BURI, JADE B.

BSN 1-9 PRELIMS

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

• Is cyclical, The national licensure examination for

registered nurses (NCLEX), uses the five
• its components follow a logical
phases:
sequence, but more than one component
maybe involved at one time. ✓ Assessment
✓ Diagnosis
• At the end of the 1st cycle, care maybe
✓ Planning
terminated if goals are achieved, or the
✓ Implementation
cycle may continue with re-assessment,
✓ Evaluation
or the plan of care maybe modified.
• These 5 phases are commonly used by
• A systematic problem-solving approach
most of the nurses although nurses may
used to identify, prevent & treat actual or
use different terms to describe the phases
potential health problems & promote
or steps of the nursing process
wellness

• A systematic way to plan, implement & ASSESSMENT

evaluate care for individuals, families, ASSESSMENT/ASSESSING
groups and communities
• is a systematic & continuous collection,
• The term Nursing Process was organization, validation & documentation
originated by Lydia Hall in 1955, and of data/information.
Dorothy Johnson in 1959, Ida Jean
Orlando in 1961 and Ernestine ✓ Collect data
Wiedenbach in 1963. ✓ Organize data
✓ Validate data
✓ Document data
HEALTH ASSESSMENT LECTURE DOCTOR A. CORPUS
BURI, JADE B.
• The completeness and correctness of
the information obtained during
assessment are directly related to the
accuracy of the steps in assessment
DATA COLLECTION/ COLLECT DATA
• Is the process of gathering information
about a client`s health status.
• Must be both systematic & continuous
to prevent the omission of significant data
& reflect a client`s changing health status.
• A Data Base contains all the information
about the client: nursing health history,
physical assessment, primary care
provider`s history & physical examination,
results of laboratory & diagnostic tests
and materials contributed by the other
health personnel.
Sources of Data Collection
1. Primary sources Client is the
primary source of data
2. Secondary sources Family
members or other support persons,
other health professionals, records
& reports, laboratory & diagnostic
analysis, relevant literature are
secondary or indirect sources.
• All sources other than the client are
considered secondary.
• All data from secondary sources should
be validated if possible.
• A complete Data Base provides a
baseline for comparing the client`s
responses to nursing & medical
interventions.
TYPES OF DATA
Subjective Data
• Referred to as symptoms or covert data
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
• Apparently only to the persons affected
& can be described or verified only by that
person
Example: itching, pain, feelings of worry
• Includes the client`s sensations, feelings,
values, beliefs, attitudes & perception of
personal health status & life situation
Objective Data
• Referred to as the signs or overt data
• Are detectable by an observer or can be
measured or tested against an accepted
standard.
• Are observable and measurable and are
obtained through physical examination
and diagnostic test.
• This can be seen, heard & felt or smelled
& they frequently or rarely.
Example: Blood Pressure, Level of Pain &
Age
DATA COLLECTION METHODS
• Principal methods used to collect data:
✓ Observing/observation
✓ Interviewing/ interview
✓ Examining/Examination
• Observing occurs when the nurse is in
contact with the client or support persons
• Interviewing is used mainly while taking
the nursing health history
• Examining is the major method used in
the physical health assessment
• Reality: nurses used all the three
methods simultaneously when assessing
clients
OBSERVING
• gather the patient`s data using the
senses
DOCTOR A. CORPUS
BURI, JADE B.
• Is a conscious, deliberate skill that is
developed through effort & with an
organized approach.
2 Aspects:
1. Noticing the data
2. Selecting, organizing & interpreting
the data
• Observing involves distinguishing of
data in a meaningful manner
• Nursing observations must be organized
so that nothing significant is missed
• Most nurses develop a sequence in
observing events
Example: A nurse is visiting into the
client`s room & observes in the following
order:
1. Clinical signs of the client`s distress
(e.g., pallor or flushing, labored
breathing & behavior indicating
pain or emotional distress)
2. Threats to the client`s safety, real or
anticipated (e.g., lowered side rails)
3. The presence of functioning of
equipment (e.g., intravenous
equipment & oxygen)
4. The immediate environment
including the people in it
INTERVIEWING
• Is a planned communication or
conversation with a purpose in order to
get information, identify problems of
mutual concern, evaluate change, teach,
provide support or provide counselling or
therapy.
Example: Nursing Health History- a part of
the nursing admission assessment
2 Types of Interviews
1. Directive Interview
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BSN 1-9 PRELIMS
• Highly structured & elicit specific
information
• Use to gather & to give
information when time is limited
(e.g., in an emergency situation)
2. Non-Directive Interview or
Rapport-Building Interview
• allows the client to control the
purpose, subject matter &
pacing.
• Rapport: an understanding
between two or more people.
• A combination of directive & non-
directive approaches usually appropriate
during the information-gathering
interview
Types of Interview Questions
Closed Questions
• used in directive interview, are
restrictive
● generally, require only “yes or no” or
short factual answers that provide specific
information
• Often begins with “when, where, who,
what, do/did/does, or is/are/was.
Example: What medication did you take?
Are you having pain now?
Open-Ended Questions
• associated with the non-directive
interview, invite clients to discover &
explore, elaborate, clarify or illustrate
their thoughts or feelings.
• Specifies only the broad topic to be
discussed & invites answers longer than
one or two words.
• May begin with “what or how”
Example: How did you feel in the situation?
What made you come into the hospital
DOCTOR A. CORPUS
BURI, JADE B. BSN 1-9 PRELIMS

Neutral Question ● Data that reflect a significant deviation

from the normal would need to be
• a question the client can answer without
reported as well as recorded
direction or pressure from the nurse.
VALIDATING DATA
Example: How do you feel about that?
What do you think that led to the • The act of “double checking or verifying
operation? data” to confirm that it is accurate &
Note: Details about the planning an factual.
interview and stages of an interview: to • The information gathered during the
read and understand in Fundamentals of assessment phase must be complete,
Nursing factual & accurate because nursing
EXAMINING/EXAMINATION diagnosis & interventions are based on
this information
• Physical examination/assessment is a
Validating data helps the nurse complete
systematic data collection method that
uses observation (sense of sight, hearing, the ff. tasks:
smell & touch) to detect health problems 1. Ensure that assessment
information is complete
• To conduct the physical examination,
the nurse uses techniques of inspection, 2. Ensure that the objective &
auscultation, palpation & percussion. subjective data agree
3. Obtain additional information that
• Can be carried out systematically; from may have been overlooked
head-to-toe approach or a body-system 4. Differentiate between cues&
approach. inferences
• The cephalocaudal or head-to-toe Cues
approach begins the examination at the
head, progresses to the neck, thorax, Are subjective or objective data that can
abdomen, extremities and ends at the toe be directly observed by the nurse.

What the client says or what the nurse can

ORGANIZING DATA
see, hear, smell or measure
● Nurses uses a written or electronic
Inferences
format that organizes the assessment
data systematically Are the nurse`s interpretation or
conclusions made based on the cues
● This is referred to as a nursing health
history, nursing assessment, or nursing Example:
DATA BASE form.
• A nurse observes the cues that an
● The format maybe modified according to incision is red, hot &swollen
the client`s physical status • The nurse makes an inference that
the incision is infected
● Nurses must make a judgment about
which data are to be reported DOCUMENTATION/DOCUMENTING
immediately & which data need only to be DATA
recorded at that time
HEALTH ASSESSMENT LECTURE DOCTOR A. CORPUS
BURI, JADE B.
• Aims to describe the collected data to
make it easier to use, retrieved or manage.
• Accurate documentation is essential &
should include all data collected about the
client`s health status
• Data are recorded in a factual manner &
not as interpreted by the nurse.
Example:
• The nurse records the client`s
breakfast intake (objective data) as
“tea 200 ml, water 100 ml, 1 pc. of
egg & I slice of toast bread” rather
than “an appetite is good”.
DIAGNOSIS/DIAGNOSING
• Is the second phase of the nursing
process
• Is a pivotal step in the nursing process
• the nurse will use his/her critical
thinking skills to interpret assessment
data & identify the client`s strength &
problems.
• The identification & development of
nursing diagnosis began formally in 1973
from the 2 faculty members of St. Louis
University & the National Conference to
identify nursing diagnosis was sponsored
by St. Louis University School of nursing &
Allied Health Professions in 1973.
• In 1982, the conference group accepted
the name “North American Nursing
Diagnosis Association (NANDA)”,
recognizing the participation &
contributions of nurses in the United
States & Canada
• In 2002, the organization changed its
name to NANDA International to further
reflect the worldwide interest in nursing
diagnosis.
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
• the purpose of NANDA International is to
define, refine & promote a taxonomy of
nursing diagnostic terminology of general
use to professional nurses.
• Taxonomy is a classification system or
set of categories arranged based on a
single principle or a set of principles.
• Members of NANDA: staff nurses,
clinical specialist, faculty, directors of
nursing, deans, theorist & researchers.
• To use the concept of nursing diagnosis
effectively in generating & completing a
nursing care plan, the nurse must be
familiar with the definition of terms used
& the components of nursing diagnosis
Definitions
✓ Diagnosing: refers to the reasoning
process
✓ Diagnosis: is a statement or
conclusion regarding the nature of
the phenomenon
✓ Diagnostic Labels: is the
standardized NANDA names for the
diagnosis
✓ Nursing diagnosis: is the client`s
problem statement consisting of
the diagnostic label plus the
etiology (causal relationship
between a problem & its related or
risk factors)
✓ Nursing Diagnosis (official
definition from NANDA): a clinical
judgment concerning a human
response to health conditions/life
processes, or a vulnerability for that
response by an individual, family,
group or community.
✓ Nursing Diagnosis (NANDA-I, 2009):
A nursing diagnosis provides the
basis for selection of nursing
interventions to achieve outcomes
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for which the nurse has
accountability.
This definition is consistent with the
following:
• Professional Nurse/Registered Nurse:
✓ Responsible for making the nursing
diagnosis, even though other
nursing personnel may contribute
data to the process of diagnosing &
may implement specified nursing
care.
✓ American Nurses Association
(2010) states that nurses are
accountable for analyzing data to
determine diagnosis or issues.
✓ The standard specifies that nurses
should use standardized
classification systems when naming
diagnosis
✓ Refers to the actuality or
potentiality of the problem or the
categorization of the diagnosis as a
health promotion diagnosis.
Kinds of Diagnosis according to
status:
 actual diagnosis
 health promotion diagnosis
 risk nursing diagnosis
 syndrome diagnosis.
• Actual Diagnosis:
✓ Is a client problem that is present at
the time of the nursing assessment.
✓ Based on the presence of
associated signs & symptoms
• Example: Ineffective Breathing
Pattern; Anxiety
Health Promotion Diagnosis:
• Relates to client`s preparedness to
implement behaviors to improve their
health condition
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
• These diagnosis labels begin with the
phrase: “Readiness for Enhanced, as in
Readiness for enhanced Nutrition”
Risk Nursing Diagnosis:
• A clinical judgment that a problem does
not exist, but the presence of risk factors
indicates that a problem is likely to
develop unless nurses intervene.
Example: people admitted in the
hospital have some possibility of
acquiring an infection; however, a
client with diabetes or a
compromised immune system is at
higher risk than others.
• The nurse would appreciate to use the
“Risk for Infection” to describe the
client`s health status
Syndrome Diagnosis:
• is assigned by a nurse`s clinical judgment
to describe a cluster of nursing diagnosis
that have similar interventions
Components of NANDA Nursing
Diagnosis
3 Components:
1. The problem and it`s definition
(Diagnostic Label)
2. The etiology
3. The defining characteristics
• Describes the client`s health problem or
response for which nursing therapy is
given
• It describes the client`s health status
clearly & concisely in a few words
Purpose of Diagnostic level
to direct the formation of client goals and
desired outcomes that may suggest
nursing interventions
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BURI, JADE B. BSN 1-9 PRELIMS

Example: Deficient knowledge DIFFERENTIATING NURSING DIAGNOSIS

(Medications) Deficient knowledge FROM MEDICAL DIAGNOSIS
(Dietary Adjustments)
Nursing Diagnosis:
• Qualifiers words that are added to some
• Is a statement of nursing judgment &
NANDA labels to give meaning to the
refers to a condition that nurses, by virtue
diagnostic statement
of their education, experiences &
Examples: Deficient (inadequate in expertise are licensed to treat.
amount, quality or degree; not
Medical Diagnosis:
sufficient; incomplete)
• Is made by a physician & refers to a
• Impaired (made worse, weakened,
condition that only a physician can treat
damaged, reduced, deteriorated)
Collaborative Problems:
• Decreased (lesser in size, amount or
degree) • Is a type of potential problem that
nurses manage using both independent &
• Ineffective (not producing the desired
physician-prescribed interventions.
effect)
• Present when a particular disease or
• Compromised (to make vulnerable to
treatment is present, that each disease or
threat)
treatment has specific complications that
Etiology (Related Factors & Risk Factors) are always associated with it.

Identifies one or more probable causes of Nursing Diagnosis:

the health problem, gives direction to the
• Involves human responses which vary
required nursing therapy, enables the
greatly from one person to the others.
nurse to individualize the client`s care.
• Thus, nurses use nursing diagnosis
Defining Characteristics
rather than collaborative problems since
• Are the cluster of signs & symptoms that nursing diagnosis are more individualized
indicate the presence of a particular to a specific client & emphasize human
diagnostic label. responses to which the nurse can
independently take actions
• For Actual Nursing Diagnosis: the
defining characteristics are the client`s
signs & symptoms

• For Risk Nursing Diagnosis: No

subjective & objective signs are present

• Thus, the factors that cause the client to PLANNING

be more vulnerable to the problem form
the etiology of a risk nursing diagnosis. • Is a deliberative

• The list of NANDA defining • systematic of the nursing process that

characteristics are still being developed & involves decision making & problem-
refined solving.

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BURI, JADE B.
• In planning, the nurse refers to the
client`s assessment data & diagnostics
statements for direction in formulating
client goals & designing the nursing
interventions required, to prevent, reduce
or eliminate the client`s health problems.
• Nursing Interventions: is any treatment
based upon clinical judgment &
knowledge, that a nurse performs to
enhance patient/client outcomes
Types of Planning
Initial Planning
• The nurse who performs the admission
assessment usually develops the initial
comprehensive plan of care.
• This nurse has the benefit to see the
client`s body language & can also gather
some intuitive kinds of information that
are not available solely from the written
data base.
• Planning should be initiated as soon as
possible after the initial assessment
Ongoing Planning
• All nurses who work with the client do
the ongoing planning.
• As nurses obtain new information &
evaluate the client`s responses to care,
they can individualize the initial plan
further
• Ongoing planning also occurs at the
beginning of a shift as the nurse plans the
care to be given that day.
• Using of ongoing assessment data, the
nurse carries out daily planning for the
following purposes:
1. To determine whether the client`s
health status was changed
2. To set priorities for the client`s care
during the shift
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
3. To decide which problems to focus
on during the shift
4. To coordinate the nurse`s activities
so that more than one problem can
be addressed at each client contact
Discharge Planning
• The process of anticipating & planning
for needs after discharge, is a crucial part
of a comprehensive health care plan &
should be addressed in each client`s care
plan
Developing Nursing Care Plans
• The end product of the planning phase
of the nursing process is a “formal or
informal” plan of care.
• Informal Nursing Care Plan: is a strategy
for actions that exists in the nurse`s mind.
Example: Mrs. Rex is very tired. As a
nurse, I need to reinforce teaching
after she is rested”
• Formal Nursing Care Plan: is a written
guide that organizes information about
the client` care.
• The most obvious benefit for a formal
written care plan is that it provides for a
continuity of care.
• Standardized Care Plan: Is a formal plan
that specifies the nursing care for group of
clients with common needs
Example: all clients with GERD
problems
• Individualized Care Plan: Is tailored to
meet the unique needs of a specific client-
needs that are not addressed by the
standardized plan of care
THE PLANNING PROCESS
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• In the process of developing client care
plans, the nurse engages in the following
activities:
1. Setting priorities
2. Establishing client goals/ desired
outcomes
3. Selecting nursing interventions &
activities
4. Writing individualized nursing
interventions on care plans
Setting Properties
• Is the process of establishing a
preferential sequence for addressing
nursing diagnosis & interventions
• The nurse & the client begin planning by
deciding which nursing diagnosis requires
attention first, which is second & so on.
• Instead of rank ordering diagnosis,
nurses can group them as having high,
medium or low priority.
Establishing client goals/desired
outcomes
• After establishing priorities, the nurse &
the client set goals for each nursing
diagnosis
• On a care plan, the goals/desired
outcomes describe, in terms of
observable client responses, what the
nurse hopes to achieve by implementing
the nursing interventions
Selection nursing interventions
• The specific nursing interventions
chosen should focus on eliminating or
reducing the etiology of the nursing
diagnosis, which is the second clause of
the diagnostic statement
Writing individualized nursing
interventions
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
• After choosing the appropriate nursing
interventions, the nurse writes them on
the care plan.
• Date nursing interventions on the care
plan when they are written & review
regularly at intervals that depend on the
individuals needs
IMPLEMENTATION/
IMPLEMENTING
• Is the action phase in which the nurse
performs the nursing interventions
• Using the Nursing Interventions
Classifications (NIC) terminology,
implementation consists of doing &
documenting the activities that are the
specific nursing actions needed to carry
out the interventions
Process of Implementation
Reassessing the client
• Before implementing an intervention,
the nurse must reassess the client to make
sure the intervention is still needed
• Even though an order is written in the
care plan, the client`s condition may have
changed
Example
• A client with a diagnosis of
“Disturbed Sleeping Pattern
related to anxiety & unfamiliar
surroundings”.
• During the nurse`s rounds, the
discovers that the client is
sleeping & therefore defers the
back massage that have been
planned as a relaxation strategy
Determining the nurse`s need for
assistance
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• When implementing some nursing
interventions, the nurse may require
assistance for one or more of the
following reasons:
1. The nurse is unable to implement
the activity safely or efficiently
alone (e.g., ambulating an obese
client)
2. Assistance would reduce stress on
the client (e.g., turning a patient
who experiences pain when moving)
3. The nurse lack of knowledge or
skills to implement a particular
nursing activity (e.g., a nurse who is
not familiar on a particular
equipment should need assistance
the first time it is applied
Implementing the nursing interventions
• It is important to explain to the client
what nursing interventions will be done,
what sensations to expect, what the client
is expected to do & the expected outcome.
• This activity involves scheduling client
contact with other departments like
laboratory & x-ray technicians, physical &
respiratory therapist
Supervising the delegated care
• Once care has been delegated to other
health care personnel, the nurse is
responsible for the client`s overall care.
• The nurse must ensure that
Documenting nursing activities
• After carrying out the nursing activities,
the nurse has completed the
implementation phase by recording the
interventions & client`s responses in the
progress notes.
• Nursing care must be recorded in
advance because the nurse may
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
determine on reassessment of the client
on the interventions being implemented
EVALUATION
• Is a planned, on-going, purposeful
activity in which clients & health care
professionals determine
✓ the client`s progress towards
achievement of goals/outcomes and
✓ the effectiveness of the nursing care
plan.
• Is an important aspect of the nursing
process because conclusions drawn from
an evaluation determine whether the
nursing interventions should be
terminated, continued or changed.
• The nurses evaluate progress towards
attainment of outcomes.
• Through evaluation, nurses demonstrate
responsibility & accountability for their
actions, indicate interest on the results of
the nursing activities, & demonstrates
desire not to perpetuate ineffective
actions but to adopt more effective ones.
WEEK #2: HEALTH
ASSESSMENT IN NURSING
PRACTICE
TYPES OF HEALTH ASSESSMENT
INITIAL COMPREHENSIVE ASSESSSMENT
• Describes in detail the client`s medical,
physical & psychosocial conditions &
needs
• Also called as an “admission assessment”
which is perform when the client enters
the hospital/health care facility
Purpose:
• To evaluate the client`s health status
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• To identify functional health patterns
that are problematic (Gordon`s Health
Patterns)
• To provide an in-depth comprehensive
data base needed for evaluating changes
in the client`s health status in the
succeeding assessments.
GORDON`S FUNCTIONAL HEALTH
PATTERNS
Health Perception-Health Management
Pattern
• Data collection is focused on the client`s
perceived level of health & well-being &
practices in maintaining health.
• E.g., patient`s opinion about health,
Immunization history, any allergies
(specific allergies, past surgeries (type of
surgery), last physical exam & reason,
current medicines taken & knowledge on
the actions of the medicines taken
Nutritional-Metabolic Pattern
• Assessment focused on the pattern of
food & fluid consumption relative to the
metabolic need & pattern indicators of
nutrient supply
• Actual or related problems to fluid
balance, tissue integrity & gastro-
intestinal system
• E.g., asking on the condition of the skin,
scalp & nails, diet, any food restrictions
related to a disease condition, any food
that the patient like or dislike
Elimination Pattern
• Data collection focused on the excretory
patterns (bowel, bladder, skin).
• Excretory problems like incontinence,
constipation, diarrhea & urinary retention
may be identified.
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
• E.g., color of urine, amount, frequency,
odor & any discharge; urinary problems
(dysuria, anuria, polyuria); if using
laxatives & if has problem during passing
defecation
Activity & Exercise Pattern
• Assessment is focused on the activities
of daily living including self-care activities,
exercise & leisure activities.
• The status of the major systems involved
with activity is evaluated including
respiratory, cardiovascular, & Musculo-
skeletal system.
• E.g., asking of any breathing problem
(apnea, hypoxia), presence of cough
(productive/non-productive), any
changes in heartbeat during exercise, type
of exercise did the patient did or any
problem during exercise
Cognition & Perception Pattern
• Assessment is focused on the ability to
comprehend &use of information on the
sensory functions.
• Data pertaining to neurologic functions
are collected to aid this process
• Sensory experiences like pain & altered
sensory maybe identified & further
evaluated.
• E.g., orientation about time & place, any
difficulty in making a sentence & loss of
memory.
Sleep & Rest Pattern
• Assessment is focused on the persons
sleep, rest & relaxation practices.
• Dysfunctional sleeping pattern, fatigue
& responses to sleep deprivation maybe
identified.
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• E.g., bedtime, nap during daytime,
feeling after waking up (fresh, headache,
drowsy), any medications taken for
sleeping, any exercise or walking at night
Self-perception & Self-Concept Pattern
• Assessment is focused on the person`s
attitudes towards self-including identity,
body image & sense of self-worth.
• The person`s level of self-esteem &
response to threat to his/her self-concept
maybe identified.
• E.g., asking the patient on their own self-
perception about themselves, satisfaction
of self-body image, asking if the patient
likes grooming.
Roles & Relationship Pattern
• Assessment is focused on the person`s
roles in the world & relationships with
others.
• Satisfaction with roles, role strain or
dysfunctional relationships maybe further
evaluated.
• E.g., asking the patient on his/her role in
the family, does all family members are
cooperative with the patient, who is the
decision maker in the family.
Sexuality & Reproductive Pattern
• Assessment is focused on the person`s
satisfaction or dissatisfaction with
sexuality patterns & reproductive
functions.
• Concerns with sexuality maybe
identified
• E.g., when was the 1st menses
(menarche) noticed, any sexual problem,
if sexual needs is active, if has problems
with infertility.
Coping & Stress Tolerance Pattern
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BSN 1-9 PRELIMS
• Assessment is focused on the person`s
perception of stress and the coping
strategies.
• Support systems are evaluated &
symptoms of stress are noted.
• The effectiveness of a person`s coping
strategies in terms of stress tolerance
maybe further evaluated.
• E.g., If you have stress then what is your
coping mechanism towards stress, asking
the client on their opinion on crying, angry
& violence
Values & Belief Pattern
• Assessment is focused on the person`s
values & beliefs including spiritual beliefs,
goals that guide his/her decisions.
• E.g., asking on the religion of the patient,
& if always offering a prayer daily.
ON-GOING OR PARTIAL ASSESSMENT
Another type of assessment that takes
place after the initial assessment to
evaluate any changes in the client's
functional health.
Consist of mini-overview of the client`s
body systems & holistic health patterns of
follow-up on the client`s health status
Nurses performed this type of assessment
when substantial periods of time have
elapsed between assessment (e.g.,
periodic output patient`s clinic visits,
home health visits, health & development
screenings)
FOCUS OR PROBLEM-ORIENTED
ASSESSMENT
• Collects data about a problem that has
already been identified
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• This type of assessment has a narrower
scope with a shorter time frame than
the initial assessment
• The nurse determine whether the
problem still exists, or the status of the
problem has been changed
• this includes the appraisal of the new,
overlooked or misdiagnosed problems.
• ICU: nurses may perform focus or
problem-oriented assessment every
few minutes to monitor changes of the
patient`s condition
EMERGENCY ASSESSMENT
• Happened in life-threatening situations
in which the preservation of life of the
patient is the top priority.
• Often the client`s difficulties involves
airway, breathing & circulatory
problems
• Abrupt changes in self-concept
(suicidal thoughts), role or
relationships (social conflicts leading
to violent acts) can also initiate an
emergency assessment.
• EA focuses on a few essential health
patterns & is not comprehensive
NURSES` ROLE IN HEALTH
ASSESSMENT
• Nurse`s role in health assessment has
changed significantly over the years.
• In 21st century, the nurse`s role in
assessment continues to expand,
becoming more crucial than ever
before.
• The role of the nurse in health
assessment has expanded drastically
from the days of Florence Nightingale
when the nurse uses the sense of sight
touch & hearing to assess clients
• Today communication and physical
assessment techniques are used
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
independently by nurses to arrive at
professional clinical judgments
concerning the client`s health.
• Advances in technology have expanded
the role of assessment and the
development of managed care has
increased the necessity of assessment
skills.
• Expert clinical assessment and
informatic skills are absolute necessities
for the future as nurses continue to
expand their role in all health care settings
ROLES & FUNCTIONS OF THE
NURSE
Caregiver
traditionally included those activities that
assist the clients physically and
psychologically while preserving the
client`s dignity.
• The required nursing actions may
involve a full care of the completely
dependent client, partial care for the
partially dependent client and supportive-
educative care to assist clients in attaining
their highest possible level of health &
wellness.
• Caregiving encompasses the physical,
psychosocial, developmental, cultural &
spiritual levels
• The nurse may provide direct care or
delegate it to other caregivers
Communicator
• Communication is integral to the nursing
roles
• In the role of a communicator, the nurse
identify client problems & communicate
these verbally or in writing to other
members of the health care team.
DOCTOR A. CORPUS
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• The nurse must be able to communicate
clearly & accurately in order for a client`s
health care needs to be met
Teacher
• The nurse helps clients learn about their
health & the health care procedures they
need to perform to restore or maintain
their health.
• The nurse assists the clients' learning
needs & readiness to learn, sets specific
learning goals in conjunction with the
client, enacts teaching strategies &
measures learning.
• Nurses also teaches unlicensed assistive
personnel to whom they delegate care &
share their expertise with other nurses &
health professionals
Client Advocate
• Acts to protect the client
• In this role, the nurse may represent the
client`s needs & wishes to other health
professionals, such as relaying the client`s
request for information to the health care
provider
• They also assist clients in exercising their
rights & help them speak up for
themselves.
Counselor
• Counseling is the process of helping the
client to recognize & cope with stressful
psychological or social problems, to
develop improved interpersonal
relationships & to promote personal
growth.
• It involves providing emotional,
intellectual, & psychological support.
• The nurse counsels primarily healthy
individuals with normal adjustment
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
difficulties & focuses on the helping the
person develop new attitudes, feelings &
behaviors by encouraging the client to
look at alternative behaviors, recognize
the choices & develop a sense of control.
Change Agent
• This can be happened when a nurse is
assisting clients to make facial s in their
behavior.
• Nurses also often act to make change in
a system, such as clinical care, if it is not
helping a client return to health.
• Nurses are continually dealing with
change in the health care system
Example: Technological change,
change in medications are just a
few changes nurses deal with daily
Leader
• influence others to work together to
accomplish a specific goal.
• The role can be employed at different
levels: individual, client, family, groups of
clients, colleagues or the community.
• Effective leadership is a learned process
requiring an understanding of the needs &
goals that motivate people, the
knowledge to apply leadership skills & the
interpersonal skills to influence others
Manager
• nurse manager delegates nursing
activities to ancillary workers & other
nurses, supervises & evaluates their
performance.
• Managing requires knowledge about
organizational structure & dynamics,
authority & accountability, leadership,
change theory, advocacy, delegation,
supervision & evaluation
DOCTOR A. CORPUS
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Nurse Care Manager
• Works with the multidisciplinary health
care team to measure the effectiveness of
the case management plan & to monitor
outcomes.
• In some institutions, the case manager
works with staff nurses to oversee the care
of a specific caseload
• In other agencies, the nurse case
manager is the primary nurse that
provides some level of direct care to the
client & the family
• Regardless of the setting, nurse care
managers help ensure that care is
oriented to the client, while controlling
costs.
Research Consumer
• Nurses often use research to improve
client care
• In a clinical area, nurses need to have:
1. Some awareness on the process &
language of research
2. Be sensitive to issues related to
protecting the rights of human
subjects
3. Participate in the identification of
significant research problems
4. Be a discriminating consumer of
research finding
Expanded Care Roles
• Nurses are fulfilling expanded career
roles such as those of NP (Nurse
Practitioner) clinical nurse specialist,
nurse midwife, nurse educator, nurse
researcher & nurse anesthetist, all of
which allow a greater independence &
autonomy
STEPS OF HEALTH ASSESSMENT
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
Collection of Subjective Data through
Interview & Health History
Biographic Data
• Usually includes information that
identifies the client such as his/her name,
address, phone number, gender and who
provided the information (client or
significant others)
• The client`s birth date, PH/SSS number,
hospital number or similar identifying
data may be included in the biographic
data section.
• When students are collecting the
information & share it with their
instructors, address & phone numbers
should be deleted & initials will be use on
the name of the patient to protect the
client`s privacy
• The client`s culture, ethnicity or
subculture may be collected by asking the
date & place of birth, nationality, marital
status, religion & languages spoken if
foreign nationals
✓ This information helps the nurse
examine special needs & beliefs
that may affect the client or
family`s health care.
• Gathering information about the client`s
educational level, occupation & working
status will assist the nurse &examiner to
tailor questions to the client`s level of
understanding.
REASONS FOR SEEKING HEALTH CARE
Two questions included in this category:
1. What is your current major health
problem?
2. How do you feel about having to
seek health care?
DOCTOR A. CORPUS
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• The 1st question What is your current
major health problem? assists then client
to focus on his/her most significant health
concern & answers the nurse`s question,
“Why are you here” “How can I help you”
• The physicians call this as the “Client`s
chief complaint (CC), but a more holistic
approach for phrasing the question may
draw out concerns that reach beyond just
a physical complaint & may address stress
or lifestyle changes
• The 2nd question, “how do you feel
about having seeking health care?”, can
encourage the client to discuss fears or
other feelings about having to see a health
care provider.
• This question may also draw out
descriptions of previous experiences–
both positive & negative
HISTORY OF PRESENT ILLNESS
• This section of health history considers
several aspects of the health problem &
ask questions whose answers can provide
a detailed description of the health
concern.
• The nurse encourages the client to
explain the health problem or symptoms
focusing on the onset, progression, &
duration of the problem; signs &
symptoms & related problems & what the
client`s perceives as causing the problem
PAST HEALTH HISTORY
• At this point, the nurse asks questions
related to the client`s past health history
(from the earliest beginnings to the
present).
• Information covered in this section
includes questions about birth, growth,
development, childhood diseases,
immunizations, allergies, previous health
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
problems, surgeries, pregnancies,
previous accidents, injuries, pain
experiences and emotional or psychiatric
problems.
• The information gathered from these
questions assists the nurse to identify the
risk factors to the client as well as the
significant others
FAMILY HEALTH HISTORY
• As researchers discover more & more
health problems that seem to run in the
families & are genetically based, the
family health history assumes greater
importance.
• The family health history should include
as many genetic relatives as the client can
recall.
• It includes the maternal & paternal,
grandparents, aunts & uncles on both
sides, parents, siblings & the client`s
children
CURRENT MEDICATIONS
• Gathering of information about the
medications taken which can provide the
nurse with information concerning
medications that the patient has taken.
LIFESTYLE
• This is a very important section of the
health history because it deals with the
client`s human responses which includes
nutritional habits, activity & exercise,
sleep & rest patterns, use of medications
& substances, self-concept & self-care
activities, social & community activities,
relationships, values & beliefs, education
& work, stress level & coping styles &
environment.
• Be sure to pay attention on the cues the
client may provide that point to possibly
more significant content
DOCTOR A. CORPUS
BURI, JADE B.
• Take brief notes so that pertinent data
are not lost & so that there can be a
follow-up if some information needs
clarification.
DEVELOPMENTAL LEVEL
• Determining the client`s developmental
level is essential to complete the client`s
portrait
• The nurse will group & analyze the data
obtained during the health history &
compare them with the normal
developmental parameters
Example: Height, weight, Erickson`s
Psychosocial Developmental Stages
PSYCHOSOCIAL HISTORY
• Psychosocial history covers many
aspects of the patient`s life
• The information gathered includes areas
related to psychological or mental health,
social history & many other factors such as
health, employment, finances, education,
religion, stress & support system including
friends and family.
SUMMARY
• Collecting subjective data is a key step
of nursing health assessment
• Subjective data consists of information
elicited & verified only by the client
• Interviewing is the means by which
subjective data are gathered
• The complete health history is
performed to collect as much subjective
data about a client is possible
WEEK #4-5 COLLECTION OF
OBJECTIVE DATA
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
A complete nursing assessment includes
both the collection of subjective data and
the objective data.
OBJECTIVE DATA
• Includes information about the client
that the nurse directly observes during
interaction with the client or information
that is elicited through physical
examination (examination) techniques.
• To become proficient with physical
assessment skills, the nurse must have
basic knowledge in the three areas:
1. Preparation
2. Positioning
3. Techniques
PREPARATION
PREPARING THE CLIENT:
• Most patients need an explanation of
the physical examination
• Clients are often anxious about what the
nurse will find during the physical
assessment
• The nurse should explain when & where
the examination will take place, why it is
important & what will happen.
• Instruct the client that all information
gathered & documented during the
assessment is kept confidential (only
health care providers know the client`s
information & have the access to it).
• Health examinations are painless, the
nurse need to determine in advance the
positions that are contra indicated for a
particular client.
• The nurse assist the client as needed to
undress and put on a gown.
• Clients should empty their bladder
before the examination to help them feel
DOCTOR A. CORPUS
BURI, JADE B.
more relax & facilitates palpation of the
abdomen & pubic area.
• If UA is required, the urine should be
collected in a container for that purpose
• The sequence of assessment differs with
children & adults
• Children, always proceed from the least
invasive or uncomfortable aspect of the
exam.to the more invasive.
• Examination of the head & neck, heart &
lungs & range of motion (ROM) can be
done early in the process, with the ears,
mouth, abdomen & genitals being left for
the end of the examination
PREPARING THE ENVIRONMENT:
• It is important to prepare the
environment before starting the
assessment.
• The environment needs to be well
lighted & the equipment should be
organized for efficient use
• The room should be warm enough to be
comfortable for the client
• Providing privacy is important. Most
people are embarrassed if their bodies are
exposed or if others can hear or view
them during assessment
• Culture, age & gender of both the client
& the nurse influenced how comfortable
the client will be & what special
arrangements might be needed.
Example: Client & the nurse are of
different genders, the nurse should
ask if is it okay for the patient to
pursue on the physical assessment
POSITIONING
• Several positions are frequently
required during the physical assessment.
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
• It is important to consider the client`s
ability to assume a position
• Clients physical condition, energy level
ang age should be taken into
consideration
• Some positions are embarrassing &
uncomfortable, therefore should not be
maintained for a long period of time.
• The assessment should be organized so
that several body areas can be assessed in
one position, thus minimizing the number
of position changes needed
Draping:
• Draping should be arranged so that
areas to be assessed is exposed & other
body areas are covered.
• Drapes provide not only a degree of
privacy but also warmth.
INSTRUMENTATION
• All instruments needed for the health
assessment must be ready for use, clean,
in good working condition & readily
accessible.
• Equipment is frequently set-up on trays
& ready for use
Examples: GLOVES (for all
examinations)- protection for any
part of examination when the
examiner may have contact with
blood, body fluid, secretions,
excretions and contaminated items
or disease-causing agents could be
transmitted to or from the agent.
FOR VITAL SIGNS TAKING
Sphygmomanometer: measure the BP of
the patients
Stethoscope: auscultate blood sounds
when measuring BP
DOCTOR A. CORPUS
BURI, JADE B. BSN 1-9 PRELIMS

Thermometer: measure body Penlight: provide light to view the mouth

temperature & throat & transilluminate the sinuses

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

EYE EXAMINATION: 4. Auscultation

Penlight: test the pupillary constriction INSPECTION

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.
• When using auditory senses, it is
important to have a quite environment for
accurate hearing.
• Inspection can be obtained with other
assessment techniques.
PALPATION
• Is the examination of the body using the
sense of touch
• The pads of the fingers are used because
their concentration of nerve endings
makes them highly sensitive to tactile
discrimination
• Palpation is used to determine the
following:
✓ Texture of the hair
✓ Temperature of the skin
✓ Vibration of a joint
✓ Position, size, consistency &
mobility of organ masses
✓ Distention of the urinary bladder
✓ Pulsation
✓ Tenderness or pain
2 TYPES OF PALPATION:
Light (superficial)palpation
• should always precede deep palpation
because heavy pressures on the fingertips
can dull the sense of touch
• For light palpation, the nurse extends
the dominant hand`s fingers parallel to
the skin surface & presses gently while
moving the hand in a circle.
• With light palpation, the skin is slightly
depressed
• If it is necessary to determine the details
of a mass, the nurse presses lightly several
times rather than holding the pressure.
Deep palpation
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
• Is usually not done during a routine
examination &requires a significant
practitioners' skills
• It is performed with extreme cautions
because pressure can damage the internal
organs
• It is usually not indicated in clients who
have acute abdominal pain or pain that is
not yet diagnosed
• Is done with two hands (bimanually) or
one hand
In deep bimanual palpation, the nurse
extends the dominant hand as for light
palpation, then places the finger pads of
the non-dominant hand on the dorsal
surface of the distal interphalangeal joint
of the middle three fingers of the
dominant hand
• The top hand applies pressure while the
lower hand remains relaxed to perceive
the tactile sensations
• For deep palpation using one hand, the
finger pads of the dominant hand press
over the area to be palpated, often the
other hand is used to support from below.
PALPATING THE SKIN TEMPERATURE:
• It is best to use the dorsum (back) of the
hand and fingers, where the examiner`s
skin is thinnest.
TESTING FOR VIBRATION:
• The nurse should use the palmar surface
of the hand
GENERAL GUIDELINES FOR PALPATION:
• The nurse hands should be clean &
warm, & the finger nails short
• Areas of tenderness should be palpated
last
DOCTOR A. CORPUS
BURI, JADE B.
• Deep palpation should be done after
superficial palpation.
• The effectiveness of palpation depends
largely on the client`s relaxation.
• Nurses can assist the client to relax by:
1. Gowning or draping the client
appropriately
2. Positioning the client comfortably
3. Ensuring that their own hands are
warm before beginning the
palpation
• During palpation, the nurse should be
sensitive to the client`s verbal & facial
expressions indicating discomfort
PERCUSSION
• Is the act of striking the body surface to
elicit sounds that can be heard or
vibrations that can be felt
2 TYPES OF PERCUSSION:
Direct Percussion
• The nurse strikes the area to be
percussed directly with the pads of two,
three or four fingers or with the pad of the
middle finger
• The strikes are rapid & the movement is
from the wrist.
• This technique is not generally used to
percuss the thorax but is useful in
percussing an adult sinuses
Indirect Percussion
• Is the striking of an object (e.g., finger)
held against the body area to be examined
• In this technique, the middle finger of
the nondominant hand (pleximeter) is
placed firmly on the client`s skin. Only the
distal phalanx & joint of this finger should
be in contact with the skin. Using the tip
of the flexed middle finger of the other
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
hand (plexor, the nurse strikes the
pleximeter, usually at the distal &
proximal joints.
• The striking motion comes from the
wrist, the forearm remains stationary. The
angle between the plexor & the
pleximeter should be 90 ̊, & the blows
must be firm, rapid & short to obtain a
clear sound.
• Percussion Is used to determine the size
& shape of internal organs by establishing
their borders.
PERCUSSION ELICIT 5 TYPLES OF SOUNDS
Flatness is an extremely dull sound
produced by very dense
Dullness is a thud like sound produced by
dense tissue such as liver, spleen or heart
Resonance is a hollow sound such as that
produced by lungs filled with air
Hyperrensonance is not produced in the
normal body, prescribed as booming &
can be heard over an emphysematous
lung.
Tympany musical/ drum like sound
produce from an air filled stomach
(distended bowel) lungs. (emphysema or
pneumothorax)
AUSCULTATION
• Is the process of listening to sounds
produced within the body
• May be direct or indirect
DIRECT AUSCULTATION
• is performed using the unaided ear
• E.g., listening to a respiratory wheeze
or grating of a moving joint.
INDIRECT AUSCULTATION
DOCTOR A. CORPUS
BURI, JADE B.
• performed using a stethoscope, which
transmit sounds to the nurses` ears
• Stethoscope is used primarily to listen to
sounds from within the body such as
bowel sound or valve sounds of the heart
&the blood pressure.
• Auscultated sounds are described
according to their pitch, intensity,
duration & quality.
1. PITCH
• is the frequency of the
vibrations (the number of
vibrations per second).
• Low-pitch sounds such as heart
sounds- have fewer vibrations
per second than high-pitch
sounds such as bronchial
sounds.
2. INTENSITY
• (amplitude) refers to the
loudness or softness of a sound.
• Some body sound are loud (e.g.,
bronchial sound heard from
the trachea)
• Others are soft (e.g., normal
breath sounds heard in the
lungs)
3. DURATION
• of a sound is it`s length (long or
short)
4. QUALITY
• of sound is a subjective
description of a sound (e.g.,
whistling, gurgling or snapping
sound).
DIAGNOSTIC TEST AND
PROCEDURES
X-RAY
• called electromagnetic waves.
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
• X-ray imaging creates pictures of the
inside of the human body.
• The images shows part of the body in
different shades of black and white.
• Used to evaluate the structure of bones
& soft tissues
• The patient is placed between an x-ray
machine and specially treated film
• Gamma rays created in the x-ray
machine pass through the patient`s body
• Different internal structures absorb the
x-rays in varying amounts, which results in
shadows of varying shades of gray being
cast on the film.
CHEST X-RAY
• Is a projection radiograph of the chest
used to diagnosed conditions affecting the
chest, its contents, and nearby structures.
Purpose:
✓ Assess the lung fields
✓ cardiac borders
✓ large arteries,
✓ clavicle
✓ ribs
✓ diaphragm & mediastinum
✓ Diagnose pulmonary or cardiac
disorders including heart failure
✓ COPD
✓ Pneumonia
✓ TB
✓ neoplastic disease
✓ Evaluate placement of feeding
tubes
✓ chest tubes
✓ central venous catheters
pacemaker wires
✓ endotracheal tubes
BASIC POSITIONS FOR CHEST X-RAY
AP (ANTERIOR-POSTERIOR)
DOCTOR A. CORPUS
BURI, JADE B.
• X-ray passes through the patient from
front to back.
PA (POSTERIOR-ANTERIOR)
• X-ray passes through the patient from
back to front.
BASIC POSITIONS FOR X-RAYS
LATERAL
• Patient is positioned on either side and
so that the x-ray passes from one side of
the body through the other side (right
lateral or left lateral).
OBLIQUE
• x-ray is angled between PA and lateral
positions.
ABDOMINAL X-RAY
• A plain film of the abdomen
• Also called as “abdominal flat plate” or
“KUB for kidneys, ureter and bladder”
Purpose:
✓ Assess the cause of abdominal pain
✓ Evaluate liver or kidney size, shape
and position
Procedure:
✓ Patient lies supine on the table.
✓ One AP (anterior-posterior) image
is taken
BONE X-RAYS
• CLAVICLE/ SCAPULA, FOOT, HAND, TOE,
FINGERS, MANDIBLE
Purpose:
✓ Assess for fracture, tumor, infection,
structural abnormalities,
degenerative diseases.
✓ Evaluate pain, loss of function,
deformity
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
Procedure:
✓ The patient may stand or sit or lie
on the x-ray table depending upon
the anatomic part being studied
JOINT X-RAYS
• Plain films of a joint or joints (hip, knee,
shoulder, elbow, ankle, wrist joints in the
feet & hands)
Purpose:
✓ Assess fracture, infection, cyst,
tumor, degenerative diseases.
Procedure:
✓ The patient lies on the x-ray table
while various views of the joints are
taken.
COMPUTED TOMOGRAPHY (CT SCAN)
• A specialized x-ray that takes cross-
sectional pictures of all types of tissues.
• Sometimes called as “CAT SCAN”. The
“A” refers to the word AXIAL, which is a
particular orientation of the image.
• Axial: relating to an axis/main axis
• It is used extensively in diagnosing
disease & injury of the:
✓ Brain, cerebral blood vessels, eyes,
inner ear & sinuses
✓ Neck, shoulders, cervical spine, and
blood vessels
✓ Chest, heart, aorta and lungs
✓ Thoracic and lumbar spine
✓ Upper abdomen, liver, kidney,
spleen & pancreas
✓ Skeletal system including bones of
the hands, feet, ankles, legs and
arms and jaws
✓ Pelvis & hips, reproductive system,
bladder & GI tract
DOCTOR A. CORPUS
BURI, JADE B.
• Also used to diagnosed cancers including
lungs, liver, pancreatic cancer, measure
tumor size and assess involvement in the
nearby tissues.
• A CT scanner can be described as a
square donut because of it`s shape
(square) & the large opening in the center.
• During the CT scan, the patient lies on
the CT table which is advanced into the
opening so that the scanner can take a
series of images.
MAGNETIC REASONANCE IMAGING (MRI)
• Is a non-invasive imaging technology
that gives a detailed pictures of internal
structures.
• Used to evaluate:
✓ Head trauma (assess for bleeding or
swelling)
✓ Neurologic symptoms suggestive of
cerebral aneurysm, stroke, tumor
or spinal cord lesion or injury
✓ Cardiac or major blood vessels
disease
✓ Renal disease (glomerulonephritis)
✓ Cancer of the pancreas. Adrenal
glands & gallbladder
✓ Musculoskeletal disorders including
problems in joints, soft tissues bone
ULTRASOUND (US)
• Also called as “SONOGRAM”
• Is a non-invasive diagnostic procedure
that uses soundwaves to create gray scale
images of internal structures.
• The high-pitched sound waves cannot
be heard by the human ear
• It is used to evaluate the shape &
position of organs & tissues, detect
masses, edema, stones & displacement of
tissues.
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
• In obstetrics, ultrasound is used to
evaluate fetal development & well-being.
ELECTROCARDIOGRAM (ECG/EKG)
• A test that records the electrical signals
of the heart
• It is common and painless test that
usually detect heart problems and
monitor the heart`s health.
BLOOD CHEMISTRY
CBC (COMPLETE BLOOD COUNT):
• lavender top-tube
• Reveals information about general
health
• Number of red blood cells (RBC)
• Number of white blood cells (WBC)
• Total amount of hemoglobin in the
blood
• Number of platelets which are critical to
clot formation
• Test the MCV, MCH & MCHC values are
useful in the diagnosis of various types of
anemia.
BUN (BLOOD UREA NITROGEN):
• red-top tube
• BUN is a by-product of protein
metabolism, is excreted primarily by the
kidneys & therefore reflects kidney
functions.
• Elevated BUN (azotemia) occurs in most
renal diseases; also rises with GI bleeding,
dehydration, high protein diet, and CHF.
CREATININE, SERUM
• red-top tube
• Breakdown product of creatinine
phosphate in the muscle
DOCTOR A. CORPUS
BURI, JADE B.
• Produced at a constant rate by the body
& excreted by the kidney. Blood level rises
in renal impairment.
• Creatinine level is a sensitive indicator of
renal function but is dependent on kidney
function.
URINALYSIS (UA)
• Provides information about the urinary
system
• Protein content in the urine is an
indicative of decreased renal function
• Red blood cells indicates damage of the
renal tubules
• Crystals indicates the presence of renal
stones
• Leucocyte esterase, nitrate and white
blood cells in the urine are indications of
urinary tract infection
• Hyaline casts indicate protein in the
urine
• WBC & RBC casts generally indicative of
upper urinary tract infection. RBC casts
are also present in other serious kidney
disorders.
• Renal Tubular Epithelial Cell casts
reflect damage to the tubules & are found
in renal tubular necrosis, viral diseases
and transplant rejection.
OTHER SOURCES OF DATA
• PRIMARY: client
• SECONDARY: family members, friends,
caregivers who know the client well often
can supplement information provided by
the client.
• OTHER SOURCE: Client`s record
CLIENT`S RECORD
HEALTH ASSESSMENT LECTURE
BSN 1-9 PRELIMS
• Includes information documented by
various health care professionals
• Also contains data regarding the client`s
occupation, religion, and marital status.
• Type of client`s records include medical
records, records of therapies and
laboratory records.
MEDICAL RECORD
• Includes medical history, physical
examination, operative report, progress
notes & consultations done by primary
caregivers; are often a source of client`s
present and past health and illness
patterns.
• The records can provide nurses with
information about the client`s coping
behaviors, health practices, previous
illnesses & allergies.
RECORD OF THERAPIES
• Provided by other health professionals
such as social workers, nutritionist,
dietitians, or physical therapist which
helps the nurse obtain relevant data not
expressed by the client.
Example:
• Social agency`s report on the
living conditions of the client
• Home Health Care agency`s
report on client`s ability to
cope at home will help the
nurse conducting an
assessment
LABORATORY`S RECORD
• Provide pertinent health information
Example:
o Result of blood glucose level
allows health professionals
to monitor the
DOCTOR A. CORPUS
BURI, JADE B. BSN 1-9 PRELIMS

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.

• Nurses must always consider the

information in client`s record

Example:

• 10 years old medical record shows

that the client`s health practices &
coping behaviors are likely to have
changed.
• Older clients may have numerous
previous records

• These records are very useful & can

contribute to full understanding of the
health history especially if the client`s
memory is impaired.

HEALTH ASSESSMENT LECTURE DOCTOR A. CORPUS