MODULE 1:

Introduction to
Health Assessment
NCM 101

Name of Student:
Section:

University of San Agustin

College of Nursing, Nutrition and Dietetics
Nursing Program

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 NCM 101: HEALTH ASSESSMENT

Introduction
This learning and assessment workbook introduces you to the nursing process and
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focuses on health assessment.

At the end of this module, you will be able to:

• Describe the phases of the nursing process.
• Identify major characteristics of the nursing process.
• Identify the purpose of assessing.
• Identify the four major activities associated with the assessing phase.

The Nursing Process

- Is a systematic method of providing care to clients and is a systematic
method of planning and providing individualized nursing care.

Read about the Nursing Process in any of the resource materials or on the internet.
READ
I have read and understood the following resource material / internet site:
_____________________________________________________________________________

Provide the definition of the following terminologies:

QUESTIONS
ASSESSMENT:

NURSING DIAGNOSIS:

PLANNING:

IMPLEMENTATION:

EVALUATION:

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 NCM 101: HEALTH ASSESSMENT

Critical Thinking
- The NURSING PROCESS a critical thinking process that professional nurses use
to apply the best available evidence to caregiving and promoting human
functions and responses to health and illness.

Given the following scenario below, answer the questions to follow.

QUESTIONS
Critical Thinking Scenario
Your patient, Mr. J is complaining of high fever. He was admitted to your care
because of rashes in his upper and lower extremities and has on and off fever for 3
days. You reviewed the patient's chart and X-ray results revealed Pneumonia,
Laboratory test indicates increase in white blood cell (WBC) count and decrease
platelet count. You checked his body temperature, and it is already 38.5 ˚C.

Is the temperature of your patient within normal range? If not, is it higher or lower?

As a nurse, what interventions/actions will you do to provide care to your patient?

What do you think are the possible causes of increase in body temperature?

What other signs and symptoms will you consider in this scenario?

Read about the Phases of the Nursing Process in any of the resource materials or on
the internet.
READ

I have read and understood the following resource material / internet site:
_____________________________________________________________________________

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 NCM 101: HEALTH ASSESSMENT

Assessment
- ASSESSING is the systematic and continuous collection, organization,
validation, and documentation of data (information).

Provide the definition of the following terminologies and give an example for each:
QUESTIONS
Initial Comprehensive Assessment:

Ongoing or Partial Assessment:

Focused or Problem – Oriented Assessment:

Emergency Assessment:

Diagnosis
- The term diagnosing refers to the reasoning process, whereas the term
DIAGNOSIS is a statement or conclusion regarding the nature of a
phenomenon.

Read about the NURSING DIAGNOSIS in any of the resource materials or on the
READ internet.

I have read and understood the following resource material / internet site:
_____________________________________________________________________________

Differentiate a Nursing Diagnosis from a Medical Diagnosis.

QUESTIONS

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 NCM 101: HEALTH ASSESSMENT

Planning
- PLANNING is a deliberative, systematic phase of the nursing process that
involves decision making and problem solving.

Read about the SMART GOALS in any of the resource materials or on the internet.
READ I have read and understood the following resource material / internet site:
_____________________________________________________________________________

Given the scenario in the critical thinking part of this module, formulate three (3)
QUESTIONS
S.M.A.R.T Goals.

1.

2.

3.

Implementation
- IMPLEMENTING is the action phase in which the nurse performs the nursing
interventions. It consists of doing and documenting the activities that are the
specific nursing actions needed to carry out the interventions.

Provide the definition of the following terminologies and give examples for each:
QUESTIONS
INDEPENDENT INTERVENTIONS:

INTERDEPENDENT INTERVENTIONS:

DEPENDENT INTERVENTIONS:

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Evaluation
- EVALUATING is a planned, ongoing, purposeful activity in which clients and
health care professionals determine (a) the client’s progress toward
achievement of goals/ outcomes and (b) the effectiveness of the nursing
care plan.

Knowing the Nursing Process and Critical Thinking Skills, reflect on the following:
SELF
REFLECTION
1. What scenario/s have you encountered in your life, that you could have wished
you had known this topic? Elaborate your example.

2. How could you have used your knowledge in this/these scenario/s?

3. As an Augustinian Nursing Student, how would this topic be beneficial to your

career path?

Thank you for answering the questions of this module with utmost honesty and zeal.
READ Keep in mind that plagiarism, in any form, is not tolerated in the Nursing Program, the
College and the University. So, please note the source of your answers in the green
boxes provided. For book sources: Name of Author and the Book Name, for internet
sources: the website.

You may, print and answer this self-directed module, scan it as PDF and upload on
the drop box in your neolms or super-impose your answers digitally on the spaces
provided, save it as PDF and upload them on the drop box in your neolms.

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