H A-Lecture

BURI, JADE BSN 1-9 PRELIMS
B.
WEEK 1: OVERVIEW OF THE NURSING • These theorists were among the 1st to
PROCESS (ADPIE) use the Nursing Process and refer to a
series of phases describing the practice
of nursing.
NURSING PROCESS (ADPIE)
• Since then, various nurses have
• Is a systematic, rational method of described the process of nursing &
planning and providing individualized organized the phases in different ways.
nursing care. PHASES/STEPS OF THE NURSING

Purpose: PROCESS
1. To identify a client`s health status • The most current Scope and
& actual or potential health care Standards of Nursing Practice includes six
problems or needs (6) phases of nursing practice (ANA,
2. To establish plans to meet the 2010):
identified needs
3. To deliver specific nursing ✓ Assessment
interventions to meet those ✓ Diagnosis
needs
✓ Outcome identification
• The client maybe an individual, a ✓ Planning
family,
✓ Implementation
a community, or a group
• Is cyclical, ✓ Evaluation
• its components follow a logical The national licensure examination for

sequence, but more than one registered nurses (NCLEX), uses the
component maybe involved at one time. five phases:
• At the end of the 1st cycle, care maybe ✓ Assessment

terminated if goals are achieved, or the
✓ Diagnosis
cycle may continue with re-assessment,
or the plan of care maybe modified. ✓ Planning
✓ Implementation
• A systematic problem-solving Evaluation
approach used to identify, prevent & ✓
treat actual or
potential health problems & promote • These 5 phases are commonly used by
wellness
most of the nurses although nurses may
use different terms to describe the
• A systematic way to plan, implement &
phases
evaluate care for individuals, families,
or steps of the nursing process
groups and communities
• The term Nursing Process was ASSESSMENT

originated by Lydia Hall in 1955, and
ASSESSMENT/ASSESSING
Dorothy Johnson in 1959, Ida Jean Orlando
in 1961 and Ernestine Wiedenbach in • is a systematic & continuous collection,
1963. organization, validation & documentation
HEALTH ASSESSMENT DOCTOR A. CORPUS
LECTURE
B. data/information.
of
✓ Collect data
✓ Organize data
✓ Validate data
✓ Document data

LECTURE
B.
• The completeness and correctness of Subjective Data
the information obtained during
• Referred to as symptoms or covert data
assessment are directly related to the
accuracy of the steps in assessment
DATA COLLECTION/ COLLECT DATA
• Is the process of gathering

information about a client`s health
status.
• Must be both systematic & continuous

to prevent the omission of significant
data & reflect a client`s changing health
status.
•A Data Base contains all the

information about the client: nursing
health history, physical assessment,
primary care provider`s history & physical
examination, results of laboratory &
diagnostic tests and materials
contributed by the other health
personnel.
Sources of Data Collection
1. Primary sources Client is the

primary source of data
2. Secondary sources Family
members or other support
persons, other health
professionals, records & reports,
laboratory & diagnostic analysis,
relevant literature are secondary
or indirect sources.
• All sources other than the client are

considered secondary.
• All data from secondary sources should

be validated if possible.
• A complete Data Base provides a

baseline for comparing the client`s
responses to nursing & medical
interventions.
TYPES OF DATA

LECTURE
•B. Apparently only to the persons affected
& can be described or verified only by
that person
Example: itching, pain, feelings of worry
• Includes the client`s sensations,

feelings, values, beliefs, attitudes &
perception of personal health status
& life situation
Objective Data
• Referred to as the signs or overt data
• Are detectable by an observer or can

be measured or tested against an
accepted standard.
• Are observable and measurable and

are obtained through physical
examination and diagnostic test.
• This can be seen, heard & felt or smelled

& they frequently or rarely.
Example: Blood Pressure, Level of

Pain & Age
DATA COLLECTION METHODS

• Principal methods used to collect data:
✓ Observing/observation
✓ Interviewing/ interview
✓ Examining/Examination
• Observing occurs when the nurse is

in contact with the client or support
persons
• Interviewing is used mainly while

taking the nursing health history
• Examining is the major method used

in the physical health assessment
• Reality: nurses used all the three

methods simultaneously when
assessing clients
OBSERVING
• gather the patient`s data using the
senses

LECTURE
B.
• Is a conscious, deliberate skill that is 1. Directive Interview
developed through effort & with an
organizedapproach.
2 Aspects:
1. Noticing the data

2. Selecting, organizing & interpreting
the data
• Observing involves distinguishing of

data in a meaningful manner
• Nursing observations must be

organized so that nothing significant is
missed
• Most nurses develop a sequence in

observing events
Example: A nurse is visiting into the

client`s room & observes in the
following order:
1. Clinical signs of the client`s distress

(e.g., pallor or flushing, labored
breathing & behavior indicating
pain or emotional distress)
2. Threats to the client`s safety, real
or anticipated (e.g., lowered side
rails)
3. The presence of functioning of
equipment (e.g., intravenous
equipment & oxygen)
4. The immediate environment
including the people in it
INTERVIEWING
• Is a planned communication or
conversation with a purpose in order
to get information, identify problems
of mutual concern, evaluate change,
teach, provide support or provide
counselling or therapy.
Example: Nursing Health History- a part

of the nursing admission assessment
2 Types of Interviews
LECTURE
B. • Highly structured & elicit the hospital
specific information
• Use to gather & to give
information when time is
limited (e.g., in an emergency
situation)
2. Non-Directive Interview
or Rapport-
Building Interview
• allows the client to control
the purpose, subject matter
& pacing.
• Rapport: an understanding
between two or more people.
• A combination of directive & non-

directive approaches usually appropriate
during the information-
gathering interview
Types of Interview Questions

Closed Questions
• used in directive interview, are

restrictive
● generally, require only “yes or no”

or short factual answers that provide
specific information
• Often begins with “when, where, who,

what, do/did/does, or is/are/was.
Example: What medication did you take?

Are you having pain now?
Open-Ended Questions
• associated with the non-directive

interview, invite clients to discover &
explore, elaborate, clarify or illustrate
their thoughts or feelings.
• Specifies only the broad topic to be

discussed & invites answers longer
than one or two words.
• May begin with “what or how”
Example: How did you feel in the

situation? What made you come into

LECTURE
B.
Neutral Question
which data are to be reported
• a question the client can answer immediately & which data need only to be
without recorded at that time
direction or pressure from the nurse.
Example: How do you feel about that?

What do you think that led to the
operation?
Note: Details about the planning an

interview and stages of an interview: to
read and understand in Fundamentals
of Nursing
EXAMINING/EXAMINATION
• Physical examination/assessment is a
systematic data collection method that
uses observation (sense of sight,
hearing, smell & touch) to detect health
problems
• To conduct the physical examination,
the nurse uses techniques of inspection,

auscultation, palpation & percussion.
• Can be carried out systematically;

from head-to-toe approach or a body-
system approach.
• The cephalocaudal or head-to-toe

approach begins the examination at the
head, progresses to the neck, thorax,
abdomen, extremities and ends at the
toe
ORGANIZING DATA
● Nurses uses a written or electronic

format that organizes the assessment
data systematically
● This is referred to as a nursing health

history, nursing assessment, or nursing
DATA BASE form.
● The format maybemodified according to

the client`s physical status
● Nurses must make a judgment about

LECTURE
B.
● Data that reflect a significant
deviation from the normal would need
to be reported as well as recorded
• The act of “double checking or

VALIDATING DATA
verifying data” to confirm that it is
accurate & factual.
• The information gathered during

the assessment phase must be
complete, factual & accurate
because nursing diagnosis &
interventions are based on this
information
Validating data helps the nurse

complete the ff. tasks:
1. Ensure that
assessment
information is complete
2. Ensure that the objective
& subjective data agree
3. Obtain additional information
that may have been
overlooked
4. Differentiate between
cues&
inferences
Cues
Are subjective or objective data that

can be directly observed by the nurse.
What the client says or what the nurse

can
see, hear, smell or measure

Inferences
Are the nurse`s interpretation or

conclusions made based on the cues
Example:
• A nurse observes the cues that

an incision is red, hot &swollen
• The nurse makes an inference
that the incision is infected
HEALTH ASSESSMENT DOCUMENTATION/DOCUMENTING

DOCTOR A. CORPUS
LECTURE
DATA
B.
• Aims to describe the collected data to • the purpose of NANDA International is
make it easier to use, retrieved or manage. to define, refine & promote a taxonomy
of nursing diagnostic terminology of
• Accurate documentation is essential
general use to professional nurses.
& should include all data collected about
the client`s health status • Taxonomy is a classification system
or set of categories arranged based on
• Data are recorded in a factual manner &
a single principle or a set of principles.
not as interpreted by the nurse.
• Members of NANDA: staff nurses,
Example:
clinical specialist, faculty, directors of
• The nurse records the client`s nursing, deans, theorist & researchers.
breakfast intake (objective data)
• To use the concept of nursing
as “tea 200 ml, water 100 ml, 1
diagnosis effectively in generating &
pc. of egg & I slice of toast
completing a nursing care plan, the
bread” rather than “an appetite is
nurse
familiarmust
with be
the definition of terms
good”.
used & the components of nursing
DIAGNOSIS/DIAGNOSING diagnosis
• Is the second phase of the nursing diagnosis.

process
• Is a pivotal step in the nursing process
• the nurse will use his/her critical

thinking skills to interpret assessment
data & identify the client`s strength &
problems.
• The identification & development of

nursing diagnosis began formally in 1973
from the 2 faculty members of St.
Louis University & the National
Conference to identify nursing diagnosis
was sponsored by St. Louis University
School of nursing & Allied Health
Professions in 1973.
• In 1982, the conference group accepted

the name “North American Nursing
Diagnosis Association (NANDA)”,
recognizing the participation &
contributions of nurses in the United
States & Canada
• In 2002, the organization changed its

name to NANDA International to further
reflect the worldwide interest in nursing
LECTURE
B.
✓ Diagnosing: refers to the reasoning

process
✓ Diagnosis: is a statement or
conclusion regarding the nature of
the phenomenon
✓ Diagnostic Labels: is the
standardized NANDA names for the
diagnosis
✓ Nursing diagnosis: is the client`s
problem statement consisting of
the diagnostic label plus the
etiology (causal relationship

between a problem & its related or
risk factors)
✓ Nursing Diagnosis (official definition
from NANDA): a clinical
judgment concerning a human
response to health conditions/life
processes, or a vulnerability for that

response by an individual, family,
group or community.
✓ Nursing Diagnosis (NANDA-I, 2009):
A nursing diagnosis provides the
basis for selection of nursing

interventions to achieve outcomes

LECTURE
B.
for which the nurse has • These diagnosis labels begin with the
accountability. phrase: “Readiness for Enhanced, as in
Readiness for enhanced Nutrition”
This definition is consistent with the
following: Risk Nursing Diagnosis:
• Professional Nurse/Registered Nurse: • A clinical judgment that a problem does

not exist, but the presence of risk
✓ Responsible for making the nursing factors indicates that a problem is
likely to
diagnosis, even though other
nursing personnel may contribute develop unless nurses intervene.
data to the process of diagnosing &
Example: people admitted in the
may implement specified
hospital have some possibility of
nursing care.
acquiring an infection; however, a
✓ American Nurses Association client with diabetes or a
(2010) states that nurses are compromised immune system is
accountable for analyzing data to at higher risk than others.
determine diagnosis or issues.
The standard specifies that nurses • The nurse would appreciate to use the
✓ “Risk for Infection” to describe the
should use standardized client`s health status
classification systems when naming
Syndrome Diagnosis:
diagnosis
✓ Refers to the actuality or
• is assigned by a nurse`s clinical judgment
potentiality of the problem or to describe a cluster of nursing diagnosis
the categorization of the diagnosis that have similar interventions
as a health promotion diagnosis.
Components of NANDA Nursing
Kinds of Diagnosis according to
Diagnosis
status:
3 Components:
 actual diagnosis • Relates to client`s preparedness to
implement behaviors to improve their
 health promotion diagnosis
health condition
 risk nursing diagnosis
 syndrome diagnosis.
• Actual Diagnosis:
✓ Is a client problem that is present

the
at time of the nursing
assessment. Based on
the presence of
✓
• Example: Ineffective Breathing

Pattern; Anxiety
Health Promotion Diagnosis:

LECTURE
B.
1. The problem and it`s

definition (Diagnostic Label)
2. The etiology
3. The defining characteristics
• Describes the client`s health problem

or response for which nursing therapy
is given
• It describes the client`s health status

clearly & concisely in a few words
Purpose of Diagnostic level

to direct the formation of client goals
and
desired outcomes that may

suggest nursing interventions

LECTURE
B.
Example: Deficient knowledge DIFFERENTIATING NURSING DIAGNOSIS
(Medications) Deficient knowledge FROM MEDICAL DIAGNOSIS
(Dietary Adjustments)
Nursing Diagnosis:
• Qualifiers words that are added to some
• Is a statement of nursing judgment
NANDA labels to give meaning to the
& refers to a condition that nurses, by
diagnostic statement
virtue of their education, experiences &
Examples: Deficient (inadequate expertise are licensed to treat.
in amount, quality or degree; not
Medical Diagnosis:
sufficient; incomplete)
• Is made by a physician & refers to a
• Impaired (made worse, weakened,
condition that only a physician can
damaged, reduced, deteriorated)
treat
• Decreased (lesser in size, amount or
Collaborative Problems:
degree)
• Is a type of potential problem that
• Ineffective (not producing the desired
nurses manage using both independent &
effect)
physician-prescribed interventions.
• Compromised (to make vulnerable to
• Present when a particular disease or
threat) treatment is present, that each disease
Etiology (Related Factors & Risk Factors) or treatment has specific complications
that are always associated with it.
Identifies one or more probable causes of
the health problem, gives direction to the Nursing Diagnosis:
required nursing therapy, enables the
• Involves human responses which vary
nurse to individualize the client`s care.
greatly from one person to the others.
Defining Characteristics • Thus, nurses use nursing diagnosis
rather than collaborative problems
• Are the cluster of signs & symptomsthat since nursing diagnosis are more
indicate the presence of a particular individualized to a specific client &
diagnostic label. emphasize human responses to which
the nurse can independently take
• For Actual Nursing Diagnosis: the
actions
defining characteristics are the client`s
signs & symptoms
• For Risk Nursing Diagnosis: No

subjective & objective signs are present
• Thus, the factors that cause the client

betomore vulnerable to the problem form PLANNING
the etiology of a risk nursing diagnosis.
• Is a deliberative
• The list of NANDA defining • systematic of the nursing process that

characteristics are still being developed & involves decision making & problem-
refined solving.
LECTURE
B.
• In planning, the nurse refers to the 3. To decide which problems to focus
client`s assessment data & diagnostics on during the shift
statements for direction in formulating 4. To coordinate the nurse`s activities
client goals & designing the nursing so that more than one problem can
interventions required, to prevent, be addressed at each client contact
reduce
or eliminate the client`s health
problems. Discharge Planning
• Nursing Interventions: is any • The process of anticipating & planning

treatment for needs after discharge, is a crucial
based upon clinical judgment & part of a comprehensive health care
knowledge, that a nurse performs to
enhance patient/client outcomes plan &
should be addressed in each client`s care
Types of Planning plan
Initial Planning Developing Nursing Care Plans
• The nurse who performs the admission • The end product of the planning
assessment usually develops the initial phase of the nursing process is a “formal
comprehensive plan of care. or informal” plan of care.
• This nurse has the benefit to see the • Informal Nursing Care Plan: is a strategy
client`s body language & can also gather for actions that exists in the nurse`s
some intuitive kinds of information that mind.
are not available solely from the 2. To set priorities for the client`s care
written data base. during the shift
• Planning should be initiated as soon as

possible after the initial assessment
Ongoing Planning
• All nurses who work with the client

do
the ongoing planning.
• As nurses obtain new information &

evaluate the client`s responses to care,
they can individualize the initial plan
further
• Ongoing planning also occurs at the

beginning of a shift as the nurse plans
the care to be given that day.
• Using of ongoing assessment data,

the nurse carries out daily planning for
the following purposes:
1. To determine whether the client`s

health status was changed
LECTURE
B. Example: Mrs. Rex is very tired.
As a nurse, I need to reinforce
teaching after she is rested”
• Formal Nursing Care Plan: is a written

guide that organizes information about
the client` care.
• The most obvious benefit for a

formal written care plan is that it
provides for a continuity of care.
clients with common needs • Standardized Care Plan: Is a formal plan

that specifies the nursing care for group
Example: all clients with GERD of
problems
• Individualized Care Plan: Is tailored to

meet the unique needs of a specific
needs that are not addressed by the client-
standardized plan of care
THE PLANNING PROCESS

LECTURE
B.
• In the process of developing client • After choosing the appropriate nursing
care plans, the nurse engages in the interventions, the nurse writes them
following activities: on the care plan.
1. Setting priorities • Date nursing interventions on the care

2. Establishing client goals/ desired plan when they are written & review
outcomes regularly at intervals that depend on the
3. Selecting nursing interventions & individuals needs
activities
4. Writing individualized nursing IMPLEMENTATION/
interventions on care plans IMPLEMENTING
Setting Properties
• Is the action phase in which the nurse
• Is the process of establishing a performs the nursing interventions
preferential sequence for addressing
• Using the Nursing Interventions
nursing diagnosis & interventions
Classifications (NIC) terminology,
• The nurse & the client begin planning implementation consists of doing &
by
deciding which nursing diagnosis requires documenting the activities that are the
attention first, which is second & so specific nursing actions needed to carry
on.
• Instead of rank ordering diagnosis, out the interventions
nurses can group them as having high, Process of Implementation
medium or low priority.
Reassessing the client
Establishing client goals/desired
• Before implementing an intervention,
outcomes
the nursemust reassess the client to
• After establishing priorities, the nurse & makethe intervention is still needed
sure
the client set goals for each nursing
diagnosis
• Even though an order is written in the
• On a care plan, the goals/desired care plan, the client`s condition may
outcomes describe, in terms of have changed
observable client responses, what the
nurse hopes to achieve by implementing Example
• A client with a diagnosis of
the nursing interventions
“Disturbed Sleeping Pattern
Selection nursing interventions related to anxiety & unfamiliar
surroundings”.
• The specific nursing interventions
• During the nurse`s rounds, the
chosen should focus on eliminating or
discovers that the client is
reducing the etiology of the nursing
sleeping & therefore defers the
diagnosis, which is the second clause of
back massage that have been
the diagnostic statement
planned as a relaxation
strategy
Writing individualized nursing
interventions
Determining the nurse`s need for
assistance
LECTURE
B.
• When implementing some nursing determine on reassessment of the client
interventions, the nurse may require on the interventions being
assistance for one or more of the implemented
following reasons: EVALUATIO
N
1. The nurse is unable to implement • Is a planned, on-going, purposeful
the activity safely or efficiently activity in which clients & health care
alone (e.g., ambulating an obese professionals determine
client)
2. Assistance would reduce stress on ✓ the client`s progress towards
the client (e.g., turning a patient achievement of goals/outcomes and
who experiences pain when ✓ the effectiveness of the nursing
moving) care plan.
3. The nurse lack of knowledge or
skills to implement a particular • Is an important aspect of the nursing
nursing activity (e.g., a nurse who process because conclusions drawn from
is not familiar on a particular an evaluation determine whether the
equipment should need assistance nursing interventions should be
the first time it is applied terminated, continued or changed.
Implementing the nursing interventions • The nurses evaluate progress towards
• It is important to explain to the client attainment of outcomes.

what nursing interventions will be done, • Through evaluation, nurses demonstrate
what sensations to expect, what the responsibility & accountability for their
client is expected to do & the expected actions, indicate interest on the results
outcome. of the nursing activities, &
demonstrates
desire not to perpetuate ineffective
• This activity involves scheduling client
actions but to adopt more effective ones.
contact with other departments like
laboratory & x-ray technicians, physical
WEEK #2: HEALTH
& respiratory therapist
ASSESSMENT IN NURSING
Supervising the delegated care
• Once care has been delegated to other
health care personnel, the nurse is PRACTICE
responsible for the client`s overall care. TYPES OF HEALTH
ASSESSMENT
• The nurse must ensure that INITIAL COMPREHENSIVE ASSESSSMENT
Documenting nursing activities
• Describes in detail the client`s medical,
• After carrying out the nursing activities, physical & psychosocial conditions &
the nurse has completed the needs
implementation phase by recording
• Also called as an “admission
the interventions & client`s responses in assessment ” when the client enters
which is perform
the progress notes.
the hospital/health care facility
• Nursing care must be recorded in
advance because the nurse may Purpose:
LECTURE
B.
• To evaluate the client`s health status

LECTURE
B.
• To identify functional health • Excretory problems like incontinence,
patterns that are problematic constipation, diarrhea & urinary retention
(Gordon`s Health Patterns) may be identified.
• To provide an in-depth comprehensive

data base needed for evaluating
changes in the client`s health status in
the succeeding assessments.
GORDON`S FUNCTIONAL HEALTH

PATTERNS
Health Perception-Health Management

Pattern
• Data collection is focused on the

client`s perceived level of health &
well-being & practices in maintaining
health.
• E.g., patient`s opinion about health,

Immunization history, any allergies
(specific allergies, past surgeries (type
of surgery), last physical exam &
reason, current medicines taken &
knowledge on the actions of the
medicines taken
Nutritional-Metabolic Pattern
• Assessment focused on the pattern of

food & fluid consumption relative to the
metabolic need & pattern indicators of
nutrient supply
• Actual or related problems to fluid

balance, tissue integrity & gastro-
intestinal system
• E.g., asking on the condition of the skin,

scalp & nails, diet, any food
restrictions related to a disease
condition, any food that the patient
like or dislike
Elimination Pattern
• Data collection focused on the

excretory patterns (bowel, bladder,
skin).

LECTURE
•B. E.g., color of urine, amount,
frequency, odor & any discharge;
urinary problems (dysuria, anuria,
polyuria); if using laxatives & if has
problem during passing defecation
Activity & Exercise Pattern
• Assessment is focused on the

activities of daily living including self-
care activities, exercise & leisure
activities.
• The status of the major systems

involved with activity is evaluated
including respiratory, cardiovascular, &
Musculo- skeletal system.
• E.g., asking of any breathing

problem (apnea, hypoxia), presence of
cough (productive/non-productive),
any changes in heartbeat during
exercise, type
of exercise did the patient did or any

problem during exercise
Cognition & Perception Pattern
• Assessment is focused on the ability

to comprehend &use of information on the
sensory functions.
• Data pertaining to neurologic functions

are collected to aid this process
• Sensory experiences like pain &

altered sensory maybe identified &
further evaluated.
• E.g., orientation about time & place,

any difficulty in making a sentence &
loss of memory.
Sleep & Rest Pattern
• Assessment is focused on the persons

sleep, rest & relaxation practices.
• Dysfunctional sleeping pattern, fatigue

& responses to sleep deprivation
maybe identified.
LECTURE
B.
• E.g., bedtime, nap during daytime, • Assessment is focused on the person`s
feeling after waking up (fresh, perception of stress and the coping
headache, drowsy), any medications strategies.
taken for sleeping, any exercise or
• Support systems are evaluated &
walking at night
symptoms of stress are noted.
Self-perception & Self-Concept Pattern
• The effectiveness of a person`s
• Assessment is focused on the coping strategies in terms of stress
person`s
attitudes towards self-including identity, tolerance maybe further evaluated.
body image & sense of self-worth.
• E.g., If you have stress then what is
your coping mechanism towards stress,
• The person`s level of self-esteem &
asking the client on their opinion on
response to threat to his/her self-concept
crying, angry & violence
maybe identified.
Values & Belief Pattern
• E.g., asking the patient on their own
self- perception about themselves, • Assessment is focused on the person`s
satisfaction of self-body image, asking if values & beliefs including spiritual
beliefs,
goals that guide his/her decisions.
the patient likes grooming.
Roles & Relationship

• Assessment Pattern
is focused on the person`s • E.g., asking on the religion of the patient,
roles in the world & relationships with & if always offering a prayer daily.
others.
ON-GOING OR PARTIAL ASSESSMENT
• Satisfaction with roles, role strain or
dysfunctional relationships maybe further Another type of assessment that takes
evaluated. place after the initial assessment to
evaluate any changes in the client's
• E.g., asking the patient on his/her role functional health.
in the family, does all family members
are cooperative with the patient, who Consist of mini-overview of the client`s
is the decision maker in the family. body systems & holistic health patterns
of
follow-up on the client`s health status
Sexuality & Reproductive Pattern
Nurses performed this type of assessment
• Assessment is focused on the when substantial periods of time have
person`s
satisfaction or dissatisfaction with elapsed between assessment (e.g.,
sexuality patterns & reproductive
periodic output patient`s clinic visits,
functions. home health visits, health & development
screenings)
• Concerns with sexuality maybe
identified FOCUS OR PROBLEM-ORIENTED
ASSESSMENT
• E.g., when was the 1st menses
(menarche) noticed, any sexual
• Collects data about a problem that has
problem, if sexual needs is active, if has
already been identified
problems with infertility.
Coping & Stress Tolerance Pattern

LECTURE
B.
• This type of assessment has a independently by nurses to arrive at
narrower
scope with a shorter time frame than professional clinical judgments
the initial assessment concerning the client`s health.
The nurse determine whether the
•
• Advances in technology have expanded
problem still exists, or the status of
the role of assessment and the
the
development of managed care has
• this includes the appraisal of the increased the necessity of assessment
new, overlooked or misdiagnosed skills.
problems.
• Expert clinical assessment and
• ICU: nurses may perform focus or informatic skills are absolute necessities
problem-oriented assessment every for the future as nurses continue to
few minutes to monitor changes of expand their role in all health care
the patient`s condition settings
EMERGENCY ASSESSMENT
ROLES & FUNCTIONS OF THE
• Happened inlife-threatening situations
in which the preservation of life of
NURSE
the
Caregiver
patient is the top priority.
•
Often the client`s difficulties traditionally included those activities that
airway, breathing & circulatory
problems assist the clients physically and
• Abrupt changes in self-concept psychologically while preserving the
(suicidal thoughts), role or client`s dignity.
relationships (social conflicts leading
• The required nursing actions may
to violent acts) can also initiate an
involve a full care of the completely
emergency assessment.
dependent client, partial care for the
• EA focuses on a few essential health
partially dependent client and
patterns & is not comprehensive
supportive- educative care to assist
clients in attaining their highest possible
NURSES` ROLE IN HEALTH
level of health & wellness.
ASSESSMENT
Nurse`s role in health assessment • Caregiving encompasses the physical,
• psychosocial, developmental, cultural &
has changed significantly over the spiritual levels
years.
• In 21st century, the nurse`s role in • The nurse may provide direct care or
assessment continues to expand, delegate it to other caregivers
becoming more crucial than ever
Communicator
before.
• The role of the nurse in health • Communication is integral to the nursing
assessment has expanded drastically roles
from the days of Florence Nightingale
• In the role of a communicator, the nurse
when the nurse uses the sense of sight
touch & hearing to assess clients

LECTURE
B.
• Today communication and physical identify client problems & communicate

these verbally or in writing to other
assessment techniques are used members of the health care team.

LECTURE
B.
• The nurse must be able to communicate difficulties & focuses on the helping the
clearly & accurately in order for a client`s person develop new attitudes, feelings &
health care needs to be met behaviors by encouraging the client to
look at alternative behaviors,
Teacher
recognize the choices & develop a sense
• The nurse helps clients learn about of control.
their & the health care procedures they
health
Change Agent
need to perform to restore or maintain
• This can be happened when a nurse is
their health. assisting clients to make facial s in their
behavior.
• The nurse assists the clients' learning
needs & readiness to learn, sets • Nurses also often act to make change
specific learning goals in conjunction in a system, such as clinical care, if it is
with
client,theenacts teaching strategies & not helping a client return to health.
measures learning.
• Nurses are continually dealing with
• Nurses also teaches unlicensed change in the health care system
assistive personnel to whom they
Example: Technological change,
delegate care & share their expertise
change in medications are just a
with other nurses & health professionals
few changes nurses deal with
Client Advocate daily
Leader
• Acts to protect the client
• influence others to work together to
• In this role, the nurse may represent accomplish a specific goal.
the
client`s needs & wishes to other health
professionals, such as relaying the • The role can be employed at different
client`s levels: individual, client, family, groups
request for information to the health care
of clients, colleagues or the community.
provider
• Effective leadership is a learned process
• They also assist clients in exercising their
requiring an understanding of the needs &
rights & help them speak up for
goals that motivate people, the
themselves. knowledge to apply leadership skills & the
Counselor interpersonal skills to influence others
• Counseling is the process of helping the Manager

client to recognize & cope with stressful
• nurse manager delegates nursing
psychological or social problems, to
activities to ancillary workers & other
develop improved interpersonal
nurses, supervises & evaluates their
relationships & to promote personal • The nurse counsels primarily healthy
performance.
growth. individuals with normal adjustment
• It involves providing emotional,

intellectual, & psychological support.
LECTURE
B.
• Managing requires knowledge about

organizational structure &
dynamics,
authority & accountability,

leadership, change theory,
advocacy,
delegation,
supervision & evaluation

LECTURE
B.
Nurse Care Manager Collection of Subjective Data through
Interview & Health History
• Works with the multidisciplinary health
care team to measure the Biographic Data

effectivenessof the case management
outcomes. • Usually includes information that
plan & to monitor
identifies the client such as his/her
• In some institutions, the case manager name, address, phone number, gender
works with staff nurses to oversee the provided
and who the information (client or
care
of a specific caseload significant others)
• The client`s birth date, PH/SSS number,

• In other agencies, the nurse case
hospital number or similar identifying
manager is the primary nurse that
data may be included in the biographic
provides some level of direct care to the
data section.
client & the family
• When students are collecting the
• Regardless of the setting, nurse
information & share it with their
care managers help ensure that care
instructors, address & phone numbers
is oriented to the client, while
should be deleted & initials will be use on
controlling costs.
the name of the patient to protect the
client`s privacy
Research Consumer
• The client`s culture, ethnicity or
• Nurses often use research to improve
subculture may be collected by asking the
client care
date & place of birth, nationality, marital
• In a clinical area, nurses need to have: status, religion & languages spoken if
foreign nationals
1. Some awareness on the process
& language of research ✓ This information helps the nurse
2. Be sensitive to issues related to
examine special needs & beliefs
protecting the rights of human
that may affect the client or
subjects
family`s health care.
3. Participate in the identification of
significant research problems • Gathering informationabout the client`s
4. Be a discriminating consumer of educational level, occupation & working
research finding status will assist the nurse &examiner to
tailor questions to the client`s level of
Expanded Care Roles understanding.
• Nurses are fulfilling expanded career REASONS FOR SEEKING HEALTH CARE
roles such as those of NP (Nurse
Practitioner) clinical nurse specialist, Two questions included in this category:
nurse midwife, nurse educator, nurse 1. What is your current major
researcher & nurse anesthetist, all of health problem?
which allow a greater independence &
2. How do you feel about having to
autonomy
seek health care?
STEPS OF HEALTH ASSESSMENT
LECTURE
B.
• The 1st question What is your current problems, surgeries, pregnancies,
major health problem? assists then client previous accidents, injuries, pain
to focus on his/her most significant experiences and emotional or
health concern & answers the nurse`s psychiatric problems.
question,
• The information gathered from these
“Why are you here” “How can I help questions assists the nurse to identify
you” the
risk factors to the client as well as the
• The physicians call this as the “Client`s significant others
chief complaint (CC), but a more holistic FAMILY HEALTH HISTORY
approach for phrasing the question may
draw out concerns that reach beyond
just
a physical complaint & may address
stress
• As researchers discover more & more
or lifestyle changes
• The 2nd question, “how do you feel health problems that seem to run in the
families & are genetically based, the
about having seeking health care?”, can family health history assumes greater
encourage the client to discuss fears or importance.
other feelings about having to see a
• The family health history should
health care provider.
include as many genetic relatives as the
• This question may also draw out client can
recall.
descriptions of previous experiences–

both positive & negative
• It includes the maternal & paternal,
grandparents, aunts & uncles on both
HISTORY OF PRESENT ILLNESS sides, parents, siblings & the client`s
children
• This section of health history considers
several aspects of the health problem & CURRENT MEDICATIONS
ask questions whose answers can provide
a detailed description of the health • Gathering of information about the
concern. medications taken which can provide
the nurse with information concerning
• The nurse encourages the client to
medications that the patient has
explain the health problem or symptoms
taken.
focusing on the onset, progression, &
LIFESTYLE
duration of the problem; signs & • This is a very important section of the
symptoms & related problems & what health history because it deals with the
the client`s perceives as causing the client`s human responses which includes
problem
PAST HEALTH HISTORY
• At this point, the nurse asks questions the present).

related to the client`s past health
• Information covered in this section
history (from the earliest beginnings to
LECTURE
development, childhood diseases,
immunizations, allergies, previous health
nutritional habits, activity & exercise,
BURI, JADE BSN 1-9sleep & rest patterns, use of medications
PRELIMS
B.
includes questions about birth, growth, & substances, self-concept & self-care
activities, social & community activities,
relationships, values & beliefs, education
& work, stress level & coping styles &
environment.
• Be sure to pay attention on the cues the

client may provide that point to
possibly more significant content

LECTURE
B.
• Take brief notes so that pertinent data A complete nursing assessment includes
are not lost & so that there can be a both the collection of subjective data
follow-up if some information needs and the objective data.
clarification.
OBJECTIVE DATA
DEVELOPMENTAL LEVEL
• Includes information about the client
• Determining the client`s developmental that the nurse directly observes during
level is essential to complete the client`s interaction with the client or information
portrait that is elicited through physical
examination (examination) techniques.
• The nurse will group & analyze the data
obtained during the health history & • To become proficient with physical
compare them with the normal assessment skills, the nurse must have
developmental parameters basic knowledge in the three areas:
Example: Height, weight, Erickson`s 1. Preparation

Psychosocial Developmental 2. Positioning
Stages 3. Techniques
PSYCHOSOCIAL HISTORY
PREPARATION
• Psychosocial history covers many
aspects of the patient`s life PREPARING THE CLIENT:

• The information gathered includes • Most patients need an explanation of
areas the physical examination
related to psychological or mental
health,
social history & many other factors such • Clients are often anxious about what
as health, employment, finances, the nurse will find during the physical
education, assessment
religion, stress & support system including
• The nurse should explain when & where
friends and family.
the examination will take place, why it
SUMMARY is important & what will happen.
• Collecting subjective data is a key step of • Instruct the client that all information
nursing health assessment gathered & documented during the
assessment is kept confidential (only
• Subjective data consists of information
elicited & verified only by the client health care providers know the client`s
information & have the access to it).
• Interviewing is the means by which
subjective data are gathered • Health examinations are painless, the
nurse need to determine in advance the
• The complete health history is positions that are contra indicated for a
performed to collect as much subjective particular client.
data about a client is possible
• The nurse assist the client as needed to
WEEK #4-5 COLLECTION OF undressand put on a gown.
OBJECTIVE DATA • Clients should empty their bladder
before the examination to help them
HEALTH ASSESSMENT feel DOCTOR A. CORPUS
LECTURE
B.
more relax & facilitates palpation of • It is important to consider the client`s
the abdomen & pubic area. ability to assume a position
• If UA is required, the urine should be • Clients physical condition, energy level

collected in a container for that purpose ang age should be taken into
consideration
• The sequence of assessment differs
with children & adults • Some positions are embarrassing &
uncomfortable, therefore should not be
• Children, always proceed from the least maintained for a long period of time.
invasive or uncomfortable aspect of
the
• The assessment should be organized
exam.to the more invasive.
so that several body areas can be
• Examination of the head & neck, heart assessed in one position, thus minimizing
& & range of motion (ROM) can be
lungs the number of position changes needed
done early in the process, with the Draping:

ears, mouth, abdomen & genitals being
• Draping should be arranged so that
left for the end of the examination
areas to be assessed is exposed & other
PREPARING THE ENVIRONMENT: body areas are covered.
• It is important to prepare the
environment before starting the • Drapes provide not only a degree of

assessment. privacy but also warmth.
• The environment needs to be well INSTRUMENTATION

lighted & the equipment should be
organized for efficient • All instruments needed for the health
use assessment must be ready for use, clean,
• The room should be warm enough to be in good working condition & readily
comfortable for the client • Several positions are frequently
required during the physical assessment.
• Providing privacy is important. Most
people are embarrassed if their bodies
are exposed or if others can hear or
view
them during assessment
• Culture, age & gender of both the

& client
the nurse influenced how comfortable
the client will be & what special
arrangements might be needed.
Example: Client & the nurse are

of different genders, the nurse
should ask if is it okay for the
patient to pursue on the physical
assessment
POSITIONING
LECTURE
B.
accessible.
• Equipment is frequently set-up on

trays & ready for use
Examples: GLOVES (for all

examinations)- protection for
any part of examination when
the examiner may have contact
with blood, body fluid,
secretions, excretions and
contaminated items or disease-
causing agents could be
transmitted to or from the
agent.
FOR VITAL SIGNS TAKING

Sphygmomanometer: measure the BP of
the patients
Stethoscope: auscultate blood

sounds when measuring
BP

LECTURE
B.
Thermometer: measure body Penlight: provide light to view the mouth
temperature & throat & transilluminate the sinuses
Watch with second hand: time the heart Tongue Depressor: depress tongue to
rate, pulse rate view throat, check looseness of teeth,
view cheeks & check strength of tongue
ANTHROPOMETRIC MEASUREMENT:
Piece of small gauze: grasp tongue &
Flexible Tape Measure: measure the mid-
examine the mouth
arm circumference
Otoscope w/ wide-tip attachment: view
Platform scale w/ height attachment:
the internal nose
measure the height & weight
• Other equipment needed during
SKIN, HAIR & NAIL EXAMINATION:
physical assessment
Ruler w/ cm. markings: measure the size
TECHNIQUES
of skin lesions
FOUR PRIMARY TECHNIQUES IN
Magnifying glass: enlarge visibility of
PHYSICAL EXAMINATION:
lesion
1. Inspection
HEAD & NECK EXAMINATION:
Small cup of water: help client swallow 2. Palpation

during examination of the thyroid gland 3. Percussion
EYE EXAMINATION: 4. Auscultation

LECTURE
B.
Penlight: test the pupillary constriction INSPECTION
Snellen Chart: test the distance vision • Is the visual examination, by assessing
using the sense of sight
Ophthalmoscope: examine the retina of
the eye • Should be deliberate, purposeful &
systematic
Cover card: test for strabismus (abnormal
alignment of the eyes) • The nurse inspect with the naked eye &
with a lighted instrument such as an
Newspaper/Rosenbaum Pocket Screener:
otoscope (to view the ear).
test the near vision
• In addition to visual observations,
EAR EXAMINATION:
olfactory (smell) and auditory (hearing)
Otoscope: view the ear canal & tympanic cues will not be noted
membrane
• Visual inspection are frequently use to
Tuning Fork: test for bone & air assess moisture, color & texture of body
conduction of sound surfaces as well as shape, position, size,
color & symmetry of the body.
MOUTH, THROAT, NOSE, SINUS
EXAMINATION: • Lighting must be sufficient for the

nurse to see clearly, either natural or
artificial
light can be used

LECTURE
B.
• When using auditory senses, it is • Is usually not done during a routine
important to have a quite environment
for
accurate hearing. examination &requires a significant
practitioners' skills
• Inspection can be obtained with • It is performed with extreme cautions

other
assessment techniques. because pressure can damage the
internal organs
PALPATION
• It is usually not indicated in clients who
• Is the examination of the body using have acute abdominal pain or pain that
the sense of touch is
not yet diagnosed
• The pads of the fingersare used
because
their concentration of nerve endings several times rather than holding the
makes them highly sensitive to tactile pressure.
discrimination
Deep palpation
• Palpation is used to determine the
following:
✓ Texture of the hair
✓ Temperature of the skin
✓ Vibration of a joint
✓ Position, size, consistency &
mobility of organ masses
✓ Distention of the urinary bladder
✓ Pulsation
✓ Tenderness or pain
2 TYPES OF PALPATION:
Light (superficial)palpation
• should always precede deep palpation

because heavy pressures on the
fingertips
can dull the sense of touch
• For light palpation, the nurse extends

the dominant hand`s fingers parallel to
the skin surface & presses gently while
moving the hand in a circle.
• With light palpation, the skin is slightly

depressed
• If it is necessary to determine the details

of a mass, the nurse presses lightly
LECTURE
•B. Is done with two hands (bimanually) or
one hand
In deep bimanual palpation, the nurse

extends the dominant hand as for light
palpation, then places the finger pads
of the non-dominant hand on the
dorsal surface of the distal
interphalangeal joint of the middle
three fingers of the
dominant hand
• The top hand applies pressure while
the lower hand remains relaxed to
perceive the tactile sensations
• For deep palpation using one hand,

the finger pads of the dominant hand
press over the area to be palpated,
often the other hand is used to support
from below.
PALPATING THE SKIN TEMPERATURE:
• It is best to use the dorsum (back) of

the hand and fingers, where the
examiner`s skin is thinnest.
TESTING FOR VIBRATION:
• The nurse should use the palmar

surface of the hand
GENERAL GUIDELINES FOR PALPATION:
• The nurse hands should be clean

& warm, & the finger nails short
• Areas of tenderness should be

palpated
last

LECTURE
B.
• Deep palpation should be done after hand (plexor, the nurse strikes the
superficial palpation. pleximeter, usually at the distal &
proximal joints.
• The effectiveness of palpation
depends
largely on the client`s relaxation. • The striking motion comes from the
wrist, the forearm remains stationary.
• Nurses can assist the client to relax by: The angle between the plexor &
the
1. Gowning or draping the client pleximeter should be 90 ,̊̊ & the blows
appropriately must be firm, rapid & short to obtain a

2. Positioning the client comfortably clear sound.
3. Ensuring that their own hands are
• Percussion Is used to determine the size
warm before beginning the
& shape of internal organs by
palpation establishing
• During palpation, the nurse should be their borders.
sensitive to the client`s verbal & facial PERCUSSION ELICIT 5 TYPLES OF
expressions indicating discomfort Flatness is an extremely dull sound
produced by very dense
PERCUSSION
Dullness is a thud like sound produced
• Is the act of striking the body surface to
by dense tissue such as liver, spleen or
elicit sounds that can be heard or heart
vibrations that can be felt
Resonance is a hollow sound such as
2 TYPES OF PERCUSSION:
that produced by lungs filled with air
Direct Percussion
Hyperrensonance is not produced in the
• The nurse strikes the area to be normal body, prescribed as booming &
percussed directly with the pads of two, can be heard over an emphysematous
three or four fingers or with the pad of lung.
the
middle finger
Tympany musical/ drum like sound
• The strikes are rapid & the movement is produce from an air filled stomach
from the wrist. (distended bowel) lungs. (emphysema
or pneumothorax)
• This technique is not generally used to
percuss the thorax but is useful in AUSCULTATION
percussing an adult sinuses • Is the process of listening to sounds
produced within the body
Indirect Percussion
• May be direct or indirect
• Is the striking of an object (e.g., finger)
DIRECT AUSCULTATION
held against the body area to be
examined • is performed using the unaided ear
• In this technique, the middle finger of • E.g., listening to a respiratory wheeze
the nondominant hand (pleximeter) is or grating of a moving joint.
placed firmly on the client`s skin. Only the
distal phalanx & joint of this finger should be in contact with the skin. Using
LECTURE
B.
the tip INDIRECT AUSCULTATION
of the flexed middle finger of the other

LECTURE
B.
• performed using a stethoscope, which • X-ray imaging creates pictures of the
transmit sounds to the nurses` ears inside of the human body.
• Stethoscope is used primarily to listen • The images shows part of the body in
to sounds from within the body such as different shades of black and white.
bowel sound or valve sounds of the
• Used to evaluate the structure of bones
heart
&the blood pressure.
& soft tissues
• Auscultated sounds are described

according to their pitch, intensity, • The patient is placed between an x-ray
machine and specia ly treated film
duration & quality.
• Gamma rays created in the x-ray
1. PITCH
machine pass through the patient`s
• is the frequency of the
body
vibrations (the number of
vibrations per second). • Different internal structures absorb the
• Low-pitch sounds such as x-rays in varying amounts, which results
heart sounds- have fewer in shadows of varying shades of gray
per second than high-pitch
vibrations being cast on the film.
sounds such as bronchial
sounds. CHEST X-RAY
2. INTENSITY • Is a projection radiograph of the chest

• (amplitude) refers to the used to diagnosed conditions affecting the
loudness or softness of a chest, its contents, and nearby
sound. structures.
• Some body sound are loud Purpose:
(e.g., bronchial sound heard
from the trachea) ✓ Assess the lung fields
• Others are soft (e.g., normal ✓ cardiac borders

breath sounds heard in the
✓ large arteries,
lungs)
3. DURATION ✓ clavicle
• of a sound is it`s length (long or ✓ ribs
short)
✓ diaphragm & mediastinum
4. QUALITY
• of sound is a subjective ✓ Diagnose pulmonary or cardiac
description of a sound (e.g., disorders including heart failure
whistling, gurgling or ✓ COPD
snapping sound).
✓ Pneumonia
DIAGNOSTIC TEST AND ✓ TB
PROCEDURES ✓ neoplastic disease
X-RAY ✓ Evaluate placement of feeding

tubes
✓ chest tubes
LECTURE
B. wires
✓ central venous
catheters pacemaker ✓ endotracheal tubes
• called electromagnetic waves. BASIC POSITIONS FOR CHEST X-RAY
AP (ANTERIOR-POSTERIOR)

LECTURE
B.
• X-ray passes through the patient from Procedure:
front to back.
✓ The patient may stand or sit or
PA (POSTERIOR-ANTERIOR)
lie on the x-ray table depending
• X-ray passes through the patient from upon the anatomic part being
back to front. JOINT studied
X-RAYS
BASIC POSITIONS FOR X-RAYS • Plain films of a joint or joints (hip, knee,
LATERAL shoulder, elbow, ankle, wrist joints in

the feet & hands)
• Patient is positioned on either side
Purpose:
and so that the x-ray passes from one
side of
the body through the other side (right ✓ Assess fracture, infection, cyst,
lateral or left lateral). tumor, degenerative diseases.
OBLIQUE Procedure:
• x-ray is angled between PA and lateral

✓ The patient lies on the x-ray table
positions. while various views of the joints
ABDOMINAL X-RAY are taken.
COMPUTED TOMOGRAPHY (CT SCAN)

• A plain film of the abdomen
• Also called as “abdominal flat plate” or • A specialized x-ray that takes cross-
“KUB for kidneys, ureter and bladder” sectional pictures of all types of tissues.
Purpose: • Sometimes called as “CAT SCAN”. The
“A” refers to the word AXIAL, which is a
✓ Assess the cause of abdominal pain
particular orientation of the image.
✓ Evaluate liver or kidney size, shape
• Axial: relating to an axis/main axis
and position
• It is used extensively in diagnosing
Procedure:
disease & injury of the:
✓
Patient lies supine on the table.
✓ One AP (anterior-posterior) image ✓ Evaluate pain, loss of function,
is taken deformity
BONE X-RAYS
• CLAVICLE/ SCAPULA, FOOT, HAND,

TOE, FINGERS, MANDIBLE
Purpose:
✓ Assess for fracture, tumor,

infection, structural abnormalities,
degenerative diseases.

LECTURE
✓ Brain,
B. cerebral blood vessels, eyes,
inner ear & sinuses
✓ Neck, shoulders, cervical spine, and
blood vessels
✓ Chest, heart, aorta and lungs
✓ Thoracic and lumbar spine
✓ Upper abdomen, liver, kidney,

spleen & pancreas
✓ Skeletal system including bones of
the hands, feet, ankles, legs and
arms and jaws
✓
Pelvis & hips, reproductive system,
bladder & GI tract

LECTURE
B.
• Also used to diagnosed cancers • In obstetrics, ultrasound is used to
including
lungs, liver, pancreatic cancer , measure evaluate fetal development & well-
tumor size and assess involvement in the being.
ELECTROCARDIOGRAM (ECG/EKG)
nearby tissues.
• A test that records the electrical signals
• A CT scanner can be described as a
of the heart
square donut because of it`s shape
(square) & the large opening in the • It is common and painless test that
center.
• During the CT scan, the patient lies usually detect heart problems and
monitor the heart`s health.
on the CT table which is advanced into
the opening so that the scanner can BLOOD CHEMISTRY
take a series of images.
CBC (COMPLETE BLOOD COUNT):
MAGNETIC REASONANCE IMAGING • lavender top-tube
(MRI)
• Is a non-invasive imaging technology
• Reveals information about general
that gives a detailed pictures of internal
health
structures.
be heard by the human ear
• Used to evaluate:
• It is used to evaluate the shape &
✓ Head trauma (assess for bleeding
position of organs & tissues, detect
or swelling) masses, edema, stones & displacement of
✓ Neurologic symptoms suggestive tissues.
of cerebral aneurysm, stroke,

tumor or spinal cord lesion or
injury
✓ Cardiac or major blood vessels
disease
✓ Renal disease (glomerulonephritis)
✓ Cancer of the pancreas. Adrenal

glands & gallbladder
✓ Musculoskeletal disorders including
problems in joints, soft tissues
bone
ULTRASOUND (US)
• Also called as “SONOGRAM”
• Is a non-invasive diagnostic procedure

that uses soundwaves to create gray
scale
images of internal structures.
• The high-pitched sound waves cannot

LECTURE
B.
• Number of red blood cells (RBC)
• Number of white blood cells (WBC)
• Total amount of hemoglobin in the

blood
• Number of platelets which are critical

to clot formation
• Test the MCV, MCH & MCHC values

are useful in the diagnosis of various
types of anemia.
BUN (BLOOD UREA NITROGEN):

• red-top tube
• BUN is a by-product of protein
metabolism, is excreted primarily by
the kidneys & therefore reflects
kidney functions.
• Elevated BUN(azotemia) occurs in

most renal diseases; also rises with GI
bleeding, dehydration, high protein
diet, and CHF.
CREATININE, SERUM
• red-top tube
• Breakdown product of creatinine

phosphate in the muscle

LECTURE
B.
• Produced at a constant rate by the • Includes information documented by
body & excreted by the kidney. Blood various health care professionals
level rises in renal impairment.
• Also contains data regarding the client`s
• Creatinine level is a sensitive indicator of occupation, religion, and marital status.
renal function but is dependent on
kidney • Type of client`s records include medical
function. records, records of therapies and
URINALYSIS (UA) laboratory records.
• Provides information about the urinary MEDICAL RECORD

system
• Includes medical history, physical
• Protein content in the urine is an examination, operative report, progress
indicative of decreased renal function notes & consultations done by primary
caregivers; are often a source of
• Red blood cells indicates damage of the
client`s present and past health and
renal tubules
illness patterns.
• Crystals indicates the presence of renal
• The records can provide nurses with
stones
information about the client`s coping
• Leucocyte esterase, nitrate and white behaviors, health practices, previous
blood cells in the urine are indications of illnesses & allergies.
urinary tract infection
RECORD OF THERAPIES
• Hyaline casts indicate protein in the
• Provided by other health professionals
urine
such as social workers, nutritionist,
• WBC & RBC casts generally indicative of dietitians, or physical therapist which
upper urinary tract infection. RBC casts helps the nurse obtain relevant data
are also present in other serious kidney not expressed by the client.
disorders.
Example:
• Renal Tubular Epithelial Cell casts • Social agency`s report on
reflect damage to the tubules & are the living conditions of the
found in renal tubular necrosis, viral client
diseases and transplant rejection. • Home Health Care agency`s
report on client`s ability to
OTHER SOURCES OF DATA
cope at home will help the
• PRIMARY: client nurse conducting an
assessment
• SECONDARY: family members, friends,
caregivers who know the client well often LABORATORY`S RECORD
can supplement information provided by
• Provide pertinent health information
the client.
Example:
• OTHER SOURCE: Client`s record
O Result of blood glucose level
CLIENT`S RECORD
allows health professionals
to monitor the
LECTURE
B.
administration of oral
hypoglycemic medications.
O Any laboratory data about
the client must be
compared to the agency or
performing laboratory`s
norms for that particular
test & for the client`s age,
gender & other
characteristics.
• Nurses must always consider the

information in client`s record
Example:
• 10 years old medical record

shows that the client`s health
practices & coping behaviors are
likely to have changed.
• Older clients may have numerous
previous records
• These records are very useful & can

contribute to full understanding of the
health history especially if the client`s
memory is impaired.

LECTURE

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BURI, JADE BSN 1-9 PRELIMS

nursing care. PHASES/STEPS OF THE NURSING

• its components follow a logical The national licensure examination for

• At the end of the 1st cycle, care maybe ✓ Assessment

• The term Nursing Process was ASSESSMENT

HEALTH ASSESSMENT DOCTOR A. CORPUS

DATA COLLECTION/ COLLECT DATA

• Is the process of gathering

• Must be both systematic & continuous

•A Data Base contains all the

Sources of Data Collection

1. Primary sources Client is the

• All sources other than the client are

• All data from secondary sources should

• A complete Data Base provides a

HEALTH ASSESSMENT DOCTOR A. CORPUS

Example: itching, pain, feelings of worry

• Includes the client`s sensations,

• Referred to as the signs or overt data

• Are detectable by an observer or can

• Are observable and measurable and

• This can be seen, heard & felt or smelled

Example: Blood Pressure, Level of

DATA COLLECTION METHODS

• Observing occurs when the nurse is

• Interviewing is used mainly while

• Examining is the major method used

• Reality: nurses used all the three

HEALTH ASSESSMENT DOCTOR A. CORPUS

1. Noticing the data

• Observing involves distinguishing of

• Nursing observations must be

• Most nurses develop a sequence in

Example: A nurse is visiting into the

1. Clinical signs of the client`s distress

Example: Nursing Health History- a part

• A combination of directive & non-

Types of Interview Questions

• used in directive interview, are

● generally, require only “yes or no”

• Often begins with “when, where, who,

Example: What medication did you take?

• associated with the non-directive

• Specifies only the broad topic to be

• May begin with “what or how”

Example: How did you feel in the

HEALTH ASSESSMENT DOCTOR A. CORPUS

Example: How do you feel about that?

Note: Details about the planning an

• To conduct the physical examination,

the nurse uses techniques of inspection,

• Can be carried out systematically;

• The cephalocaudal or head-to-toe

● Nurses uses a written or electronic

● This is referred to as a nursing health

● The format maybemodified according to

● Nurses must make a judgment about

• The act of “double checking or

• The information gathered during

Validating data helps the nurse

Are subjective or objective data that

What the client says or what the nurse

see, hear, smell or measure