Course Title: Health Assessment

Course No. NCM 101

Course Description: This course deals with concepts, principles and techniques of communication, history taking, and physical assessment of a
simulated scenario in varied settings. The learners are expected to demonstrate beginning skills in performing comprehensive
health assessment utilizing the nursing process.

Course Credit: Theory: 3 units (54 hours); RLE: 2 unit (102 hours)

Placement: First Year, Second Semester

Pre-requisites: NCM 100

Program Outcomes:
1. Apply knowledge of physical, social, natural and health sciences and humanities in the practice of nursing.
2. Provide safe, appropriate and holistic care to individuals, families, population groups, and community utilizing the nursing
process.
3. Apply guidelines and principles of evidence-based practice in the delivery of care
4. Practice nursing in accordance with existing laws, legal, ethical, and moral principles.
5. Communicate effectively in speaking, writing, and presenting using culturally appropriate language.
6. Document to include reporting up-to-date client care accurately and comprehensively.
7. Work effectively in collaboration with inter-, intra-, and multi-disciplinary and multi-cultural teams.
8. Practice beginning management and leadership skills using systems approach in the delivery of client care.
9. Engage in lifelong learning with a passion to keep current with national and global developments in general, and nursing
and health developments in particular.
10. Demonstrate responsible citizenship and pride in being a Filipino.
11. Apply techno-intelligent care systems and processes in health care delivery.
12. Adopt the nursing core values in the practice of the profession

Level Outcomes: At the end of the first year given simulated situations in selected settings, the learners demonstrate basic nursing skills in
rendering safe and appropriate care utilizing the nursing process.

Course Outcomes: 1. Apply knowledge of physical, social, natural and health sciences and humanities in health assessment.
2. Perform safe and appropriate health assessment in a given health scenario utilizing the nursing process.
3. Discuss guidelines and principles of evidence-based practice in conducting health assessment.
4.Use the ethical and legal considerations when conducting health history and physical examination.
 5. Communicate effectively in using culturally appropriate language in conducting health assessment.
6. Document assessment data accurately and comprehensively.
7. Appreciate the collaborative relationship of the health team in performing health assessment.
8. Practice beginning management and leadership skills in health assessment.
9. Assume responsibility for personal lifelong learning.
10. Demonstrate responsible citizenship and pride in being a Filipino.
11. Realize the importance of techno-intelligent care systems in health assessment.
12. Adopt the nursing core values in health assessment.

Alignment Matrix of Program Outcomes with Content

PROGRAM OUTCOMES COURSE OUTCOMES LEARNING OUTCOMES CONTENT/TOPIC

Apply knowledge of
physical, social, natural and
health sciences and
humanities in the practice
of nursing.
Apply knowledge of physical,
social, natural and health
sciences and humanities in
health assessment.
Use principles of social, physical, Introduction to Health Assessment
natural and health sciences and
humanities in health assessment. A. Overview of the Nursing Process (ADPIE)
1. Assessment
Use appropriate nursing concepts 2. Analyse/Diagnose
and actions in health assessment 3. Planning
holistically and comprehensively. 4. Implement
5. Evaluation

Perform safe, appropriate
and holistic care to
individuals, families,
population groups, and
community utilizing the
nursing process.
Perform safe and appropriate
health assessment in a given
health scenario utilizing the
nursing process.
Assess with health scenario one’s
health status/competence.
B. Health Assessment
1.Types
 Initial Assessment
 On-going Assessment
 Focused or Problem oriented
 Emergency Assessment
Steps In Health Assessment
A. Data Collection Process
1. General Survey
 Physical Presence
 Psychological presence

- Diagnostics Consideration
- Distress
 - Pain
a. Pain Assessment
(PQRST)
P-recipitating Factors
Q- uality
R- radiation/region
S-everity
T-timing
Apply guidelines and Discuss guidelines and Explain guidelines and principles of (COLD/SPA)
principles of evidence- principles of evidence-based evidence-based practice in the C-haracter
based practice in the practice in conducting health health assessment based on varied O-onset
delivery of care based on assessment. theories. L-ocation
the Philippine Nursing Law D-uration
and other.
S-everity
P-attern
A-associated factors

1. Collecting Subjective Data

 Health History
- Biographical Data
- Chief Complaints
- Present Health History
- Past Health History
- Family History
- Psychosocial History
- Activities of Daily Living
- Review of System (ROS)

 Functional Assessment (Gordon’s Functional Health

patterns)
- Physical ADC
- Activities of Daily Living
- Katz Index of Independence
- Barthel Index

Apply techno-intelligent Realize the importance of Introduce appropriate technology to 2. Collecting Objective Data
care systems and techno-intelligent care perform safe and efficient health
processes in health care systems in health assessment.
delivery. assessment.  Vital Signs (TPR-BP)

- T-emperature
- P-ulse
- R-espiration
- B-lood Pressure
a. Korotkoff sounds
b. Measuring Blood Pressure
c. Measurements Sites
d. Equipment

 Physical Assessment Techniques

- Inspection
a. Guidelines of inspection

- Palpation
a. Characteristics Identified through palpation
b. Types of palpation

- Percussion
a. Uses of percussion
b. Types of percussion
c. Different percussion tones
d. Techniques of indirect percussion

- Auscultation
a. Use of stethoscope
b. Techniques of auscultation
c. Classification of auscultated sounds

 Physical Assessment
- Skin, Hair, Nails
- Head, Neck and Lymph nodes
- Eyes
- Ears, Nose, Mouth and Throat
 - Breast and Lymph nodes
- Thorax and Lungs
a. Posterior chest
b. Anterior chest
- Heart
- Peripheral Vascular System and
Lymphatics
- Abdomen
- Musculoskeletal system
- Mental Status and Neurologic
Techniques
a. Appearance and Behavior
b. Mood
c. Thought Process and Perception
d. Cognitive Functions
- Female Genitalia
- Male Genitalia
- Anus, Rectum and Prostate

 Laboratory Test
 Diagnostic Procedures
- Non –invasive
- Invasive

3. Validation/Rationalization of subjective/objective data

Practice nursing in Use the ethical and legal Identify ethico-legal considerations Legal Consideration in Health Assessment
accordance with existing considerations when when providing safe, quality, and  Specific Guidelines
laws, legal, ethical, and conducting health history and professional nursing care.  RA 9173 Philippine Nursing Act of 2002 Article VI
moral principles. physical examination. Nursing Practice Section 28. Scope of Nursing (a)
Protect client rights based on “  Patient’s Bill of Rights and Responsibilities of Rights
Patient’s Bill of Rights and - Medical Care
Obligations” - Informed Consent
 Health Insurance Portability and Accountability Act
(HIPAA)
- Requiring Protection and Confidential

Communicate effectively in
speaking, writing, and
presenting using culturally
appropriate language.
Document to include up-to-
date reporting of client care
accurately and
comprehensively
Work effectively in
collaboration with inter-,
intra-, and multi-disciplinary
and multi-cultural teams.
Practice beginning
management and
leadership skills using
Communicate effectively in
using culturally appropriate
language in conducting
health assessment.
Document assessment data
accuratelyand
comprehensively.
Appreciate the collaborative
relationship of the health
team in performing health
assessment.
Practice beginning
management and leadership
skills in health assessment.
Implement policies related to
informed consent in conducting
health assessment.
Utilize appropriate communication/
interpersonal techniques in
conducting health assessment.
Adhere to guidelines in
documentation related to health
assessment.
Describe the harmonious
relationship among members of the
health team in performing health
assessment.
Utilize time and appropriate
resources efficiently and effectively.
Handling of Protected Health Information
 Data Privacy Act of 2012 (RA 10173)
-Collection, Processing and Consent.
Ethical Considerations
 Ethical principles
- Autonomy
- Beneficence
- Nonmaleficence
- Justice
- Fidelity
- Veracity
- Utilitarianism
Communication Techniques and Client Interview
1. Communication Techniques
 Factors affecting communication
 Effective communication technique.
2. Client Interview
 Factors Affecting The Interview
 Stages Of The Interview Process
Documentation of data
1. Purposes of Assessment Documentation
2. General Documentation Guidelines
 Written Notes
 Electronic Documentations
3. Examination-Specific Documentation Guidelines
4. Assessment forms used for documentation
Nurse’s Role in Health Assessment
Evolution of the Nurse’s role in Health Assessment
Guidelines in Conducting Health Assessment
1. Preparing the patient
systems approach in the
delivery of client care.
Engage in lifelong learning
with a passion to keep
current with national and
global developments is
general, and nursing and
health developments in
particular.
Demonstrate responsible
citizenship and pride in
being a Filipino
Adopt the nursing core
values in the practice of the
profession
Assume responsibility for
personal lifelong learning.
Demonstrate responsible
citizenship and pride in being
a Filipino.
Adopt the nursing core
values in health assessment.
Prepare a plan for conducive
environment for health assessment.
Enhance competency in conducting
health assessment.
Exemplify love for country in service
of the Filipinos.
Use nursing core values in
conducting health assessment.
Demonstrate caring as the core of
nursing, love of God, love of country
and love of people.
2. Preparing the Equipment/Instrument
3. Preparing the environment
4. Aftercare
Self-Directed Learning
 Program Instruction on Physical Assessment
 Online Access on Health Assessment and Physical
Examination
 Assessment In Brief Cards
Filipinos Cultural Characteristics and Health Care Beliefs and
Practices
 Communication Styles
 Family, Social and Work Relationship
 Health Values and Beliefs
 Health Custom and Practices
Learning Plan

Learning Outcomes Content/Topic Learning Strategies Assessment

Classroom TA RLE TA
Describe the harmonious Nurse’s Role in Health Assessment Interactive discussion 3 Paper and pencil
relationship among members Evolution of the Nurse’s role in Health test
of the health team in Assessment
performing health assessment.

Utilize appropriate
communication/ interpersonal
techniques in conducting
health assessment.
Use principles of social,
physical, natural and health
sciences and humanities in
health assessment.
Use appropriate nursing
concepts and actions in health
assessment holistically and
comprehensively.
Communication Techniques and Client Lecture Discussion 3 Paper and pencil
Interview test
1.Communication Techniques
 Factors affecting communication Role play/Video Sociogram/Video
 Effective communication technique. 6 Tape feedback
Rubrics
2.Client Interview
 Factors Affecting the Interview
- Stages of The Interview
Process
Introduction to Health Assessment Lecture Discussion 6 Paper and pencil
test
A. Overview of the Nursing Process
(ADPIE)
1. Assessment
2. Analyze/Diagnose Case Vignette on 12 Rubrics
3. Planning Assessment
4. Implement
5. Evaluation
B. Health Assessment
1.Types
 Initial Assessment
 On-going Assessment
 Focused or Problem oriented
 Emergency Assessment
Utilize time and appropriate
resources efficiently and
effectively.
Prepare a plan for conducive
environment for health
assessment.
Assess with health scenario
one’s health
status/competence.
Guidelines in Conducting Health Assessment Lecture Discussion 6 Paper and pencil
test
1. Preparing the patient
2. Preparing the Equipment/Instrument CD-ROM on Health 12 Performance
Assessment: Checklist
3. Preparing the environment Demonstration and
Return Demonstration
4. Aftercare
Steps In Health Assessment Lecture Discussion Paper and pencil
B. Data Collection Process 3 test
1. General Survey
 Physical Presence
 Psychological presence
 Diagnostics Consideration
 Distress Case Scenario 6 Rubrics
 Pain
Pain Assessment
(PQRST)
P-recipitating Factors
Q- uality
R- radiation/region
S-everity
T-timing
(COLD/SPA)
C-haracter
O-onset
L-ocation
D-uration
S-everity
P-attern
A-associated factors Video Clips on Health
History Taking Critic Rubrics on
1. Collecting Subjective Data 6 Video clips
  Health History
- Biographical Data Each learner prepares 12 CON Template
- Chief Complaints her/his own health on History Taking
- Present Health History history Rubrics
- Past Health History
- Family History
- Psychosocial History
- Activities of Daily Living
- Review of System
(ROS)

2. Collecting Objective Data Lecture Discussion 12 Paper and pencil

test
Explain guidelines and  Vital Signs (TPR-BP)
principles ofevidence-based
practice in the health T-emperature
assessment based on varied P-ulse Review of Literature Submit an
theories. R-espiration on Evidence-based evidence-based
B-lood Pressure practices practice in Health
- Korotkoff sounds Assessment:
- Measuring Blood Pressure Rubrics
- Measurements Sites
- Equipment

Introduce appropriate  Physical Assessment Techniques CD-ROM on Health

technology to perform safe - Inspection Assessment: 36 Performance
and efficient health a. Guidelines of Demonstration and checklist:
assessment. inspection Return Demonstration Rubrics

- Palpation
a. Characteristics
Identified through
palpation
b. Types of palpation

- Percussion
a. Uses of percussion
 b. Types of percussion
c. Different percussion
tones
d. Techniques of indirect
percussion

- Auscultation
a. Use of stethoscope
b. Techniques of
auscultation
c. Classification of
auscultated sounds

 Physical Assessment
- Skin, Hair, Nails
- Head, Neck and Lymph
nodes
- Eyes
- Ears, Nose, Mouth and
Throat
- Breast and Lymph
nodes
- Thorax and Lungs
a. Posterior chest
b. Anterior chest
- Heart
- Peripheral Vascular
System and Lymphatics
- Abdomen
- Musculoskeletal system
- Mental Status and
Neurologic Techniques
a. Appearance and
Behavior
b. Mood
c. Thought Process
and Perception

Adhere to guidelines in
documentation related to
health assessment.
Identify ethico-legal
considerations when providing
safe, quality, and professional
nursing care.
Protect client rights based on “
Patient’s Bill of Rights and
Obligations”
Implement policies related to
informed consent in
d. Cognitive
Functions
- Female Genitalia
- Male Genitalia
- Anus, Rectum and
Prostate
 Laboratory Test
 Diagnostic Procedures
- Non –invasive
- Invasive
3. Validation/Rationalization of
subjective/objective data
Documentation of data Lecture Discussion 3 Paper and Pencil
1. Purposes of Assessment test
Documentation
2. General Documentation Guidelines Prepare sample 12 Rubrics on
 Written Notes documentation: (1) documentation
 Electronic Documentations written; (2) electronics
3. Examination-Specific Documentation
Guidelines
4. Assessment forms used for
documentation
Legal Consideration in Health Assessment Lecture Discussion Paper and Pencil
test
 Specific Guidelines
 RA 9173 Philippine Nursing Act of
2002 Article VI Nursing Practice Flipped Classroom 6 Instant Feedback
Section 28. Scope of Nursing (a)
 Patient’s Bill of Rights and
Responsibilities of Rights
- Medical Care
- Informed Consent
 Health Insurance Portability and
conducting health assessment
. Protected Health
Exemplify love for country in
service of the Filipinos.
Use nursing core values in
conducting health
assessment.
Demonstrate caring as the
core of nursing, love of God,
love of country and love of
people.
Enhance competency in
conducting health
assessment.
Accountability Act (HIPAA)
- Requiring Protection and
Confidential Handling of
Information
 Data Privacy Act of 2012 (RA 10173)
- Collection, Processing
and Consent. Feedback on
Ethical Considerations Flipped Classroom application of
 Ethical principles ethical principles
- Autonomy through sample
- Beneficence scenarios
- Nonmaleficence
- Justice
- Fidelity
- Veracity
- Utilitarianism
Lecture Discussion Paper and Pencil
Filipinos Cultural Characteristics and Health 3 test
Care Beliefs and Practices
 Communication Styles
 Family, Social and Work Relationship
Boodle fight scenario 6 Group Feedback
 Health Values and Beliefs to share cultural,
belief, practices and
 Health Custom and Practices health care of their
particular region
Self-Directed Learning Guidelines on Self- 3 Portfolio
directed learning
 Program Instruction on Physical
Assessment
 Online Access on Health Assessment
and Physical Examination
  Assessment In Brief Cards

Learning Environment:
Air conditioned Classroom equipped with audio visual facilities
Resources: Instructional Resources includes: Video Clips, Case Vignette, Case Scenario, Clinical Guidelines,
CD-ROM on Health Assessment

Course Requirements: Paper and Pencil test

Sociogram
Rubrics
Performance Checklist
Evidence-Based Practice Journal Readings
Instant and Group Feedbacks
Portfolio

Grading System:
A. First half(Preliminary - Midterm)
Preliminary test 20%
Class Performance 40%
Midterm examination 40%
100% MIDTERM GRADE
B. Second half(Finals)
Class Performance 40%
Final Examination 60%
100% FINAL GRADE
C. Final Grade
MIDTERM GRADE 50%
FINAL GRADE 50%
100% FINAL GRADE
References:
Estes, Mary Ellen Z,(2014). “Health Assessment And Physical Examination.”5thEdition,Cergage Learning
Weber,Janet&Kelley,Jane.,(2010).”Health Assessment in Nursing.”4thEdition,Lippincott Williams & Wilkins
Weber,Janet.,(2008).” Assessment made Incredibly Easy.” Lippincott Williams & Wilkins
Prescribed Laboratory Manual:
Weber,Janet, et.al,(2014).”Lab Manual for Health Assessment in Nursing.”5thEdition,Lippincott Williams & Wilkins
Weber,Janet, et.al,(2018).”Lab Manual for Health Assessment in Nursing.”5thEdition,Lippincott Williams & Wilkins
Prescribed Handbook:
Weber,Janet&Kelley,Jane.,(2006).”Nurses Handbook of Health Assessment.”5th Edition, Lippincott Williams & Wilkins

Prepared by/date: Approved by/date: Noted by:

Jan Jarrel B. Gillego, RN, MAN

Lilian B. DelaHostria, RN, MAN

Elsa M. Regalado, RN, MAN Ma. Cecilia Ortiz-Quibel, RN, PhD Dr. Ramon C. Maniago

Faculty Members Dean Executive Dean