HEALTH ASSESSMENT IV.

VALIDATING AND DOCUMENTATING DATA

V. USING DIAGNOSTIC REASONING SKILLS AND
MIDTERM
ANALYSIS
REVIEWER 1
COURSE DESCRIPTION PHYSICAL ASSESSMENT
- Deals with concepts, principles ad techniques of history taking
using various tools, physical examination, psycho-social assessment
1. SKIN
and interpretation of lab test.
2. SCALP & HAIR
- To arrive at a nursing diagnosis in varied settings.
3. NAILS
4. HEAD AND FACE
5. NECK
TERMINAL COMPETENCIES
6. LYMPH NODES OF THE HEAD AND NECK
Simulated and actual conditions/situations, the student will be able 7. EYE
to: 8. EAR
9. MOUTH, THROAT, NOSE AND SINUS
1. differentiate normal from abnormal findings. 10. THORACIS AND LUNG
2. utilize concepts, principles, techniques and appropriate 11. BREAST AND LYMPHATIC ASSESSMENT
assessment tools with varying age group and development. 12. HEART AND NECK VESSELS
COURSE OUTLINE 13. PERIPHERAL VASCULAR
14. ABDOMEN
I. CONCEPTUAL OVERVIEW OF NURSING HEALTH
15. FEMALE GENITALIA
ASSESSMENT
16. MALE GENITALIA
II. THE CLIENT IN THE CONTEXT: CULTURE, SPIRITUALITY
17. MUSCULOSKELETAL SYSTEM
AND FAMILY.
18. NEUROLOGIC ASSESSMENT
III. COLLECTING AND ANALYZING OF DATA
PHYSIOLOGIC ASSESSMENT SCIENCE OF NURSING

- Analytical Thinking
- Based on scientific principles and research data
1. PAIN
- Analytical thinking skills can be learned
2. NUTRITIONAL ASSESSMENT
- assessment and development of an individual with different
group.
CRITICAL THINKING

3. NEWBORN - Purposeful, goal-directed thinking process

- Strives to resolve patient care issues using clinical reasoning.
- Combines Logic, Intuition, and Creativity (L – I – C)
ART AND SCIENCE OF NURSING - Essential to Nursing Practice.

NURSING CLINICAL REASONING

- Disciplined, Creative, and Reflective approach (D – C – R)

- A blend of art and science
- Skills in both areas develop with experience.
ART OF NURSING
- Incorporates aspects of caring and sharing into practice.
- Professional intuition develops with experience.
- Guides nursing Care
- Concurrently with critical thinking
- Conducted from some point of view
- Based on data, info, and evidence
- Expressed Through and Shaped by Concepts and Ideas.
- Implications and Consequences
PURPOSE:

- Establish potential strategies for patients to reach desired health

goals.
COMPONENTS OF CRITICAL THINKING 4. EXPLANATION
- Requires that conclusions drawn from inferences be correct and
1. Interpretation
justifiable
2. Analysis
- Scientific and nursing literature serve as bases for clinical
3. Inference
justification
4. Explanation
5. Evaluation
6. Self-regulation
5. EVALUATION
- Examines the validity of the information and hypothesis.

1. INTERPRETATION
- Decodes hidden messages
6. SELF-REGULATION
- Clarifies the meaning of information
- Key components of Critical Thinking
- Categorizes information
- Reflects on critical thinking skills and determines which techniques
were effective and which were problematic

2. ANALYSIS
- Examines ideas and data
I. CONCEPTUAL OVERVIEW OF NURSING HEALTH
- Identifies discrepancies
- Reflects on reasons for discrepancies ASSESSMENT

3. INFERENCE ASSESSMENT
- Speculates, Derives, or Reason to specific premise based on - First and the most critical phase
information and assumption
- Skill develops with experience
 - Data is inadequate or inaccurate, incorrect nursing judgements PLANNING
maybe made that adversely affect the remaining phases of the
- Determining outcome criteria
process.
- Developing a plan
*AS NURSES WE SHOULD ALWAYS BE AWARE THAT
ASSESSMENT IS ONGOING AND CONTINOUS
THROUGHOUT ALL THE PHASE OF THE NURSING PROCESS* IMPLEMENTATION

- Carrying out the plan

PURPOSE OF HEALTH ASSESSMENT

- Collect subjective and objective data

EVALUATION
- Determine client’s overall level of functioning to make professional
judgement. - Assessing whether outcome criteria have been met
- Revising plan as necessary

PHASES OF HEALTH ASSESSMENT (ADPIE)

NURSING HEALTH ASSESSMENT

1. HEALTH HISTORY
ASSESSMENT 2. PHYSICAL ASSESSMENT
- Collecting subjective and objective data

HEALTH HISTORY
DIAGNOSIS - Gathers subjective data from patient
- Analyzing data to make professional judgement - Information may or may not be validated by physical findings
- Nsg. Dx, Collaborative problems, or Referral
 POSSIBLE SOURCES TYPES OF ASSESSMENT
1. Patient
2. Family
3. Neighbors 1. INITIAL COMPREHENSIVE ASSESSMENT
4. Friends - Collection of subjective and objective data
5. Bystanders - Needed/done when client first enters health care system
6. Old Charts - To establish a baseline data against future health status changes
7. Medical Records can be measured and compared

2. ONGOING OR PARTIAL ASSESSMENT

PHYSICAL ASSESSMENT - Occurs after the Initial Comprehensive Assessment is
established
- Objective data
- Consists of mini-overview of client’s body system
- Observable, Measurable data
- Holistic patterns as a follow – up on his health status

POSSIBLE APPROACHES
3. FOCUSED OR PROBLEM – ORIENTED ASSESSMENT
1. Body Systems
- Consist of a thorough assessment of a particular client problem
2. Head – to – Toe
- Does not cover areas not related to the problem
3. Functional Health Patterns

4. EMERGENCY ASSESSMENT
- Very rapid assessment performed in a life – threatening
DIAGNOSTIC AND LABORATORY DATA
situations
- Objective Data - To determine the status of the client’s life – sustaining physical
- May includes items such as body fluids studies, cultures, X-rays, functions
and diagnostic procedures.
EVOLUTION OF NURSE’S ROLES IN HEALTH
ASSESSMENT
PAST
- From the time of Florence Nightingale
- Nurses uses sense of sight, touch, and hearing
- Primary Care method if delivery of care
PRESENT
- Communication and Physical Assessment Techniques used
Independently
- To arrive at professional clinical judgements concerning client’s
health
- Advances in technology have expanded the role of assessment
- Development of managed care has increased the necessity of
assessment skills
FUTURE
- Increase specialization and diversity of assessment skills of
nurses.
- Necessity for clinical assessment and informatics skills
II. THE CLIENT IN THE CONTEXT: CULTURE,
SPIRITUALITY AND FAMILY
CULTURES
- Totality of socially transmitted behavioral patterns, arts, beliefs,
values, customs, life-ways, and all other products of human work
- Thought characteristic of population or people that guide their
worldview and decision making
- Composed all verbal and behavioral systems and transmit meaning
*CULTURE INVOLVES ULTURAL AND BEHAVIORAL VATIONS
CONSIDERED TO BE CULTURE-BASED SYNDROMES, AND THESE ARE
PREPARED TO BE SEPARATE ILLNESS WITHIN CERTAIN CULTURE*
CULTURAL COMPETENCE in F2F interactions from culturally diverse backgrounds.

1. CULTURAL DESIRE ALWAYS KEEP IN MIND THE FOLLOWINGS

- Motivation to want to engage in intercultural encounters

1. Be sensitive to non-verbal cues and communication
2. Appreciate differences, but build on similarities
2. CULTURAL AWARENESS
3. Remember that cultural competence is a journey
4. Every individual is unique
- Becoming appreciative and sensitive towards values, belief, life
5. Avoid judging others based on your personal values and rules
ways, practices, and problem-solving strategies
6. Avoid relying solely on textbooks/written materials

3. CULTURAL KNOWLEDGE

SIPIRTUALITY
- The process of seeking and obtaining a sound educational
foundation - Search for meaning and purpose in life
- Seeks to understand life’s ultimate questions in relation to sacred.
4. CULTURAL SKILLS

- Ability to collect relevant cultural data regarding the client’s RELIGION

health history and present problems - Rituals, Practices, and Experiences involving a search for sacred
- Accurately performing a physical assessment

5. CULTURAL ENCOUNTERS SPIRITUAL ASSESSMENTS

- Active and ongoing conversations that assesses the spiritual needs

- Process that allows the health care provider to engage directly
of clients.
SPIRITUAL CARES Do you Consider yourself spiritual or religious?

- Addressing the spiritual needs of the clients as they unfold What things do you believe in that give meaning to your life?
through spiritual assessment

I:
SPIRITUAL ASSESSMENT TECHNIQUES
Is it important in your life?

What influence does it have on how you take care of yourself?

NON – FORMAL
How have your beliefs influenced our behavior during this illness?
- Helpful to have a Quick reference to guide assessment
What role do your beliefs play in regaining your health?
- (Asking Open – Ended Questions, Allowing Clients to Disclose
pertinent information)
- Use of FICA Spiritual Assessment Tools
C:

Are you part of a spiritual or religious community?

F – FAITH & BELIEFS Is this of a support to you?
I – IMPORTANCE AND INFLUENCE Is there a person or group of people who you really love or who are really
C – COMMUNITY important to you?

A – ADDRESS

A:

F: How would you like me, your nurse, to address these issues in your health
care?
What is your faith or belief?
GENERAL RECOMMENDATION BRIEF RELIGIOUS COPING QUESTIONNAIRE (RCOPE)

 I look to God for strength, support, and guidance in crisis.

1. Consider spirituality as an important component of client’s well-

a. A great deal
being and mental health
b. Quite a bit
2. Address spirituality at each complete physical examination
c. Somewhat
3. Resect client’s privacy regarding spiritual beliefs, do not impose
d. Not at all
your beliefs on others
4. Make referrals

FAMILY

FORMAL - Is whoever they say they are

- Many of these measures are PAPER – AND – PENCIL SELF

WHY ASSESS FAMILIES?
RESPONSE
- Ill person’s family is an essential part of the context in which
- Use of Daily Spiritual Experience Scale
the illness occurs.
- Use of Brief Religious Coping Questionnaire (RCOPE)
- They interact in such a way that non one component can be really
separated from the rest

DAILY SPIRITUAL EXPERIENCE SCALE

 I feel God’s presence COMMUNITY

 I feel thankful for my blessings
- Geopolitical communities determined by natural boundaries
 I feel God’s love for me directly
- Communities organized based on the relationship among a group of
 I am spiritually touches by the beauty of creation
people
 PURPOSE: METHOD USED TO OBTAIN DATA
- To determine the health-related concerns of its members
- Client Interview
regardless of type

 COMMUNITY HISTORY
SKILLS NEEDED TO OBTAIN DATA
 DEMOGRAPHIC INFORMATION
 PHYSICAL ENVIRONMENT - Interview
 HEALTH AND SOCIAL SERVICES - Therapeutic communication skills
- Caring ability
- Empathy
III. COLLECTING AND ANALYZING OF DATA - Listening Skills

SUBJECTIVE DATA EXAMPLES

- “I have a headache”
- “It frightens me.”
DESCRIPTION - “I am not hungry”
- Data elicited and verified by the client - “I love you” AYIEH  CHAROT TAWA KA MUNA HAHAHA

SOURCES

- Client OBJECTIVE DATA

- Family and Significant others
- Client Record
- Other health care professional DESCRIPTION

- Data directly or indirectly observed through measurement

SOURCES - X-ray films reveals Fracture

- Observation (ANO NA NANGYARI SA PATIENT NA TO)

- Physical Assessment (PA) findings of a nurse or other health care
professional
- Documentation of assessment made in client record
- Observations made by Family or Significant Others

METHOD USED TO OBTAIN DATA

-
-
Observation
Physical Examination GOD BLESS
SKILLS NEEDED TO OBTAIN DATA

-
-
Inspection
Palpation
FUTURE NURSE
- Percussion
- Auscultation

EXAMPLES

REVIEW WELL!!
- Respiration 16 per minute
- BP: 180/100
- Apical Pulse: 80 (Irregular)