Health Assessment-LEC/RLE STUDY NOTE: 1

NCM 201 | COLLEGE OF NURSING TRANSCRIBER: PATHAY, ANTONIETTE

SAN PEDRO COLLEGE

WAYS TO DEVELOP ASSESSMENT SKILLS UNDERSTANDING CLIENT IN CONTENT OF

1.Identifying assumptions
2.Identifying an organized &
comprehensive approach to
assessment
3.Validation
4.Distinguishing normal from
abnormal when identifying
signs & symptoms
5.Making inferences
Clustering related cues or
gather set of cues
7. Distinguishing relevant
from irrelevant data
8. Recognizing
inconsistencies
9. Identifying patterns–
(sequence of recurring
behavior)
CULTURE, FAMILY, AND SPIRITUALITY
We need to consider these aspects because they
influence the client.
10. Identifying missing Culture can influence communication patterns,
information
dietary habits, family roles, and life-death-
11. Promoting health by issues.
identifying risk factors Family is an important support system for most
ill people. Also, when people become ill, their
12. Diagnosing actual & role in the family changes, and the family unit
potential problems from may need to recognize to sustain itself
the assessment data Religion and spirituality influence health beliefs
and practices. For example, the Jehovah's
witnesses may refuse blood transfusion even in
a life-threatening situation.
13.Setting priorities
14.Determining patient-
centered expected
outcomes
15.Determining specific
interventions that will
achieve your outcomes
16.Evaluating &
correcting thinking

CRITICAL THINKING SKILLS PRESENT IN

YOU

The element that I have in me is Intellectual Integrity

because I believe that doing what is right, even when it's
hard is the essence of being a healthcare worker. On the
other hand, the skill that I want to develop is an
Intellectual sense of Justice.
Health Assessment-LEC/RLE STUDY NOTE: 2
NCM 201 | COLLEGE OF NURSING TRANSCRIBER: PATHAY, ANTONIETTE
SAN PEDRO COLLEGE

ORGANIZING DATA ACCORDING TO GORDON’S 11 FUNCTIONAL HEALTH

PATTERNS
Health Assessment-LEC/RLE STUDY NOTE: 3
NCM 201 | COLLEGE OF NURSING TRANSCRIBER: PATHAY, ANTONIETTE
SAN PEDRO COLLEGE

NANDA NURSING DIAGNOSIS TABLE

Health Assessment-LEC/RLE STUDY NOTE: 4
NCM 201 | COLLEGE OF NURSING DATE: FEBUARY 16, 2021
SAN PEDRO COLLEGE TRANSCRIBER: PATHAY, ANTONIETTE

1. Communication
Communication is a process of sharing information and As a Nurse:
meaning, of sending and receiving messages. The During history taking, keep your body posture relaxed to
messages we communicate are both verbal and convey calm, reassuring attitude. Work at the same
nonverbal level as your patient. Standing over her or him conveys
 Nonverbal behavior a sense of dominance and authority, enhancing her or
Is an important source of data. Often, the nonverbal his sense of dependence. Give reaffirming gestures
message being sent is more accurate than the such as nodding. Your facial expression should convey
verbal one care and concern. Maintain eye contact to show the
It includes: patient you are interested in what she or he has to say
a. Vocal cues or paralinguistic
Vocal cues describe the quality of your voice and its c. Object cues
inflections, tone, intensity, and speed when Your patient’s dress and grooming reflect his or her
speaking. identity and how he or she feels about himself or
Vocal Cues herself.
Pain Moaning Object Cues
Afraid Softly with trepidation
Poor grooming May indicate psychological
Anger, doubt, Can all be conveyed by such as depression
disbelief, disapproval the tone of voice
Older patient Speaks loudly due to May signal an underlying
hearing loss physical problem that
Patient w/ Rapid speech affects self-care
Hyperthyroidism or
bipolar disorder
As a Nurse:
Your appearance is equally important. Your groom- ing
As a Nurse: and dress should be neat and appropriate for the
Your speech should be calm, reassuring, and without situation and reflect your professionalism. Be sure to
inflections that convey judgment or disapproval. Speak wear a tag with your name and title.
slowly enough and loudly enough so that your patient
can hear you and respond appropriately. d. Personal space
Is the territory surrounding a person that she or he
b. Action cues or kinetics
perceives as private or the physical distance that
Are body movements that convey messages.
needs to be maintained for the person to feel
Posture, arm position, hand gestures, body
comfortable
movements, facial expressions, and eye contact all
Personal Space Distance
convey a message.
Public space 12 feet or more
Action Cues Social-consultative 4 to 12 feet
Relaxed posture Conveys openness space (impersonal
Tensed posture Conveys anger, convo or interviews)
discomfort of mistrust Personal distance 18 inches to 4 feet
Guarded posture Indicates pain Intimate distance 0 to 18 inches
Tripod position Assumed to ease Taking health history 3 to 4 feet
breathing
Abnormal hand May indicate underlying As a Nurse:
gestures neurological problem Be aware of your position in relation to your patient. Be
Facial expression May signal underlying sure to explain what you are doing, and look for clues that
problem such as pain, your patient is becoming uncomfortable. If so, you may
fear, and anxiety need to back off and try another approach.
Lack of eye contact May reflect shyness,
depression, disinterest, or
mistrust
 e. Touch
Touch is a means of communication. An array of
feelings, including anger, caring, and protectiveness,
can be conveyed through touch.
As a Nurse:
We must touch patients in order to collect data. Gaining
your patient’s trust can help you obtain an accurate,
comprehensive health history. It can also make the
physical assessment quicker and easier for both of you.
larynx healthy because it contains your vocal folds,
or cords.
F. Bronchoscopy
Bronchoscopy is a procedure that lets doctors look
at your lungs and air passages. It's usually
performed by a doctor who specializes in lung
disorders (a pulmonologist). During bronchoscopy, a
thin tube (bronchoscope) is passed through your
nose or mouth, down your throat and into your lungs

2. Definition of the following diagnostic tests

A. ECG
Electrocardiogram: A recording of the electrical
activity of the heart. An ECG is a simple,
noninvasive procedure. Electrodes are placed on the
skin of the chest and connected in a specific order to
a machine that, when turned on, measures electrical
activity all over the heart. Output usually appears on
a long scroll of paper that displays a printed graph of
activity on a computer screen.

B. Stress test
A stress test measures how healthy your heart is
and how well it works during physical stress. Some
heart problems are easier to identify when your
heart is working hard to pump blood throughout your
body, such as when you exercise.

C. Echocardiogram
An echocardiogram (echo) is a graphic outline of the
heart's movement. During an echo test, ultrasound
(high-frequency sound waves) from a hand-held
wand placed on your chest provides pictures of the
heart's valves and chambers and helps the
sonographer evaluate the pumping action of the
heart.

D. Lung scan
A lung scan is an imaging test to look at your lungs
and help diagnose certain lung problems. A lung
scan may also be used to see how well treatment is
working. A lung scan is a type of nuclear imaging
test. This means that a tiny amount of a radioactive
matter is used during the scan

E. Laryngoscopy
A laryngoscopy is an exam that gives your doctor a
close-up view of your larynx and throat. The larynx is
your voice box. It's located at the top of your
windpipe, or trachea. It's important to keep your
 How Belief Systems Influence Healthcare
Belief system Significant beliefs and
symbols
Christianity
Roman Catholic ■ Important religious rites: baptism, holy
communion, and anointing of the sick.
■ Crucifix and rosary (beaded chain with
small crucifix) are important symbols.
Missal and Bible are important reading
materials.
■ Abstain from meat during Lent and other
holy days.
Eastern Orthodox ■ Practices same rites as Roman
Catholic and Anglican Church: baptism,
holy communion and anointing of the sick.
■ Orthodox cross has a diagonal cross bar
near the bottom of the upright bar and two
cross bars at the top. Wearing this cross is
important to the religious person.
■ Parishes are often established along
ethnic/national lines (e.g., Greek, Russian,
Ukrainian).
■ Church follows different liturgical
calendar, so most high holy days are
celebrated at different times than rest of
Christian world.
Episcopalian or Important religious rites: baptism, holy
Anglican communion, and anointing of the sick.
■ Both crucifix and plain cross are used.
Book of Common Prayer and Bible are
important reading materials.
■ Fast on high holy days and abstain from
meat on Fridays in Lent.
Other Protestant ■ Wide range of practices found among a
Denominations diversity of denominations (e.g., Baptist,
Pentecostal, Lutheran, Methodist).
■ A plain cross and Bible are symbols
common to almost all Protestant
denominations.
■ When practiced, baptism is usually
reserved for older children or adults. Holy
communion is practiced infrequently, if at
all.
■ Special prayers for sick are a more
common practice than anointing.
Jehovah’s Witness
■ Beliefs literally based on the
bible.
Christian Scientist
■ Believe that God is all good and
nothing that is real exists outside.
■ God, sin, sickness, and death seen
as mortal error or illusion.
■ Learning about body harms them
spiritually
Effects on health care
■ Modern healthcare accepted, but many rely on a
strong sense of faith for healing. Healing services
may be held.
■ Rites may be requested in the hospital as
needed. Stillborn or critically ill infants are baptized
as soon as possible after delivery.
■ Prayers for and by ill person are encouraged.
■ Presence of symbols often a source of comfort.
■ Opposed to abortion and most forms of birth
control.
Generally accepts modern healthcare.
■ Disapproves of birth control and strongly opposes
abortion.
■ Orthodox priest may be called on for blessings,
exorcisms, and direct healing.
■ Having religious symbols near is a source of faith
and comfort.
■ Organ donation is acceptable.
■ Similar to Roman Catholics.
■ Some Episcopal parishes practice healing by
“laying on of hands” and prayers of special
intention.
■ Rites may be requested in the hospital as
needed. Stillborn or critically ill infants are baptized
as soon as possible after delivery.
■ Prayers for and by ill person are encouraged.
■ Responsible family planning and free choice are
important. No sanctioned restrictions on birth
control or abortion.
■ Because there are many different denominations,
nurse must ask questions that address specific
religious practices that may affect patient’s health
and healthcare (e.g., dietary restrictions).
■ Use of prayers and healing by “laying on of
hands” varies. Strict Christian Scientists reject all
medical treatment and rely on prayer for healing.
■ Interpretation of biblical scripture within each
denomination determines acceptance of such
practices as blood transfusions, abortion, or organ
transplantation.
Believe that blood transfusions
and blood products are forbidden.
■ Organic disease does not exist,
disease is mental.
■ No understanding of signs or
symptoms.
■ Refuse or delays medical treatment.
■ Suffer needlessly, neglect lifethreatening
conditions.
Mormon
■ Believe physical body and spirit
make up soul.
■ Purpose on earth is to gain
experience and prove self worthy
to return and live with God.
Judaism
■ Encompasses three groups of
believers with different practices:
Orthodox (most traditional),
Reform (most liberal) and
Conservative (has elements of
both traditional and liberal
practices).
■ Common symbols are the Star of
David and the Torah, the first five
books of the Bible written on
scrolls. It contains guidelines for
life. A prayer book may be carried
for reading of special prayers.
■ Services held after sundown on
Friday and/or before sundown on
Saturday.
■ Male infants usually circumcised
at 8 days old in a religious
ceremony known as a bris.
■ Orthodox and some Conservative
Jews keep kosher dietary laws.
■ Men may wear a yarmulke, a small
skull cap. Cap is often worn in
temple by all men but may be
worn at all times.
Islam
■ Based on teachings of Mohammed.
■ In North America, adherents of
Islam may be either traditional
ethnic Muslims or members of the
Nation of Islam, a primarily
African American group.
■ The Qur’an (Koran) is the sacred
book of Islam. Many have a special
prayer rug that they carry.
Symbols vary, but generally
include a crescent moon in some
position.
■ Ritual prayer, five times a day
while kneeling and facing toward
Mecca (in Middle East) and specific
dietary restrictions are common to
all members.
■ Alcohol and pork are forbidden.
■ Many practice fasting during the
month of Ramadan.
■ Women dress in clothing that
hides the body
Hinduism
■ Caution against use of tobacco,
alcohol, tea, coffee.
■ Emphasize positive benefits of
good eating habits, physical and
spiritual fitness.
■ Misuse of drugs (illegal, legal,
prescription, or controlled) seen as
a violation of health code.
■ May affect compliance with
medical treatment plan.
■ Be sure to ask questions about diet
and religious practices, such as,
“Do you follow any dietary rules
that we should know about while
you are here in the hospital?”
■ Prayer is important to all groups.
■ Observation of Sabbath and other
holy days is important. Some
patients may refuse treatment on
those days or refuse to eat on
traditional days of fasting. Kosher
food is available in most hospitals.
■ Religious law provides for the
individual’s responsibility to stay
healthy, both physically and
mentally. Traditional medicine is
valued as well as prayer for relief
of suffering.
■ Organ transplants are allowed, but
donation of organs from dying
people is not permitted without
the donor’s consent.
■ Caregivers must be of the same
gender to protect modesty.
■ Women may continue to wear
traditional head scarf with or
without face veil while
hospitalized. Traditional hospital
gowns may be unacceptable.
■ Some have a fatalistic view of
health and may refuse treatment.
■ Islam has rituals related to all
aspects of life and death. Be aware
of these needs and show sensitivity
for the patient and family.
■ Medications that have an alcohol
base, such as elixirs and cough
syrups, may be unacceptable.
 ■ Ancient religion originating in
India. Many Indians now living in
North America continue to follow
their religion.
■ Universal symbol is the om symbol.
■ A major tenet is achieving a state
of oneness with the universe.
Prayer is important to achieve
oneness.
■ Many gods have power over the
individual. Religious shrines are
often erected in the home.
■ Killing any living creature is
forbidden, so many sects are
vegetarians
New Age
■ Although not a religion, this belief
system is growing in popularity.
■ Beliefs are borrowed from
Buddhism, Native Americans,
humanism, physics, and occultism,
among others.
■ Objects such as pyramids and
crystals are thought to impart
strength and healing energy.
■ There is great diversity of thinking,
but some common beliefs are that
all people are divine, right and
wrong are determined by the
individual, and reality can be
controlled.
Nonreligious
Agnostic ■ Believes that it is impossible to
know if God or other Supreme
Being exists.
Atheist ■ Does not believe in any God but
may have beliefs that are of the
spiritual dimension.
No Organized ■ People who believe in a Supreme
Religion Being that is unidentified may
avoid an organized religion but still
have spiritual beliefs and needs
■ Patients may want to set up a
small shrine in the hospital room.
■ Although the traditional sari is not
religion based, some women may
wish to wear it while in the
hospital. It is a long length of soft
cloth that is wrapped around the
body like a long skirt, with the
loose end draped over the head
like a scarf.
■ The belief in karma (unchangeable
fate) may influence the approach
to self-care and the seeking of
healthcare.
■ The crystal is a common symbol. It
is thought to impart healing
energy and may be rubbed over
the skin in close proximity to
diseased tissue. Nurses need to
recognize the crystal as a possible
belief object and not as jewelry.
■ No clergy, but several believers
may meditate with patient to
increase healing power. These
beliefs do not usually prevent the
patient from seeking traditional
therapies.
■ Diverse and individual influences
on healthcare.
■ Assess each patient individually.
■ Diverse and individual influences
on healthcare.
■ Must assess each patient
individually.
■ Diverse and individual influences
on healthcare.
■ Must assess each patient
individually.
Health Assessment-LEC/RLE STUDY NOTE: 5
NCM 201 | COLLEGE OF NURSING DATE: FEBUARY 24, 2021
SAN PEDRO COLLEGE TRANSCRIBER: PATHAY, ANTONIETTE

PERCUSSION NOTES
Resonant sounds Are low pitched, hollow sounds heard over
normal lung tissue.

Flat or extremely dull sounds Are normally heard over solid areas such as
bones.

Dull or thud like sounds
Are normally heard over dense areas such as the
heart or liver. Dullness replaces resonance when
fluid or solid tissue replaces air-containing lung
tissues, such as occurs with pneumonia, pleural
effusions, or tumors.

Hyperresonant sounds That is louder and lower pitched than resonant

sounds are normally heard when percussing the
chests of children and very thin adults.
Hyperresonant sounds may also be heard when
percussing lungs hyper inflated with air, such as
may occur in patients with COPD, or patients
having an acute asthmatic attack. An area of
hyperresonance on one side of the chest may
indicate a pneumothorax.

Tympanic sounds Are hollow, high, drum like sounds. Tympanic is

normally heard over the stomach but is not a
normal chest sound. Tympanic sounds heard
over the chest indicate excessive air in the chest,
such as may occur with pneumothorax.

Resonant sounds Are low pitched, hollow sounds heard over

normal lung tissue.