lOMoARcPSD|35160701

Introduction of Health Assessment Nursing Qualifying Exams

Reviewer
Nursing (Adventist University of the Philippines)

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Health Assessment
Nursing Qualifying Examination Reviewer
Fely Rose Boquida
INTRODUCTION ▪ From health history
▪ From physical
Health assessment is an evaluation process
examination
collecting and analyzing information to
• On-going or partial assessment – this is
determine health status by performing a physical
done at regular intervals while caring for
exam after taking a health history.
the client
Nursing Process • Focused or problem-oriented assessment
– done to assess a specific health
• Assessment problem
• Diagnosis o Character
• Planning o Onset
• Implementation o Location
• Evaluation o Duration
o Severity
Physical assessment is systematically collecting
o Pattern
information about the body systems through
o Associative factors
observation, inspection, auscultation, palpation,
• Emergency assessment – rapid
and percussion.
assessment for emergency patients
Steps o Focuses on
▪ Airway
• Collection of data ▪ Breathing
• Validation of data ▪ Circulation
• Documentation of data ▪ Disability
Types of Health Assessment Core values of nursing
• Initial comprehensive assessment – the • Caring
assessment you do upon • Love of God
arrival/admission of the client • Love of country
o Subjective data (symptoms) • Love of people
▪ Client’s perception of
health of all body parts HOLISTIC NURSING ASSESSMENT AND
or systems PATIENT INTERVIEW
▪ Past medical history
Growth and Development Assessment is an
▪ Family history
assessment of the developmental levels across
• By genogram
the life span

• Psychosexual Theory (Sigmund Freud

1935)
o Freud is the father of
psychoanalysis
o This theory explains that
humans constantly seek
different pleasure for different
periods/stage of life.
▪ Lifestyle and health
o Id, Ego, Superego
problems
o Stages
o Objective data (signs)
▪ Oral (0-1.5) - mouth

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Health Assessment
Nursing Qualifying Examination Reviewer
Fely Rose Boquida
▪ Anal (1.5-3) – bowel ▪ Pre-operational -
and bladder control development of
▪ Phallic (3-6) - genitals symbolic thought and
▪ Latency (6-11) – libido internal representation
inactive of the world via
▪ Genital (Adolescence) – language and mental
maturing sexual imagery
interests ▪ Concrete-operational –
• Psychosocial Theory (Erik Erikson more logical thinking
1968) on concrete events and
o Human development is a problem solving
product of interaction between ▪ Formal-operational –
individual needs and abilities increased logical
and societal expectations and thought and beginning
demands to understand more
o Stages: abstract and theoretical
▪ Trust vs Mistrust concepts
(Infant) • Moral Development Theory (Lawrence
▪ Autonomy vs Shame Kholberg 1981)
and Doubt (Toddler) o Affective and cognitive domains
▪ Initiative vs Guilt determine what is right from
(Preschooler and School wrong
age) o Development of individual
▪ Identity vs Role morality over time
Confusion (Adolescent) o Stages
▪ Intimacy vs Isolation ▪ Pre-conventional –
(Young adult) focused on
▪ Generativity vs reward/punishment and
Stagnation (Middle self-interest
Age) ▪ Conventional – focused
▪ Ego integrity vs Despair on pleasing others and
(Older Adult) law and order
• Cognitive Theory (Dr. Jean Piaget 1970) ▪ Post-conventional –
o Biology of Thinking focused on social
o Cognitive ability is limited upon contract and principle
birth but can be built throughout
During health assessment a nurse…
life with new knowledge.
o There is an interrelationship • Must ask
between physical maturity, o Biographical data
social interaction, o Educational level
environmental stimulation, and o Psychosocial environment
experience o Family history
▪ Sensorimotor – learning • Must check
through sensory o Overall impressions of client
experience and object ▪ Appropriateness
manipulation according to age

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Health Assessment
Nursing Qualifying Examination Reviewer
Fely Rose Boquida
▪ Patient perception
towards self
• Assess for violence
o Physical
o Psychological
o Economic
o Sexual
• Assess culture
o Cultural awareness
o Cultural skill
o Cultural knowledge
o Cultural encounter
o Cultural desire
o Consider:
▪ Ethnicity
▪ Generational status
▪ Educational level
▪ Religion
▪ Previous health
experiences
▪ Occupation and income
level
▪ Beliefs about time and
space
▪ Communication needs
and preferences
• Assess spirituality and religious
practices
o Religion and spirituality are
different
o Religion is the search for the
sacred or bigger being
o Spirituality is the search for
meaning and purpose in life
o Assessment tools
▪ Spiritual belief system
▪ Personal spirituality
▪ Integration with a
spiritual community
▪ Ritualized practices and
restrictions
▪ Implications for
medical care
▪ Terminal events
planning
▪ Sources of hope
▪ Organized religion
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▪ Personal spirituality
practices
▪ Effects on medical care
and end-of life issues
• Assess nutritional status
o Must check
▪ General status and
appearance
▪ Body build, muscle
mass, and fat
distribution
▪ Height and weight
▪ Ideal body weight
▪ Hydration
Vital Signs
• Temperature (36.5’C – 37.77’C)
• Pulse (60-100 bpm)
• Respirations (12-20 bpm)
• Blood pressure (120/80 mmHg)
• Pain (scale) – use coldspa
Diagnostic Reasoning
• Counter check and validate
• Cluster data and identify
o Health promotion diagnosis
o Risk diagnosis
o Actual diagnosis
S.B.A.R
Provides the healthcare team a reliable
framework to communicate urgent and non-
urgent information.
• Situation
• Background
• Assessment
• Recommendation
Interview
• It is important to establish rapport and a
trusting relationship with the patient
• Gather a comprehensive information of
client’s over-all health
• Encourage nurse-client collaboration
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Health Assessment
Nursing Qualifying Examination Reviewer
Fely Rose Boquida
• There can be verbal and non-verbal • Muskuloskeletal
exchanges • Neurological
• Phases
Positioning during assessment
o Pre-introductory
o Introductory • Seated position
o Working
o Closing/Termination
Communication during the interview

• Non-verbal
o Appearance
o Demeanor • Supine
o Facial expression
o Attitude
o Silence • Prone
o Listening
• Verbal
o Open-ended questions • Fowler’s
o Closed-ended questions
o Laundry list
o Rephrasing
o Well-placed phrases
o Inferring • Sims
o Providing information
Special considerations

• Age-related variations • Trendelenburg

o Pediatric
o Geriatric
• Cultural Variations
• Emotional variations
Review of Systems • Knee-Chest position

• Skin, hair and nails

• Head and neck
• Ears
• Eyes • Lithotomy
• Mouth, throat, nose, and sinuses
• Thorax and lungs
• Breast and regional lymphatics
• Heart and neck vessels
• Peripheral Vascular Techniques
• Abdomen • Inspection – using vision, smell, and
• Anus and rectum hearing to observe and detect
• Male and female genitalia normal/abnormal findings

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Health Assessment
Nursing Qualifying Examination Reviewer
Fely Rose Boquida
• Palpation – use of touch to assess
o Finger pads – pulses, texture,
size, consistency, shape, and
crepitus
o Ulnar/Palmar surface –
vibrations, thrills, fremitus
o Dorsal surface – temperature
o Light palpation – superficial
surface
o Moderate palpation – depress
the skin surface 1-2 cm
o Deep palpation – depress skin
surface 2.5-5 cm
o Bimanual palpation – using two
hands one to apply pressure and
other to feel the structure
• Percussion – tapping the patient that
cause a vibration to travel through the
skin to the upper layers of the
underlying structures

• Auscultation – using a stethoscope

to listen to sounds inside the body
o Diaphragm – used for high
pitched sounds (normal
heart sounds, breath sounds,
and bowel sounds)
o Bell – used for low pitched
sounds (abnormal heart
sound and bruits)

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