laboratory findings to
arrive at a nursing diagnosis. The learners are expected to perform holistic nursing assessment of an
individual adult client. Proper documentation and the use of nursing process.

OVERVIEW:
This module discusses methods, purposes, preparation, guidelines, and the techniques in physical
assessment. It focuses on the difference of each technique and how to perform it with the help of the
different equipment. Also, it explains and demonstrate the concept of skull, face, skin, hair, and nails
assessment.
LEARNING PROCESS

1 • Module Overview

2 • Learning Map

3 • Small leaps

4 • Bigger leaps

5 • Conquering the heights

6 • Recapturing the trail

SMALL LEAP
Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Weber Health Assessment in
Nursing Chapter 01: Nurse’s Role in Health Assessment: Collecting and Analyzing Data

2 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Nursing assessment
Collective subjective and objective data to determine a client’s overall level of functioning in order to make a
professional clinical judgment Medical assessment Focuses primarily on the client’s physiologic development
status

3 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Phases of the Nursing Process

4 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Initial Comprehensive Assessment
Collection of subjective data about the client’s perception of health of all body parts or systems Past medical
 history Family history Lifestyle and health practices

5 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Assessment Ongoing or
partial assessment: consists of data collection that occurs after the comprehensive data base is established
Focuses on problem-oriented assessment: consists of a thorough assessment of a particular client problem
and does not cover areas not related to the problem Emergency assessment: very rapid assessment
performed in life-threatening situations

6 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following
statement True or False? A partial assessment is done when the client first enters a health care facility.

7 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. A partial or ongoing
assessment of the client consists of data collection that occurs after the comprehensive database is
established. This takes place after the client is admitted to the health care facility.

8 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of Health Assessment
Preparing for the assessment –Review client’s record –Review client’s status with other health care team
members –Educate about client’s diagnosis and tests performed

9 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Collection of Subjective Data
Biographical information Physical symptoms related to each body part or system Past health history Family
history Health and lifestyle practices

10 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Collection of Objective Data
Physical characteristics Body functions Appearance Behavior Measurements Results of laboratory testing

11 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Comparing Subjective and
Objective Data

12 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following
statement True or False? Subjective data are sensations or symptoms, perceptions, desires, preferences,
 beliefs, ideas, values, and personal information that can be elicited and verified only by the client.

13 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True. Subjective data
are sensations or symptoms, perceptions, desires, preferences, beliefs, ideas, values, and personal
information that can be elicited and verified only by the client.

14 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Steps of Health Assessment
Validating assessment data Documenting data

15 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Analysis Phase of Nursing
Process Identify abnormal data and strengths. Cluster the data. Draw inferences and identify problems.
Propose possible nursing diagnoses. Check for defining characteristics of those diagnoses. Confirm or rule out
nursing diagnoses. Document conclusions.

16 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following
statement True or False? A nurse is not supposed to draw inferences and identify problems during data
analysis.

17 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False. A nurse is
supposed to draw inferences and identify problems during data analysis after identifying abnormal data and
strengths and clustering data.

18 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical assessment integral
part of nursing Nurses relied on natural senses Palpation Movement of health care from acute care setting to
community care and proliferation of baccalaureate and education Advanced practice nurses Evolution of the
Nurse’s Role in Health Assessment: Past

19 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Managed care and internal case
management has impact on assessment role of the nurse –Acute care nurses –Critical care outreach nurses –
Ambulatory care nurses –Home health nurses –Public health nurses –School and hospice nurses Evolution of
the Nurse’s Role in Health Assessment: Present
20 Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Evolution of the Nurse’s Role in
Health Assessment: Future Rising educational cost Increasing complexity of acute care Growing aging
population Expanding health care needs Increasing impact of children and homeless Intensifying mental
health issues Expanding health services network Increasing reimbursement for health promotion and
preventive care services