NCM 101 : Lecture

- health assessment will always be the - process of obtaining data (subjective or

bases of the nursing care objective) , organizing the data ,
validating (analyzing) the data , and
1950’s (Lydia Hall) documenting the data.
- she is the key person in making the - assessment serves as baseline
nursing process information or basis of nursing care
- she promulgated the 3’s of nursing - main skills that we use for assessment
is;
➢ critical thinking skills
- because we are
continuously analyzing
➢ adaptable (flexible)
- the skills must be in
accordance to the
patients care
➢ communication skills
- assessment should be done AT ALL
TIMES
- the 3 c’s are interrelated to each other

1970’s (ANA - american nurses association)

- ANA created the nursing process
- only expanded the 3c’s
Initial Comprehensive Assessment
- the baseline , upon entry , or at the start
of the patient admission
- a systematic process/scientific - It contains ;
(flexible /interchanging )of giving nursing ➢ patient information
care to your patient ● name , age , date of
birth ( how to ask the
age without asking it) ,
1970 (APIE) 1978 (ADPIE) and gender
● anthropometric
measurements
A - assessment A - assessment
- height
P - planning D - diagnosis
- weight
I - intervention P - planning
- latest v/s
E - evaluation I - intervention
➢ chief complains
E - evaluation
➢ history of present illness

On-going Assessment
- continuous until the patients problem
has been resolved
- always check from the baseline for
changes

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 NCM 101 : Lecture
- usually during the pts stay in the er or
hospital

Focused or Problem-Oriented Assessment

- relevant/ A MUST
- it is performed when a comprehensive
- key to gather data effectively and
database exists for a client who comes
efficiently
to the health care agency with a
- key to transverse multiple cultural
specific health concern
variations
- it focuses in the chief complaint
- deeply uncover clients information with
ease
Emergency Assessment
- important in under 18 patients
- a very rapid assessment performed in
- you can able to safely gather data
life threatening situations (choking ,
without clients hesitation
cardiac arrest , drowning), an immediate
- List of communication skills
diagnosis is needed to provide prompt
➢ listening skills
treatment
- to make your patient
- using ABC techniques (air way ,
comfortable during
breathing , circulation)
assessment
- also assess the environment
- developing social
distance (3 feet)
- maintain a good eye
contact
● except east
FOUR MAJOR STEPS: asian ,muslims ,
1. Collection of subjective data people with
- elicited from the patient through ● mental
interview disorders
2. Collection of objective data - smile (do not do facial
- data that is measured by the grimace)
nurse - tone of voice (neutral)
3. Validation of data - posture
- Confirm the data we have ● open posture it
assessed should be
4. Documentation of data slightly leaning
- Charting forward
● do not cross
your arms
● avoid side eyes
● do not cross
- review the client’s record , if available your legs
- keep an open mind and to avoid ● raise your voice
premature judgments ➢ silence skills
- educate yourself about the client’s - to make pt. feel you are
diagnoses or tests performed. not rushing the
- take a minute to reflect on your own assessment
feelings - allows pt. to think
- obtain and organize materials further their responses

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 NCM 101 : Lecture
- allowing pt.
vent/express emotions COMPREHENSIVE HEALTH HISTORY
➢ open ended question heredofamilial disease
- usually allowing pt. to ➔ Ask in the form of family
further discuss/express genogram
their history of present illness
- really important in initial ➔ Chronological sequence of
comprehensive events that is include to the
assessment current illness
➢ close-ended question ➔ Signs and symptoms
- answerable by yes or accompanying the pt. all
no question , brief throughout te illness (past to
questions present)
- usually use in focused ➔ any interventions done to
assessment alleviate the s/s
- Also in emergency history of past illness or
assessment only for hospitalization
conscious pt. ➔ chronological manner
➢ giving examples ➔ these are all instances pt. has
- you allow pt. to properly been sick with a specific
discuss what they feel diagnosis/hospitalization
through the nurses maintenance medication
leading cues ➔ maintenance for lifers
➢ continuing the conversation chief complaints
- nurses must allow the ➔ hours prior to admission
conversation to go Perception about the illness
on/forward ➔ It's the pt. perception , opinion
- never let the or feelings about the illness
communication die out
due to improper PATIENTS LIFESTYLE
responses - this are the patterns/habits that are
➢ avoid misleading questions usually perform of the patient
- never add phrases or
words that will force pt. NUTRITION STATUS
to give information Diet
- asking misleading - the content of the diet
questions leads to - frequency (how often
generalized the patient eats, as
standards 3 meals)
- special diets
water intake
- At least drink to 8-10
glasses per day (1-2
liters/day)
- data coming from the pt. Itself - Include you tea , coffee
- these includes the following; , energy drinks , juices ,
fruit shakes

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 NCM 101 : Lecture
Eliminations SOCIAL RELATIONSHIPS/PATTERNS
1. bowel ➔ Socialization round the people around
➔ always ask for the him/her
frequency (1-2 a times a ➔ How often do u socialize with you family
day normal in some ➔ How often do u socialize with you
books) friends
➔ appearance ➔ Lover (common law wife/husband)
➔ quantity (you will know if ➔ co- workers
there is a problem or ➔ Anyform of socialization (tagay , dinner ,
not) or laag ba)
2. urinary
➔ How often the patients urinate COPING
or what you call frequency (1 ➔ this is very important because
mL , kidney generates nowadays mental health condition is
30-60ml/hr) rampant
➔ color ➔ Coping strategies
➔ changes in pattern ➔ Healthy
➔ the amount (just ask for approx) ➔ dysfunctional
SLEEP
➔ This is the parameter how does the pts. SPIRITUAL
live ➔ Beliefs
➔ duration ➔ cultural
➔ usual sleeping time
➔ quality of sleep CURRENT HEALTH STATUS
● medication - health status
● interrupted - Vaccinations
● sleeping problems ➔ childhood immunization
➔ pattern ➔ current vaxx

TREATMENTS RECEIVED
DAILY ACTIVITIES ➔ procedures done
Activity patterns
➔ You will always starts with their MAINTENANCE MEDICATION
occupation - Ask the pts. If he/she is compliant
➔ pattern (usual time sa
occupation)
➔ Is this a stressful job (include
this)
Bathing
➔ ask the pts frequency in bathing - The one that will erdomer the collection
Exercise of data is the nurse
➔ ask about their daily exercise - Physical examination
➔ duration and the frequency EQUIPMENTS;
Hobbies ❖ Ears
➔ usually buhaton sa pts. ● Otoscope - will
➔ And how often the pts do his/her visualize the external or
hobbies the middle ear

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 NCM 101 : Lecture
● Tuning pork - to check - Lungs
sound lateralization , to - Head , face , neck ,eyes , ears,
test has or no hearing nose , throat (HEEMT)
loss - Back
❖ Eyes - Breast
● Penlight - this will check you - Upper extremities
pupillary reflex - Axilla
● Opthalomscope - to visualize - heart
the inner chamber ★ Supine (on your back)
● Snellers chart - use to check If pt. has back problem
visual acuity, the degree you - Abdominal assessment
can see the object (used to ● Inspection
check eye problems due to ● Palpitation
refraction) ● Auscultation
● Reading materials - the test for - Chest , heart , and lungs
visual clarity - Breast
- Upper Extremities
❖ Other devices - HEEMT + face
● sphygmomanometer ★ Prone (on your abdomen)
- Blood pressure Not recommended If the pt. Jas cardiac
● Stethoscope and respiratory problems
- auscultation - Hip assessment
● Tongue depressor - Back
- Check for gag reflex ★ Dorsal recumbent
- Inspection: the tongue , Not for the pt. Who has abdominal
uvula , palate , tonsils assessment (abdominal muscle are
● Tape measure contracted)
- It measure dimensions - Chest
of the structures - Breast
- 3d - Upper extremities
● ruler - Peripheral pulses
- 2s measurement of ★ Sims position
structure No to elderly pt. With joint problems
- L/w/h - Rectal and vaginal examination
★ Knee-chest position
● percussion hammer No to the pt. With joint problems
- percussion - Rectal assessment
● goniometer ★ Standing position
- Check degree of flexion - balance and posture and gait
of joints - Assess male genitalia
● Vaginal speculum ★ Lithotomy position
- dilate vagina for - Vaginal exam
inspection
POSITIONING: STANDARD PRECAUTION
★ Sitting position (fowler's position) ➢ Wash your hands before beginning the
Sitting if the pts cannot tolerate supine examination , after the examination and
position , immediately after accidental direct
- To check the chest; contact with blood or other body fluids

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 NCM 101 : Lecture
➢ Wear gloves if you have an open cut or ○ Temperature (Warm or
skin abrasion if the client has an open or cold)
weeping cut , if you are collecting body ○ Moisture (Dry or wet)
fluids and if you are assessing mucous ○ Mobility (Fixed ,
membrane morable , still ,
➢ Wear a mask and protective eye vibrating)
goggles if you are performing a ○ Consistency (Soft ,
examination in which you are likely to hard , fluid-filled)
be slashed with blood or other body ○ Size (Small , medium
fluid droplets large )
○ Strength (pulse Strong
, bounding , weak ,
thready)
○ Shape (Well-defined or
irregular)
- IPPA (except for abdominal ○ degree of tenderness
assessment) (Painful or non-painful)
- IAPePa (abdominal) ● Parts of the hands for palpation
1. Fingertips
1. Inspection - Finde discrimination ,
● The use of the sense of sight , pulses , texture , size ,
smell and hearing consistency , shape
● Observing the structure for ,crepitus (abnormal)
abnormalities
● Compare the infected data to 2. ulnar/palmar surface
normal standards - Vibration , thrills ,
● Make sure the room is fremitus (normal)
comfortable (and not too hot ri 3. Dorsal surface
too cold) - Temperature
● Good light source ● Types of palpation
● Look and observe touching ❖ Light palpation
- Sometimes alter the - Little to no depression
quality of the surface - <1cm depression
● Completely expose the area that - Circular motion
is needed to be assessed - Pules ,
● Take not for abnormalities like tenderness,surface ,
color changes , size , location , skin texture ,
consistency ,symmetry m temperature , and
movement , behavior , oder , moisture
and sounds ❖ Moderate palpation
● Compare the test result to the - 1.2cm depression
normal standards - Circular motion
2. Palpation - Size , consistency and
● Use hands to touch and feel the mobility
ff: - Dominant hand
○ Textures (Rough or - Lumps , tumors , cyst
smooth)
❖ Deep palpation

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- 2.5-5cm (1-2 inches)
depression
- Dominant on top of
non-dominant
- Very deep organs
covered with muscle
- Liver and the kidney
❖ Bimanual Palpation
- Two hands side to side
of the body part
- 1 hand to provide
pressure , 1 hand to feel
- Uterus , breast , spleen
- Size , shape , tone that varies with the
consistency and
mobility
- Leopold's maneuver
3. Percussion
● It feels like magic
● Percussion involve tapping body part to
produce sound waves
● These sound waves or vibrations enable
the examiner to assess underlying
● Uses of percussion
★ Eliciting pain - visceral
★ Determining location , size and
shape
★ Determining density
★ Detecting abnormal masses
★ Eliciting reflexes
● TYPES OF PERCUSSION
★ Direct
○ Direct tapping of a body
part with one or two
fingertips to elicit
possib;le tenderness
(spongy feeling in the
skin)
We do not use direct to
check sound waves ,
we use it to check
tenderness
★ Blunt
○ Is used to detect
tenderness over organs
(kidney) by placing one
hand on the body
surfaces using the fist of
the other hand to trike
the back of the hand flat
on the body surface
★ Indirect
○ The most commonly
used method of
percussion
○ The tapping done with
this type of percussion
produces a sound or
density of underlying
structures
○ Practice percussing by
tapping your clavicle to
elicit a flat tone and
your puffed-out cheek to
elicit a tympanic
tone.A good way to
detect changes in a
tone is to fill a carton
halfway with fluid and
practice percussion on it
4. Auscultation
● A type of assessment
technique that require
that use of a
stethoscope to listen
for heart-sounds ,
movement of blood
through the
cardiovascular system ,
movement of the bowel
, and movement of air
through the respiratory
★ PARTS OF STETHOSCOPE
○ Diaphragm
■ One with the white
■ Listen to
○ Bell
■ To listen for low-pitched
sounds such as
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 NCM 101 : Lecture
abnormal heart sounds
and bruits (abnormal
loud , blowing , or
murmuring sound heard
during auscultation)
★ GUIDELINES OF AUSCULTATION
○ Eliminate noises
○ Expose body part you are going
to auscultate
○ Warm the diaphragm or bell of
the stethoscope before placing
on skin
○ Explain what you are listening
for
○ Avoid listening through clothing
- Before u document the data you should
need to validate
Validate/Validating
★ Battle of common sense
★ Data that is being collected is true and
correct
★ It involves;
○ reassessment
○ clarify
■ Only for subjective data
○ verify
■ To check if the
information is accurate ,
you need to verify the
data with another nurse
Compare
★ Very important in assessment of data
★ Checking the actual result to the gather
data
★ You must know whats the normal finding
before compering
Hyper-resonance - more prolonged and distinct
than resonance
Documentation
- This is for records is the vehicle for
communication
- Document at all times , esp in HEALTH
ASSESSMENT because the team
knows the status of patients
- Legal purposes
- The documentation is law-bounded , it
means the document is a legal
document (confidential)
- A facility base , meaning each facility
has their own documentation type
GUIDELINES FOR SUBJECTIVE DATA
❖ More like narrative , sentences
❖ Under pts. Profile sheet
➢ from the patient
❖ Complains
➢ It should be in a COLDSPA
format
➢ C - character (description)
➢ O - onset
➢ L- location
➢ D- duration
➢ S- severity
➢ P- pattern
➢ A- associated factor
❖ Key assessment
➢ Food allergies (sometimes durg
allergies
■ Very detailed
■ Onset and duration
GUIDELINES FOR OBJECTIVE DATA
❖ Checklist
❖ focused-checklist
FORM OF DOCUMENTATION
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 NCM 101 : Lecture
1. Electronic MABOANG) & type b (
- Healthcare softwares laid-back , known to be gentle
2. Paper documentation persons)
- hardcopy 5. Spiritual
- tangible 6. Cultural practices
★ guidelines 7. Neurologic impairment
○ accurate a. Very important bcs there are
○ no erasure some disease that affect you as
■ If not intended write a person ( e.g., alzheimer's ,
horizontal line on the ADHD , autism)
erased statement and 8. Development level
affixed your signature a. 24-26
above
○ Affix signature with time and Mental Disorders
date ● Highlights
★ do not use; ● DSM 5
○ Correction tape/ink ○ Half a billion ( nearly half
○ Removable ink suffers depression)
○ Pencil ● Really diagnose
● It affects the person entirely
● what to assess
○ Depression
○ Anxiety
○ Bipolar disorders
● Mental health
○ Schropinia
○ Cognition
○ OCD
○ Orientation
○ Alzheimers
○ Level of consciousness
○ Dementia
● Mental disorders
○ How mental status affects the
SUBJECTIVE DATA
pts ADL’s
❖ Biographical Data
➢ to check orientation
Factors:
➢ name , address , and tel number
1. Economic and social status
■ Current level of
2. Lifestyle
consciousness ,
a. Unhealthy or poor choices in life
orientation and
3. Exposed to violence
memory-recall
a.
➢ age , date of birth , and gender
b. More gullible
■ Orientation and patients
c. They may copy what they
current developmental
experience before
level
4. Personality
■ Cognition and
a. According to psychology there
self-perception
are 2 types of personalities ;
➢ Marital status
type a (high achievers ,
■ Orientation
competitive , short-tempered ,
who wants to achieve
something by themselves ,
narcissistic people , at risk

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➢ Educational level/attainment
■ Create an impression
on pt. socio-economic
status

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