lOMoARcPSD|25973474
UGRD-NCM6101 Health Assessment TO HELP
OTHER STUDENT WHO IS STYRUGGLING WITH
Nursing (AMA Computer University)
Studocu is not sponsored or endorsed by any college or university
Downloaded by kevin wacira ()
, lOMoARcPSD|25973474
UGRD-NCM6101 Health Assessment
Course Description
This course deals with concepts, principles and techniques of history of head to toe physical assessment
using various tools and interpretation of laboratory findings to arrive at a nursing diagnosis. The
learners are expected to perform holistic nursing assessment of an individual adult client.
Week 1: Introduction
Health Assessment Module
HEALTH ASSESSMENT
THE NURSING PROCESS
The nursing process is the cornerstone of nursing profession. It is synonymous with problem – solving
approach for discovering the health care and nursing care needs of patients. Nursing was able to build its
own scientific body of knowledge through Nursing Process.
Lydia Hall, a nursing theorist, originated the term “Nursing Process” in 1955.
Nursing Process is an organized, systematic manner of providing goal-oriented and
humanistic care that is both efficient and effective
It is composed of six sequential and interrelated steps: Assessment, Diagnosis,
Outcome Identification, Planning, implementation and Evaluation (ADOPIE).
It is goal oriented and humanistic:
1. The plan of care is developed and implemented with great consideration of unique needs and concerns
of individual patients
2. It is individualized
3. It involves aspect of human dignity
It is efficient because it is relevant to the needs of the patient
It promotes patients’ satisfaction and progress
It is effective because it utilizes resources wisely in terms of human, time and cost resources
SIX PHASES OF THE NUSING PROCESS
1. ASSESMENT. Is collecting, validating, organizing, recording, data about the patient’s health status
Downloaded by kevin wacira ()
, lOMoARcPSD|25973474
• Purpose: to establish a database
• Activities during Assessment:
Types of Assessment
1. On-going partial
2. Comprehensive
3. Focused on emergency
A. Collection of data: involves gathering information about the patient, considering the physical,
psychological, emotional, socio-cultural, and spiritual factors that may affect patient’s health status
Types of Data
a. Subjective data (symptoms). Verbalized by patient
Examples: dizziness, anxiety, fatigue, weakness, anorexia, tinnitus
b. Objective data (signs): observed and measured by the nurse
Examples: Temperature = 37.5oC; Pulse = 65 beats per
minute; Respiratory rate = 18 cycles per minute; BP = 120/80
Pain = pain scale, 8 out of 10 (1=lowest, 10=highest)
Pallor; diaphoresis, edema, poor skin turgor, weight loss;
etc Methods of Collection of Data
a. Interview – planned, purposeful conservation
Examples: Collection of data for health history
b. Observation – uses of senses
Use of units of measurement
Physical Examination Techniques (IPPA – Inspection, Palpation, Percussion,
Auscultation) Interpretation of laboratory results
Sources of Data
a. Primary source: patient
b. Secondary sources: family members, significant others, friends, Records & Chart
Downloaded by kevin wacira ()
, lOMoARcPSD|25973474
B. Validating Data/Validating: Accuracy of Information
Ex.: Dark urine – indicates dehydration or patient may have taken certain medication or food. Validate
dehydration by assessing vomiting, diarrhea, inadequate fluid Intake
2. DIAGNOSIS– diagnostic statement or Nursing Diagnosis (clinical act of identifying problems)
Purpose: identify patient’s health care needs and to prepare diagnostic statements
Statement of patient’s potential or actual alteration of health status Uses PRS/PES format: P – problem;
R – related to; S – signs & symptoms
P – problem; E – etiology; S – signs & symptoms
C. Outcome Identification – formulating and documenting measurable, realistic, patient- focused goals.
Purposes:
• To provide individualized care
• To promote patient participation
• To plan care that is realistic and measurable • To allow involvement of support
people Comparing with Standards
Ex.: Passage of frequent watery stool may lead to dehydration and loss of electrolyte like potassium and
sodium
Nursing Diagnosis Statement: Fluid volume deficit related to frequent passage of watery stool
3. OUTCOME IDENTICATION – refers to formulating and documenting measurable, realistic, patient-
focused goals. It provides the basis for evaluating nursing diagnosis.
Purposes:
A. To provide individualize care
B. To promote patient participation
C. To plan care that is realistic and measurable
D. To allow involvement of support people
Activities During Outcome Identification
1. Establishing priorities
a. Life – threatening situations (highest priority)
Ex.: Difficulty of breathing, chest pain, haemorrhage, suicidal tendencies
Downloaded by kevin wacira ()
UGRD-NCM6101 Health Assessment TO HELP
OTHER STUDENT WHO IS STYRUGGLING WITH
Nursing (AMA Computer University)
Studocu is not sponsored or endorsed by any college or university
Downloaded by kevin wacira ()
, lOMoARcPSD|25973474
UGRD-NCM6101 Health Assessment
Course Description
This course deals with concepts, principles and techniques of history of head to toe physical assessment
using various tools and interpretation of laboratory findings to arrive at a nursing diagnosis. The
learners are expected to perform holistic nursing assessment of an individual adult client.
Week 1: Introduction
Health Assessment Module
HEALTH ASSESSMENT
THE NURSING PROCESS
The nursing process is the cornerstone of nursing profession. It is synonymous with problem – solving
approach for discovering the health care and nursing care needs of patients. Nursing was able to build its
own scientific body of knowledge through Nursing Process.
Lydia Hall, a nursing theorist, originated the term “Nursing Process” in 1955.
Nursing Process is an organized, systematic manner of providing goal-oriented and
humanistic care that is both efficient and effective
It is composed of six sequential and interrelated steps: Assessment, Diagnosis,
Outcome Identification, Planning, implementation and Evaluation (ADOPIE).
It is goal oriented and humanistic:
1. The plan of care is developed and implemented with great consideration of unique needs and concerns
of individual patients
2. It is individualized
3. It involves aspect of human dignity
It is efficient because it is relevant to the needs of the patient
It promotes patients’ satisfaction and progress
It is effective because it utilizes resources wisely in terms of human, time and cost resources
SIX PHASES OF THE NUSING PROCESS
1. ASSESMENT. Is collecting, validating, organizing, recording, data about the patient’s health status
Downloaded by kevin wacira ()
, lOMoARcPSD|25973474
• Purpose: to establish a database
• Activities during Assessment:
Types of Assessment
1. On-going partial
2. Comprehensive
3. Focused on emergency
A. Collection of data: involves gathering information about the patient, considering the physical,
psychological, emotional, socio-cultural, and spiritual factors that may affect patient’s health status
Types of Data
a. Subjective data (symptoms). Verbalized by patient
Examples: dizziness, anxiety, fatigue, weakness, anorexia, tinnitus
b. Objective data (signs): observed and measured by the nurse
Examples: Temperature = 37.5oC; Pulse = 65 beats per
minute; Respiratory rate = 18 cycles per minute; BP = 120/80
Pain = pain scale, 8 out of 10 (1=lowest, 10=highest)
Pallor; diaphoresis, edema, poor skin turgor, weight loss;
etc Methods of Collection of Data
a. Interview – planned, purposeful conservation
Examples: Collection of data for health history
b. Observation – uses of senses
Use of units of measurement
Physical Examination Techniques (IPPA – Inspection, Palpation, Percussion,
Auscultation) Interpretation of laboratory results
Sources of Data
a. Primary source: patient
b. Secondary sources: family members, significant others, friends, Records & Chart
Downloaded by kevin wacira ()
, lOMoARcPSD|25973474
B. Validating Data/Validating: Accuracy of Information
Ex.: Dark urine – indicates dehydration or patient may have taken certain medication or food. Validate
dehydration by assessing vomiting, diarrhea, inadequate fluid Intake
2. DIAGNOSIS– diagnostic statement or Nursing Diagnosis (clinical act of identifying problems)
Purpose: identify patient’s health care needs and to prepare diagnostic statements
Statement of patient’s potential or actual alteration of health status Uses PRS/PES format: P – problem;
R – related to; S – signs & symptoms
P – problem; E – etiology; S – signs & symptoms
C. Outcome Identification – formulating and documenting measurable, realistic, patient- focused goals.
Purposes:
• To provide individualized care
• To promote patient participation
• To plan care that is realistic and measurable • To allow involvement of support
people Comparing with Standards
Ex.: Passage of frequent watery stool may lead to dehydration and loss of electrolyte like potassium and
sodium
Nursing Diagnosis Statement: Fluid volume deficit related to frequent passage of watery stool
3. OUTCOME IDENTICATION – refers to formulating and documenting measurable, realistic, patient-
focused goals. It provides the basis for evaluating nursing diagnosis.
Purposes:
A. To provide individualize care
B. To promote patient participation
C. To plan care that is realistic and measurable
D. To allow involvement of support people
Activities During Outcome Identification
1. Establishing priorities
a. Life – threatening situations (highest priority)
Ex.: Difficulty of breathing, chest pain, haemorrhage, suicidal tendencies
Downloaded by kevin wacira ()
