WELCOME TO

NCM 101j-J
NURSING HEALTH ASSESSMENT
SESSION 1

Jan Paolo M. Barandino, RN MAN

Professor
LEARNING OBJECTIVES
1. Discuss how nursing assessment skills are
needed for every situation the nurse
encounters
2. Differentiate nursing assessment and a
medical assessment
3. Describe which phases of the nursing process
involve assessment by the nurse
4. List and describe the steps of the nursing
process
5. Compare and contrast the four basic types of
nursing assessment
INTRODUCTION
Nursing is 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
HEALTH ASSESSMENT

Provides Identify the

foundation for
Evaluate
strength of responses of the
quality nursing clients in
care and promoting health
of the person to
intervention health problems
Identify client’s and intervention
needs and
clinical problems
NURSING PROCESS
The nursing process
consists of five dynamic
and interrelated phases:

1- ASSESSMENT
2- DIAGNOSIS
3- PLANNING
4- IMPLEMENTATION
5- EVALUATION
PHASES OF THE NURSING
PROCESS
PHASE DESCRIPTION
ASSESSMENT Collecting subjective and
objective data
DIAGNOSIS Analyzing subjective and
objective data to make a
professional nursing judgment
PLANNING Determining outcome criteria
and developing a plan
IMPLEMENTATION Carrying out the plan
EVALUATION Assessing whether outcome
criteria have been met and
revising the plan as necessary
ASSESSMENT
• FIRST and MOST
CRITICAL PHASE
• ON GOING and
CONTINUOUS
THROUGHOUT all
phases

… more than just gathering information about the health

status, it is analyzing and synthesizing that data, making
judgements about effectiveness of nursing interventions and
evaluating client care outcomes (AACN, 2008)
PURPOSE – Establish database
1- To collect data pertinent to the patient’s
health status- objective and subjective
2- To identify deviations from normal
3- To discover the patients strengths,
limitations and coping resources
4- To provide holistic care
5- To pinpoint actual problems
6- To spot factors that place the patient at
risk of health problems
7- To build rapport with patient and family
TYPES OF HEALTH
ASSESSMENT
INITIAL COMPREHENSIVE ASSESSMENT

ONGOING OR PARTIAL ASSESSMENT

FOCUSED OR PROBLEM-ORIENTED ASSESSMENT

EMERGENCY ASSESSMENT
TYPES OF HEALTH
ASSESSMENT
INITIAL COMPREHENSIVE ASSESSMENT

ONGOING OR PARTIAL ASSESSMENT

FOCUSED OR PROBLEM-ORIENTED ASSESSMENT

EMERGENCY ASSESSMENT
INITIAL COMPREHENSIVE
• Admission assessment
• Involves collection of subjective data about
the client’s perception of his or her health of
all body parts of systems, past health history,
family history, and lifestyle and health
practices and objective data gathered during
a step-by-step physical examination
TYPES OF HEALTH
ASSESSMENT
INITIAL COMPREHENSIVE ASSESSMENT

ONGOING OR PARTIAL ASSESSMENT

FOCUSED OR PROBLEM-ORIENTED ASSESSMENT

EMERGENCY ASSESSMENT
ONGOING OR PARTIAL
• Time-lapsed Assessment
• Consists of data collection that occurs after
the comprehensive database is established
• Consists of a mini-overview of the client’s body
systems and holistic health patterns as a
follow-up on health status
• To determine the status of a specific problem
identified in the earlier assessment and to
identify new or overlooked problem
TYPES OF HEALTH
ASSESSMENT
INITIAL COMPREHENSIVE ASSESSMENT

ONGOING OR PARTIAL ASSESSMENT

FOCUSED OR PROBLEM-ORIENTED
ASSESSMENT

EMERGENCY ASSESSMENT
PROBLEM-ORIENTED
• Focused-Oriented assessment
• Consists of a thorough assessment of a
particular client problem and does not
address areas not related to the problem
• Collects data about a problem that has
already been identified
• Determine whether problem still exists and
whether the status of the problem has
changed
TYPES OF HEALTH
ASSESSMENT
INITIAL COMPREHENSIVE ASSESSMENT

ONGOING OR PARTIAL ASSESSMENT

FOCUSED OR PROBLEM-ORIENTED ASSESSMENT

EMERGENCY ASSESSMENT
EMERGENCY
• Rapid assessment performed in life-
threatening situations
• Time is of the essence rapid identification of
and intervention for the client’s health
problems
• Major and only concern is to determine the
status of the client’s life-sustaining physical
functions
• EXAMPLE: A-irway B-reathing C-irculation
when cardiac arrest is suspected
STEPS OF ASSESSMENT
Collection of Subjective Data

Collection of Objective Data

Validation of Data

Documentation of Data
COLLECTION OF DATA
SUBJECTIVE Anything that cannot be verified, feelings, pain,
DATA sensation, symptoms
• Biographical Information
COVERT DATA • History of present health concern
• Personal health history
• Family history
• Health and lifestyle practices
OBJECTIVE Measured metric, observed using the 5 senses,
DATA observed using 4 physical examination techniques
• Physical characteristics, Appearance
OVERT DATA • Body functions
• Behavior, Measurements
• Laboratory Results
VALIDATION OF DATA
• PURPOSE: process of confirming or verifying that
the subjective and objective data are reliable
and accurate
• Steps include:
• Deciding whether the data require validation
• Determining ways to validate the data
• Identifying area for which data are missing
• Data requiring validation:
• Discrepancies or gaps between subjective and
objective data
• Discrepancies or gaps between what the client says
at one time versus the other time
• Findings that are highly abnormal and or inconsistent
with other findings
METHODS OF VALIDATION
✓ Recheck your own data through a repeat
assessment

✓ Clarify data with the client by asking additional

questions

✓ Verify the data with another health care

professional

✓ Compare your objective findings with your

subjective findings
DOCUMENTING DATA
• PURPOSE: promote effective communication
among multidisciplinary health team members
to facilitate safe and efficient client care. It
provides a legal record of a client’s care while in the
facility.

• Electronic Medical Record EMR VS Electronic Health

Record EHR
DIAGNOSING
• A process which results to a diagnostic statement or
NURSING DIAGNOSIS.
• It is the clinical act of identifying problems.
• To diagnose in NURSING, it means to ANALYZE
ASSESSMENT INFORMATION and derive meaning
from this analysis.
• PURPOSE: To identify the patient’s health care needs
and to prepare DIAGNOSTIC STATEMENTS.

• NURSING DIAGNOSIS is a statement of

patient’s POTENTIAL or ACTUAL ALTERATION of
health status. It uses critical-thinking skills of analysis
and synthesis.
DIAGNOSING
• NURSING DIAGNOSIS (NURSING DIAGNOSES) uses
the PRS/ PES format.
• Problem
• Related to factors
• Signs and Symptoms

• Problem
• Etiology (study of causation, or origination)
• Signs and Symptoms
DIAGNOSING
1. ORGANIZING DATA. Clustering facts into groups of
information.

EXAMPLE: Data about patient’s NUTRITIONAL

STATUS…
• Subjective Data:
• “ I have no appetite to eat.”
• “I feel dizzy most of the time.”
• “I feel nauseated”
• “Foods and fluids taste bitter.”
• “I feel weak and tired most of the time.”
DIAGNOSING
• Objective Data:
• Weight loss ( 2kilos in 2 weeks)
• Poor skin turgor
• Walks slowly and holds into furniture
• Cracked lips and dry mucous membrane
• RBC = 3 million/ cu mm (Low RBC count)
• Serum albumin level – 2.5 mg/dL (Low albumin)
DIAGNOSING
2. COMPARING DATA gathered during assessment
against standard.
• STANDARDS are accepted norms, measures or
patterns for purposes of comparison.
DIAGNOSING
3. ANALYZING DATA after comparing with standard.
• Passage of frequent watery stools may lead to
DEHYDRATION and loss of electrolytes (Na+ and K+)
• Pallor, dyspnea, weakness, fatigue indicate
inadequate oxygenation.
• Noisy breathing respiratory muscle weakness,
unable to cough up thick mucous secretions
indicate inability to clear airways.
DIAGNOSING
4. IDENTIFYING GAPS and INCONSISTENCIES IN DATA.
• EXAMPLE: Patient claims she is gaining too much
weight but actually is underweight.

5. DETERMINING THE PATIENT’S HEALTH PROBLEMS,

HEALTH RISKS AND STRENGTHS
• EXAMPLE: Inadequate nutrition
• EXAMPLE: Altered Body image

6. FORMULATING NURSING DIAGNOSES statements

What is the difference between a
NURSING diagnosis and a
MEDICAL diagnosis?
FORMULATING NURSING
DIAGNOSES STATEMENTS
 CORRECT: Acute Pain related to physical
exertion.
 INCORRECT: Acute pain related to Myrocardial
Infarction

 CORRECT: Ineffective breathing pattern related

to increased airway secretions
 INCORRECT: Ineffective breathing pattern
related to pneumonia
FORMULATING NURSING
DIAGNOSES STATEMENTS
 CORRECT: Anxiety related to lack of
knowledge about cardiac catheterization
 INCORRECT: Cardiac catheterization related to
angina

 CORRECT: Diarrhea related to food intolerance

 INCORRECT: Diarrhea related to colon cancer