NCM 101 HEALTH ASSESSMENT

Course Description

This course deals with concepts, principles and techniques of history

taking, head to toe physical examination and psychological 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.

Class schedule: 3 Units (54 hours)

Set A Monday-Tuesday 7:30-9:00am

Southern Luzon State
University Brgy Kulapi,
Lucban Quezon
09156167882
Dear BSN 1
This module came out in this time of pandemic and is designed
to provide an overview and a practical understanding of the different
principles related to health assessment. To be used in addition to the
traditional book, this module provides a series of reflective questions to
prompt further discussion via online learning. Moreover, learning at a
distance may be a different environment for many of you. You will
generally set your own schedules and work at your own pace. It may be
difficult at first, but we need to adapt to the new situation, the new
normal.

OVERVIEW

This Health Assessment module forms the foundation of all nursing care. Assessment is a plan of care
that identifies the specific needs of a person and how those needs will be addressed by the skilled
nursing facility. Health assessment 01, provides an illustrated approach to the process of holistic
assessment, including health assessment, physical examination skills, clinical examination techniques,
and patient teaching guidelines.

This module is designed to teach readers to assess a patient’s physical, psychological, social,
emotional, cultural, spiritual, and nutritional dimensions of health as a foundation of nursing care. The
skills of interviewing, inspection, palpation, percussion, auscultation, and documentation are refined
to teach readers to make clinical judgements and promote positive patient outcomes.

This module composed of 3 units. The 1st unit composed of four modules, the 2nd unit composed of
seven modules, and the 3rd unit composed of 13 modules.

LEARNING OBJECTIVES

This course will provide the nurse with the knowledge needed to provide a complete health
assessment for an adult patient. After successful completion of this course, you will be able to:

1. Ask appropriate questions when conducting a comprehensive health history to elicit data that will
be used to guide a physical examination

2. List the components of the comprehensive physical examination and review of systems based on
red flags identified in the patient history

3. Determine when to perform four different types of health assessments, a. Complete or

comprehensive, b. Interval or abbreviated, c. Focused, d. Special populations

DISCUSSION

NURSING DATA COLLECTION, DOCUMENTATION, AND ANALYSIS

MODULE 1 NURSE’S ROLE IN HEALTH ASSESSMENT: COLLECTING AND

ANALYZING DATA

Learning Objectives
 1. Differentiate between a holistic nursing assessment and a physical medical assessment
2. List and describe the steps of nursing process
3. Compare and contrast the 4 basic types of nursing assessment
4. Describe the nurse’s role in assessment

Introduction to Health Assessment

Nursing – the protection, promotion, and optimization of health and abilities, prevention of
illness and injury; alleviation of suffering through the diagnosis and treatment of human responses
and advocacy in the care of individuals, families, communities, and populations” American Nurses
Association (2010).
Emphasis is placed on “diagnosis and treatment of human responses” based on “accurate
client assessment”, including how effective nursing interventions are “to promote health and
prevent illness and injury”
To accomplish this pertinent and comprehensive data collection, the nurse:
1. Collects data in a systematic and ongoing process
2. Involves the Patient, family, other health care providers, and environment, as appropriate, in
a holistic data collection
3. Prioritizes data collection activities based on the patient’s immediate condition, or anticipated
needs of the patient and situation
4. Uses appropriate evidence-based assessment techniques and instruments in collecting
pertinent data
5. Uses analytical models and problem-solving tools
6. Synthesizes available data, information, and knowledge relevant to the situation to identify
patterns and variances
7. Documents relevant data in a retrievable format
8. Derives the diagnosis or issues based on assessment data
9. Validates the diagnosis or issues in a manner that facilitates the determination of the expected
outcomes and plan

A. Overview of Nursing Process (ADPIE)

Health assessment is more than just gathering information about the health status of the
client. It is analyzing the data, making judgments about the effectiveness of nursing interventions,
and evaluating client care outcomes.

nursing process steps - Bing

Each step of the nursing process depends on the accuracy of the preceding step. Evaluation
involves examining all the previous steps, it especially focuses on achieving desired outcomes. The
arrow between assessment and evaluation goes in both directions because they are ongoing
processes as well as separate phases. When the outcomes are not as anticipated, the nurse needs to
revisit all the steps, collect new data, and formulate adjustments to the plan of care.