Health Assessment (Lecture)
STUDENT ANSWER SHEET BS NURSING / First YEAR
Session # 1
Materials:
LESSON TITLE: Introduction to Health Assessment Book, pen and notebook, index card/class list
LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can:
1. Learn the definition of health and health assessment and how it is practiced in the field of nursing; References:
Bates’ Nursing Guide to Physical
2. Identify the five steps of the nursing process and how they Examination and History Taking (Second Edition)
are applied in all aspects of nursing; by Beth Hogan-Quigley, Mary Louise Palm, and
3. Enumerate and describe the types of health assessment Lynn Bickley. and to differentiate them from
one another.
SUBJECT ORIENTATION (10 minutes)
Your classroom instructor for this subject, Health Assessment (Lecture) . Listed
below are the additional information vital in orientation:
1. The calendar of activities for major examinations must be relayed.
2. Classroom rules and regulations will be informed per the instructor’s discretions.
3. Computation of grades specific for this subject must be thoroughly explained to students.
4. The essence and significance in grade computation of these modules must be introduced.
5. If this is the first subject of the class, the instructor must initiate an election for block officers.
6. Any other information that will be deemed necessary by the instructor must be properly coordinated to
the class.
MAIN LESSON (50 minutes)
1 of 6
,You will study and read Chapter 1 of your book about this lesson:
Definition of Health
• Health is a relative state in which a person is able to live to his or her potential and includes the “7 facets”:
• Physical health – how the body works and adapts
• Emotional health – positive outlook and emotions channeled in a healthy manner
• Social well-being – supportive relationships with family and friends
• Cultural influences – favorable connections to promote health
• Spiritual influences – living peacefully, morally, and ethically
• Environmental influences – favorable conditions to promote health
• Developmental level – how one thinks, solves problems, and makes decisions
• Health is a sum of these facets and is not solely defined as the absence of disease or eating right, but
rather by the contribution of all dimensions.
Health Assessment
• The nursing health assessment entails both a comprehensive health history and a complete
physical examination, which are used to evaluate the health and status of a person.
• The nursing health assessment involves a systematic data collection that provides information to facilitate
a plan to deliver the best care for the patient.
• The first part of health assessment is the health history, which also incorporates the “7 facets”.
• The nurse asks pertinent questions to gather data from the patient and/or family. Past medical records
may also be used to collect additional information.
• Learning about the patient’s physical and psychological issues, social and cultural associations,
environment, developmental level, and spiritual beliefs contribute to the history.
• The second component of the health assessment is the physical examination.
• The nurse uses a structured head-to-toe examination to identify changes in the patient’s body systems.
• An unusual or abnormal finding may support the history data or trigger additional questions.
• The purpose of the nursing health assessment is to determine the patient’s health status, risk factors,
and need for education as a basis for developing a nursing plan of care.
2 of 6
, • The NURSING PROCESS is the ability of the nurse to extrapolate the findings, prioritize them, and
finally formulate and implement the plan of care is the overall goal.
• The information obtained throughout the health assessment should be documented in a clear,
concise manner. This information is collated in the patient’s medical records.
NURSING PROCESS
• The nurse uses the NURSING PROCESS (a problem-solving process) to identify patient problems; set a
goal and develop an action plan; implement the plan; and evaluate the outcome.
• The NURSING PROCESS steps are:
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
• Assessment – it is the first step of the nursing process. It is the subjective and objective data gathered
during the initial health history and physical examination and collected on each patient encounter.
• Diagnosis has a nursing focus and is based on real or potential health problems or human responses to
health problems. The nurse uses clinical reasoning to formulate diagnoses based on the assessment data
and the patient’s problem list.
• Planning is devising the best course of action to address the patient’s diagnoses. During planning, the
nurse and patient select goals for each diagnosis in order to alleviate, decrease, or prevent the problems
addressed in the nursing diagnosis.
• Implementation of the interventions can be completed by the patient, the family, or members of the
health care team. The interventions should clearly relate to the nursing diagnosis and the planned goals.
• Evaluation is a continuing process to determine if the goals have been attained. The nursing care plan is
revised based on the patient’s condition and whether the goals are realistic or appropriate for the
patient.
• During the assessment phase the nurse gathers patient data via the health history and examination of
the patient.
• A clinical reasoning process is then used to analyze the patient data and develop hypotheses as the
patient’s problem or problems.
• Once the problems are defined, the nurse develops the plan of care and implements and evaluates it.
3 of 6
, • assessment findings and the plan of care in the patient record to communicate the patient’s story and the
nurse’s clinical reasoning and plan to other health care team members.
• Critical thinking is ongoing, as is assessment of the patient.
Types of Health Assessment:
• The admission of a new patient to a clinic, hospital, long-term care facility, or visiting nurse agency
usually requires a comprehensive health assessment.
a. A focused or problem-oriented assessment is where the nurse focuses on gathering information about the
patient’s problem.
• A follow-up history is a form of a focused assessment.
• An emergency history is the data collection which focused on the patient’s emergent problem with
a systematic prioritization of need beginning with the ABCs of airway, breathing, and circulation.
CHECK FOR UNDERSTANDING (10 minutes)
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to
correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio
is not allowed. You are given 25 minutes for this activity:
Multiple Choice
1. Which of the following facets of health is demonstrated if the patient feels very much optimistic about
the results of her pregnancy?
a. Spiritual influences
b. Physical health
c. Cultural influences
d. Emotional health
ANSWER: D
RATIO: Emotional health is one of the facets of health that shows positive outlook and emotions channeled in
a healthy manner.
4 of 6
STUDENT ANSWER SHEET BS NURSING / First YEAR
Session # 1
Materials:
LESSON TITLE: Introduction to Health Assessment Book, pen and notebook, index card/class list
LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can:
1. Learn the definition of health and health assessment and how it is practiced in the field of nursing; References:
Bates’ Nursing Guide to Physical
2. Identify the five steps of the nursing process and how they Examination and History Taking (Second Edition)
are applied in all aspects of nursing; by Beth Hogan-Quigley, Mary Louise Palm, and
3. Enumerate and describe the types of health assessment Lynn Bickley. and to differentiate them from
one another.
SUBJECT ORIENTATION (10 minutes)
Your classroom instructor for this subject, Health Assessment (Lecture) . Listed
below are the additional information vital in orientation:
1. The calendar of activities for major examinations must be relayed.
2. Classroom rules and regulations will be informed per the instructor’s discretions.
3. Computation of grades specific for this subject must be thoroughly explained to students.
4. The essence and significance in grade computation of these modules must be introduced.
5. If this is the first subject of the class, the instructor must initiate an election for block officers.
6. Any other information that will be deemed necessary by the instructor must be properly coordinated to
the class.
MAIN LESSON (50 minutes)
1 of 6
,You will study and read Chapter 1 of your book about this lesson:
Definition of Health
• Health is a relative state in which a person is able to live to his or her potential and includes the “7 facets”:
• Physical health – how the body works and adapts
• Emotional health – positive outlook and emotions channeled in a healthy manner
• Social well-being – supportive relationships with family and friends
• Cultural influences – favorable connections to promote health
• Spiritual influences – living peacefully, morally, and ethically
• Environmental influences – favorable conditions to promote health
• Developmental level – how one thinks, solves problems, and makes decisions
• Health is a sum of these facets and is not solely defined as the absence of disease or eating right, but
rather by the contribution of all dimensions.
Health Assessment
• The nursing health assessment entails both a comprehensive health history and a complete
physical examination, which are used to evaluate the health and status of a person.
• The nursing health assessment involves a systematic data collection that provides information to facilitate
a plan to deliver the best care for the patient.
• The first part of health assessment is the health history, which also incorporates the “7 facets”.
• The nurse asks pertinent questions to gather data from the patient and/or family. Past medical records
may also be used to collect additional information.
• Learning about the patient’s physical and psychological issues, social and cultural associations,
environment, developmental level, and spiritual beliefs contribute to the history.
• The second component of the health assessment is the physical examination.
• The nurse uses a structured head-to-toe examination to identify changes in the patient’s body systems.
• An unusual or abnormal finding may support the history data or trigger additional questions.
• The purpose of the nursing health assessment is to determine the patient’s health status, risk factors,
and need for education as a basis for developing a nursing plan of care.
2 of 6
, • The NURSING PROCESS is the ability of the nurse to extrapolate the findings, prioritize them, and
finally formulate and implement the plan of care is the overall goal.
• The information obtained throughout the health assessment should be documented in a clear,
concise manner. This information is collated in the patient’s medical records.
NURSING PROCESS
• The nurse uses the NURSING PROCESS (a problem-solving process) to identify patient problems; set a
goal and develop an action plan; implement the plan; and evaluate the outcome.
• The NURSING PROCESS steps are:
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
• Assessment – it is the first step of the nursing process. It is the subjective and objective data gathered
during the initial health history and physical examination and collected on each patient encounter.
• Diagnosis has a nursing focus and is based on real or potential health problems or human responses to
health problems. The nurse uses clinical reasoning to formulate diagnoses based on the assessment data
and the patient’s problem list.
• Planning is devising the best course of action to address the patient’s diagnoses. During planning, the
nurse and patient select goals for each diagnosis in order to alleviate, decrease, or prevent the problems
addressed in the nursing diagnosis.
• Implementation of the interventions can be completed by the patient, the family, or members of the
health care team. The interventions should clearly relate to the nursing diagnosis and the planned goals.
• Evaluation is a continuing process to determine if the goals have been attained. The nursing care plan is
revised based on the patient’s condition and whether the goals are realistic or appropriate for the
patient.
• During the assessment phase the nurse gathers patient data via the health history and examination of
the patient.
• A clinical reasoning process is then used to analyze the patient data and develop hypotheses as the
patient’s problem or problems.
• Once the problems are defined, the nurse develops the plan of care and implements and evaluates it.
3 of 6
, • assessment findings and the plan of care in the patient record to communicate the patient’s story and the
nurse’s clinical reasoning and plan to other health care team members.
• Critical thinking is ongoing, as is assessment of the patient.
Types of Health Assessment:
• The admission of a new patient to a clinic, hospital, long-term care facility, or visiting nurse agency
usually requires a comprehensive health assessment.
a. A focused or problem-oriented assessment is where the nurse focuses on gathering information about the
patient’s problem.
• A follow-up history is a form of a focused assessment.
• An emergency history is the data collection which focused on the patient’s emergent problem with
a systematic prioritization of need beginning with the ABCs of airway, breathing, and circulation.
CHECK FOR UNDERSTANDING (10 minutes)
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to
correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio
is not allowed. You are given 25 minutes for this activity:
Multiple Choice
1. Which of the following facets of health is demonstrated if the patient feels very much optimistic about
the results of her pregnancy?
a. Spiritual influences
b. Physical health
c. Cultural influences
d. Emotional health
ANSWER: D
RATIO: Emotional health is one of the facets of health that shows positive outlook and emotions channeled in
a healthy manner.
4 of 6
