Final

Schedule of
classes (1C)
Time of Lecture
- Synchronous: 7:30am – 12:00pm (Monday)
- SDL: 7:30am – 12:00pm (Wednesday)
Time of Laboratory:
Monday:
- Synchronous: 12:30 pm – 5:00 pm
- SDL: 5:00 pm – 9:00pm
Wednesday:
- Synchronous: 12:30 pm – 4:30 pm
- SDL: 4:30 pm – 9:00 pm
 Final
Schedule of
classes (1A)
Time of Lecture
- Synchronous: 7:30am – 12:00pm (Tuesday)
- SDL: 7:30am – 12:00pm (Thursday)
Time of Laboratory:
Tuesday:
- Synchronous: 12:30 pm – 5:00 pm
- SDL: 5:00 pm – 9:00pm
Thursday:
- Synchronous: 12:30 pm – 4:30 pm
- SDL: 4:30 pm – 9:00 pm
OBJECTIVES :

•Review the Nursing Process

•Discuss the role of Nurses in Health

Assessment Process

•List and explain the types, methods

techniques, components of Assessment

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Review of the
Nursing
Process
 Nursing Process

• is a systematic, rational, dynamic, and

cyclic process used by the nurse in
planning and providing care.
 HEALTH
ASSESSMENT
By: Marc Patrich Sanchez RN, MAN
 Health Assessment
• Health assessment is an essential nursing
function which provides foundation for
quality nursing care and intervention
• It helps to identify the strengths of the clients
in promoting health
• Health assessment helps to identify client’s
needs, clinical problems
• To Evaluate responses of the person to
health problems and intervention
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 Purposes of Assessment
1. To collect data pertinent to the
patient’s health status – subjective
/objective
2. To identify deviations from normal
3. To discover the patients
strengths,limitations and coping
resources
4. To pinpoint actual problems
5. To spot factors that place the pt
6. To build rapport with patient and at risk of
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 Medical Assessment
Nursing Assessment
Vs
Assessment is the part of medical practice
the process is same BUT The outcome differ
•Medical assessment Diagnosis and treatment

•Nursing assessment - focus on patient as a person

and reach to the optimal level of wellness
(Holistic Approach)

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 TYPES OF ASSESSMENT

ASSESSME
NT

INITIAL TIME LAPSED

Assessment Assessment

FOCUS EMERGENCY
Assessment Assessment

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Initial Assessment
It is done within specified time after admission
to Hospital
Purpose: To establish a complete data base
for problem identification, reference and future
comparison Eg: Admission assessment

Focus or Ongoing Assessment

Purpose: To determine the status of a
specific problem identified in the earlier
assessment & to identify new or
overlooked problem
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 Emergency Assessment
During any physiologic and psychologic crisis
of the patient
Purpose: To identify life threatening problems
eg. ●ABC assessment in Cardiac arrest
●Assessment of suicidal attempt on violence
Time lapsed Assessment
Several months after the initial assessment
Purpose: To compare current status to
baseline data previously obtained
Eg Reassessment of clients functional
health patterns in home care 25
 On-Going Assessment
• Ongoing – Systematic monitoring
of specific problems

Eg. Pain Assessment -( Pain score )

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 Preparing the Physical
Setting
• The assessment may take place in a
variety of physical settings such as
hospital rooms, outpatient clinic,
physician’s office, school health
office, or a client’s home. But it is
important for the nurse to ensure a
good condition.
 PLANNING THE INTERVIEW AND
SETTING:

• Time  need to be scheduled when the client is

comfortable and free of pain
 PLANNING THE INTERVIEW AND
SETTING:

•Place  must have adequate privacy to promote

communication
 PLANNING THE INTERVIEW AND
SETTING:

- Distance  most people feel comfortable 3 to 4

ft apart during an interview
 Methods of Assessment

The primary methods are –

●Observing
●Interviewing
●Examining

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 Observing
Is a conscious deliberate skill developed
only through and with an organized
approach.
Eg. Data observed with 4 senses – vision,
hearing, smell and touch
Interviewing
Is a planned communication or a conversation with
a purpose Eg. History taking
2 approaches : Directive , non directive

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EXAMINING
Physical Examination
•Systematic data collection method –
Observational skills to detect health
problems

Assessment sequencing
•Head – to- Toe assessment
•Body system assessment (Signs and symptoms
– complaints – lead to clues )
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 The Art of Physical Examination …

Using Techniques of –
•Inspection
•Palpation
•Percussion
•Auscultation

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INSPECTION : close and careful visualization of
the person and of each body system
Eg Rashes…. Color changes … edema

PALPATIO
N • Texture
•Temp • organ size &
••Moisture
Rigidity & spasticity location
• Crepitation /vibration
• Position& size • Tenderness/pain
• Presence of lumps & masses
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 PERCUSSION :
Assess underlying structures of
location,
size, density of underlying tissues
AUSCULTATION :
Listening to sounds produced by the
body
•Stethoscope --
•Doppler
•Feto- scope
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 Collecting Data
ASSESSME
NT Organizing
Process Data
Validating Data

REPORT Documenting
Data
DATA

4 Closely Related Activities

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 1. Collecting Data : Gathering Information
Sources of data
Primary or Secondary PRIMARY SOURCE
----- patient –
Alert, oriented patient is most reliable
source Aged, mentally deterioration seriously
ill ??? s,
SECONDARY SOURCE – Family member
significant others, medical records, diagnostic
procedures
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 PHASES of the INTERVIEW
• It has three basic phases:
1.INTRODUCTORY

2.WORKING

3.SUMMARY and CLOSING

 PHASES of the INTERVIEW
1. INTRODUCTORY

• After introducing himself to the client,

• the nurse explains the purpose of the interview ,
• discusses the types of questions that will be asked,
• explains the reason for taking notes,
• and assures the client that information be confidential.
 PHASES of the INTERVIEW
2. WORKING
•During this phase, the nurse elicits the
client’s comments about major data.*
 BIOGRAPHIC DATA
 REASONS FOR SEEKING HEALTH CARE
 HISTORY OF PRESENT ILLNESS
 PAST HEALTH HISTORY
 FAMILY HISTORY
 REVIEW of BODY SYSTEMS
 LIFESTYLE and HEALTH PRACTICES
 PHASES of the INTERVIEW
3. SUMMARY and CLOSING

•The nurse summarizes information obtained during the

working phase and validates problems and goals with the
client.
•ALSO:
- IDENTIFIES AND DISCUSSES POSSIBLE PLANS
to RESOLVE the PROBLEM
- ASK for other CONCERNS and if there are any
FURTHER QUESTIONS
 1. COLLECTING
DATA

Process of gathering information

Nurse collects …..
A.Subjective –(Symptom)
Verbal statement by the patient Eg… Nausea
, pain , fatigue ,itching

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 MAJOR AREAS of
SUBJECTIVE DATA:
• Biographical Information (Name, Age, Religion,
Occupation)

• Physical Symptoms related to each body part or system

• Past health history

• Family History

• Health and lifestyle practices

 1. COLLECTING
DATA

B. Objective--- (Signs) (overt ) data

-Detected by an observer - can be measured
over an accepted standard
Can be seen, felt, heard, smelt – information by
observation or examination
Eg. Discoloration of the skin
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 Collecting Objective Data
• *Objective data are directly observed by
the examiner.
– Physical characteristics (e.g. skin color, posture)

– Body Functions (e.g., HR, RR)

– Appearance (dress, hygiene)

– Behavior (mood, affect)

– Measurements (BP, Temp, ht, wt)

– Results of lab testing

 PQRST Method for PAIN Assessment

• O = Onset What you were doing when the pain

started ?
Was the onset sudden or gradual ?
• P = Provokes - What causes pain?
What makes it better? What makes it Worse?
• Q = Quality What does it feel like?
Is it sharp? Dull?
Stabbing? Burning? Crushing? ( Try to let
patient describe the pain)
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• R = Radiates Where does the pain radiate?
– Is it in one place?
– Does it go anywhere else?
• Did it start elsewhere and now localized to one
spot?

• S = Severity
How severe is the pain on a scale of 1 - 10
(This is a difficult one as the rating will differ from
patient to patient )
• T = Time
– Time pain started?
– How long did it last?
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 While Collecting data …..

When you communicate to collect data

Aware of verbal /nonverbal messages to
patient
•Genuineness : be open ,honest and
•sincere with
Respect : patient
be Non judgemental, let him
accepted asfeel
a unique individual
•Empathy: Is knowing what patient means
and acknowledge and understanding how
he /she feels
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 ORGANIZING DATA

• Cluster the data into groups of

information
( identify the pattern of illness) (Data base)

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 VALIDATING DATA
• Double checking or verifying the data
whether it is factual or accurate
• The assessment information must be accurate,
factual and complete –
• Nursing diagnosis and interventions based on
this

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 DOCUMENTING DATA
• Accurate documentation is essential which
include all data collected about client’s health
status.

Record in a FACTUAL manner NOT interpretation

• Eg. Recording the breakfast intake as –
Ate 2 pieces of Bread toast , 1 egg and a cup of
coffee
Instead of “Good appetite”
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 Skills require for Health Assessment

A. Cognitive skills : Assessment is a “thinking “process

•Critical thinking --- why , how .. What
•Clinical decision making use knowledge &
experience
B.Problem solving Skill – with Scientific methods-
experience – “ intuition” (with experience)
C.Psychomotor skills – Assessment is “doing”
D.Affective/Interpersonal Skill –
Assessment is “feeling” trust and mutual respect
E.Ethical skills : Assessment is “ being responsible &
accountable” for your practice
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All

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