HEALTH ASSESSMENT

HOUSE RULES

1. Come to class on time, in the right uniform, and well-

groomed.
2. Extend courtesy not only to the Professor but to everyone
as well. Act like future Professional Nurses.
3. Gadgets ARE NOT ALLOWED AT ALL TIMES inside the
classroom.
4. Listen attentively, take down notes, and PARTICIPATE
ACTIVELY.
5. Present Admission Slip if absent. Three tardiness is
equivalent to one day absence from class.

2
 HEALTH ASSESSMENT

• The course deals with concepts, principles &

techniques of history taking using various
tools, physical examination (head to toe),
psychosocial assessment and interpretation
of laboratory findings to arrive at a nursing
diagnosis on the client across the lifespan in
community and hospital settings.
TERMINAL COMPETENCIES

At the end of the course (36 hours) and given

simulated and actual conditions/ situations, the
student will be able to:
• Differentiate normal from abnormal assessment
findings;
• Utilize concepts, principles, techniques and
appropriate assessment tools in the assessment of
individual client with varying age group and
development;
• Observe bioethical concepts/ principles and core
values and nursing standards in the care of clients.
4
 NURSING PROCESS

•Sets of actions used to determine, plan,

implement and evaluate nursing care.
•Systematic, rational method of planning and
providing individualized care.
 PURPOSE

• To help the nurse manage each patient’s

nursing care, intelligently, scientifically and
judiciously.
 CHARACTERISTICS

• It is problem-oriented
• It is goal-oriented
• It is orderly and planned, step-by-step
• It is universally applicable to all patients,
families, and communities that nursing
serves
FIVE COMPONENTS OF THE NURSING
PROCESS

Assessment

Evaluation Nursing Diagnosis

Implementation Planning
 Overview of the Nursing Process

• Assessing- collecting, organizing, validating, and

documenting client data.
• Diagnosing- analyzing and synthesizing data
• Planning- determining how to prevent, reduce, or
resolve the identified priority client problems.
• Implementing- carrying out (or delegating) and
documenting the planned nursing interventions.
• Evaluating- measuring the degree to which goals/
outcomes have been achieved.

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 Nursing Process in Action

•Assessing
•- collect data, organize data, validate data, document
data
•Diagnosing
•- analyze data, identify health problems, risks and
strengths, formulate diagnostic statements
•Planning
•Prioritize problems/diagnoses, formulate
goals/desired outcomes, select nursing interventions,
write nursing interventions
• Implementing
• Reassess the client, determine the nurse’s need for
assistance, implement the nursing interventions,
supervise delegated care, document nursing
activities
• Evaluating
• Collect data related to outcomes, compare data
with outcomes, relate nursing actions to client
goals/outcomes, draw conclusions about problem
status, continue, modify, or terminate the client’s
care plan.
Assessment: The First Phase of the
Nursing Process

• the most critical phase of the nursing process

• deliberate and systematic collection of data to
determine client’s current and past health and
functional status.
• determines client’s current and past coping
patterns
Assessment: The First Phase of the
Nursing Process

• is ongoing and continuous throughout all

the phases of the nursing process.
A Critical Thinking Approach to Assessment
• Analysis • Analysis

Client’s
Client
Record

Client’s
Health Team
Significant
Members
others
• Analysis • Analysis
 Subjective & Objective Data
Subjective Data
data are elicited and verified by the
client
method used to obtain data:
Interview
skills needed to obtain data:
interview and therapeutic
communication skills, caring
ability, empathy, listening skills
examples: “I can’t see clearly”,
“My backache is worsening each
day”, “I give up”, “I know God is
with me in all of these”
Objective Data
data are directly or indirectly
observed or measured
method used to obtain data:
observation & physical exam
skills needed to obtain data:
inspection, palpation, percussion,
auscultation
examples: reddened patches all
over posterior chest, bipedal
edema, BP: 90/60 mmHg, weight:
55kg, height: 185cms
15
 HEALTH HISTORY GUIDELINES

INTERVIEW

• A planned communication or a conversation

with a purpose
 PURPOSES OF INTERVIEW

1. Get or give information

2. Identify problems of mutual concern
3. Evaluate change
4. Teach
5. Provide counseling or therapy
 Approaches to Interviewing

1. DIRECTIVE INTERVIEW

• Highly structured, elicits specific information

• Nurse establishes purpose of and controls the
interview
• Used to gather and get information when time is
limited
 Approaches to Interviewing

2. NON-DIRECTIVE INTERVIEW
• Rapport building
• Nurse allows client to control the purpose, subject
matter, and pacing.

NOTE: A combination of Directive and Non-directive

interview approaches is usually appropriate during
information-gathering interview.
TYPES OF COMMUNICATION

•VERBAL

•NON-VERBAL
 Types of Interview Questions

1. CLOSED-ENDED QUESTIONS
• Used in directive interview
• Restrictive, generally requires a “yes” or
“no” or short factual answers giving
specific information
• Often begin with “when”, “where”, “who”,
“what”, “do (did,does)”, “is (are, was)”
 Types of Interview Questions

2. OPEN-ENDED QUESTIONS
• Used in non-directive interview
• Invite clients to discover and explore, elaborate,
clarify, illustrate their thoughts or feelings
• Answers are longer than two words
• Gives clients freedom to divulge information
that they are ready to disclose
• Useful in the beginning of an interview or to
change topics and to elicit attitudes
• May begin with “what” or “how”
 Types of Interview Questions

3. NEUTRAL QUESTIONS

• Client can answer without direction or pressure

from the nurse
• Is open-ended, used in non- directive interviews
 Types of Interview Questions

4. LEADING QUESTIONS

• Is closed, used in directive interview

• Directs client’s answer
• Gives clients less opportunity to decide
whether the answer is true or not
NON VERBAL COMMUNICATION

• FACIAL EXPRESSION

• ATTITUDE

• SILENCE

• LISTENING
STRUCTURE/PHASES OF AN INTERVIEW

1. OPENING (or Introductory)

• Most important part of the interview, sets tone for
the remainder of the interview
• Purpose is to establish rapport and orient the
interviewee
• The nurse must be careful not to overdo this stage
• In this stage, the Nurse explains the purpose &
nature of the interview, like what information is
needed, how long will it take, & what is expected
of the client, how the information will be used, &
that the client has the right not to provide data.
STRUCTURE OF AN INTERVIEW

2. BODY (Working)
• Client communicates what he or she thinks, feels,
knows, perceives in response to questions from
the nurse.
• Effective development of the interview demands
that the nurse use communication techniques that
make both parties feel comfortable & serve the
purpose of the interview
STRUCTURE OF AN INTERVIEW

3. CLOSING (Summary and Closing)

• The nurse terminates the interview when the
needed information has been obtained.
• In some cases, the client may terminates the
interview
• Closing is important for maintaining the rapport
and trust and for facilitating future interactions.
 STRUCTURE OF AN INTERVIEW
The following techniques are commonly used to close an
interview:
1. Offer to answer questions.
2. Conclude by saying “Well, that’s all I need to know for now.”
Preceding a remark with the word ‘well’ generally signals that the
end of the interaction ids near.
3. Thank the client. You may also shake the client’s hand.
4. Express concern for the person’s welfare and future.
5. Plan for the next meeting, if there is to be one, or state when it will
happen next.. Include the day, time, place, topic, and purpose.
6. Provide summary to verify accuracy & agreement. Summarizing
not only terminates the interview but also reassures the client that
the nurse has listened.
 PLANNING THE INTERVIEW
AND SETTING
1. Nurse should review available
information.
2. Nurse reviews the institution’s data
collection form if there’s any, otherwise,
the nurse may prepare an interview
guide.
 CONSIDERATIONS DURING
AN INTERVIEW
1. Time
2. Place
3. Seating Arrangement
4. Distance
5. Language
 GUIDELINES DURING AN
INTERVIEW
• Listen attentively, using all your senses,
and speak slowly and clearly.
• Clarify points that are not understood.
• Plan questions to follow a logical
sequence.
• Ask only one question at a time. Multiple
questions limit the client to one choice and
may confuse the client.
 GUIDELINES DURING AN
INTERVIEW
• Acknowledge the client’s right to look at things
the way they appear to him and not the way they
appear to the nurse or someone else.
• Do not impose your own values on the client.
• Avoid using personal examples, such as saying,
“if I were you,…”
• Nonverbally convey respect, concern, interest,
and acceptance.
 GUIDELINES DURING AN
INTERVIEW
• Be aware of the client’s and your own body
language.
• Be conscious of the client’s and your own voice
inflection, tone, and affect.
• Sit down to talk with the client (be at an even
level).
• Use & accept silence to help the client search
for more thoughts or to organize them.
• Use eye contact to be calm, unhurried, and
sympathetic.
Interview Guidelines

• gerontologic variations in communication

• cultural variations
• emotional variations
Gordon's Functional Health Patterns
• Marjorie Gordon (1987) proposed functional
health patterns as a guide for establishing a
comprehensive nursing data base. These 11
categories make possible a systematic and
standardized approach to data collection,
and enable the nurse to determine the
following aspects of health and human
function:
Gordon's 11 Functional Health
Patterns
1. Health Perception and Health Management.
2. Nutrition and Metabolism
3. Elimination
4. Activity and Exercise.
5. Cognition and Perception.
6. Sleep and Rest.
7. Self-Perception and Self-Concept.
8. Roles and Relationships.
9. Sexuality and Reproduction.
10.Coping and Stress Tolerance.
11. Values and Belief.
Describes the client’s perceived
health & well being and how
health is managed.

HEALTH PERCEPTION &

MANAGEMENT
•History (subjective data):

•Client’s general health?

•Any colds in past year?
•If appropriate: any absences from work/school?
•Most important things you do to keep healthy?
Use of cigarettes, alcohol, drugs?
•Perform self exams, i.e. Breast/testicular self-examination?
•Accidents at home, work, school, driving?
•In past, has it been easy to find ways to carry out doctor’s or nurse’s
suggestions?
•(If appropriate) What do you think caused current illness?
•What actions have you taken since symptoms started?
•Have your actions helped?
•(If appropriate) What things are most important to your health?
•How can we be most helpful? done exercise every what?

HEALTH PERCEPTION & MANAGEMENT

This pattern describes food and
fluid consumption relative to
metabolic need & pattern
indicators of local nutrient
supply.
NUTRITIONAL/ METABOLIC
History (subjective data):

• Typical daily food intake including snacks?

• Use of supplements, vitamins?
• Typical daily fluid intake?
• Weight loss/gain? Height loss/gain?
• Appetite?
• Breastfeeding? Infant feeding?
• Food or eating: Discomfort, swallowing difficulties, diet restrictions, able to
follow?
• Healing – any problems? Skin problems: lesions? Dryness? Dental problems?

Examination (examples of objective data):

• Skin assessment, oral mucous membranes, teeth, actual weight/height,
temperature. Abdominal assessment.

NUTRITIONAL/ METABOLIC
DIET RECALL

M T W TH F SA SU

Breakfast
(include time of meal)

Snack

Lunch

Snack

Dinner

Snack
ELIMINATION

Describes the pattern of

excretory function (bowel,
bladder, skin).
ELIMINATION
History (subjective data):

• Bowel elimination pattern (describe) Frequency, character,

discomfort, problem with bowel control, use of laxatives (i.e. type,
frequency), etc.?
• Urinary elimination pattern (describe) Frequency, problem with
bladder control?
• Excess perspiration? Odour problems? Body cavity drainage,
suction, etc.?

Examination (examples of objective data):

• If indicated, examine excretions or drainage for characteristics,
colour, and consistency. Abdominal assessment.
ACTIVITY/ EXERCISE

This pattern describes activity

level, exercise program, and
leisure activities.
ACTIVITY/ EXERCISE
History (subjective data):
• Sufficient energy for desired and/or required activities?
• Exercise pattern? Type? regularity?
• Spare time (leisure) activities?
• Child-play activities?
• Perceived ability for feeding, grooming, bathing, general mobility,
toileting, home maintenance, bed mobility, dressing and shopping?

Examination (examples of objective data):

Demonstrate ability for the following criteria:
• Gait. Posture. Absent body part. Range of motion (ROM) joints. Hand
grip - can pick up pencil?
• Respiration. Blood pressure. General appearance.
• Musculoskeletal, cardiac and respiratory assessments.
MONDAY, NOV. 7 ACTIVITIES

5:00 am Woke up

5:30 am Ate Breakfast

6:00 am Took a bath

6:30 am Dress up for school

7:00 am Walked to school

7:45 am Reached school

Etc.

Until sleeping time

ACTIVITY DIARY/RECALL
SLEEP/REST

Describes patterns of sleep, rest,

and relaxation.
SLEEP/REST

History (subjective data):

• Generally rested and ready for activity after sleep?
• Sleep onset problems? Aids? Dreams (nightmares),
early awakening?
• Rest / relaxation periods?

Examination (examples of objective data):

• Observe sleep pattern and rest pattern if applicable
• Dark circles around the eyes, eye bags, yawning,
inability to concentrate, etc.
 M T W TH F SA SU

Time went to bed

Approximate time fell asleep

Wake up period/ sleep interruptions (how

long)
Time woke up the next morning

Feeling after waking up

Naps(time slept & woke up; duration)

Activities done before bedtime

Bedtime rituals

SLEEP DIARY
COGNITIVE/PERCEPTUAL

Describes the ability of the

individual to understand and
follow directions, retain
information, make decisions,
and solve problems. Also
assesses the five senses.
COGNITIVE/PERCEPTUAL
History (subjective data):
• Hearing difficulty? Hearing aid?
• Vision? Wears glasses? Last checked? When last changed?
• Any change in memory? Concentration?
• Important decisions easy/difficult to make?
• Easiest way for you to learn things? Any difficulty?
• Any discomfort? Pain? COLDSPA C - Character O - Onset L - Location D -
Duration S – Severity P - Pattern A - Associated factors (Weber, 2003)

Examination (examples of objective data):

• Orientation.
• Hears whispers? Reads newsprint?
• Grasps ideas and questions (abstract, concrete)?
• Language spoken. Vocabulary level.
• Attention span.
SELF PERCEPTION/SELF CONCEPT

Describes client’s self-worth,

comfort, body image, feeling
state.
SELF PERCEPTION/SELF CONCEPT
History (subjective data):
• How do you describe yourself?
• Most of the time, feel good (or not so good) about self?
• Changes in body or things you can do? Problems for you?
• Changes in the way you feel about self or body (generally or since illness
started)?
• Things frequently make you angry? Annoyed? Fearful? Anxious? Depressed?
• Not able to control things? What helps?
• Ever feel you lose hope?
Examination (examples of objective data):
• Eye contact. Attention span (distraction?).
• Voice and speech pattern.
• Body posture.
• Client nervous (5) or relaxed (1) (rate scale 1-5) Client assertive (5) or passive
(1) (rate scale 1-5)
ROLES/RELATIONSHIP
History (subjective data):
• Live alone?
• Family? Family structure? Any family problems you have difficulty handling
(nuclear/extended family)? Family or others depend on you for things?
How well are you managing?
• If appropriate – How families/others feel about your illness?
• Problems with children?
• Belong to social groups?
• Close friends? Feel lonely? (Frequency)
• Things generally go well at work / school?
• If appropriate – income sufficient for needs?
• Feel part of (or isolated in) your neighborhood?

Examination (examples of objective data):

• Interaction with family members or others if present.
SEXUALITY/REPRODUCTIVE
History (subjective data):
• If appropriate to age and situation – Sexual
relationships satisfying? Changes? Problems?
• If appropriate – Use of contraceptives? Problems?
• Female – when did menstruation begin? Last
menstrual period (LMP)? Any menstrual problems?
• (Gravida/Para if appropriate)
Examination (examples of objective data):
• None unless a problem is identified or a pelvic
examination is warranted as part of full physical
assessment (advanced nursing skill).
COPING/STRESS TOLERANCE
History (subjective data):
• Any big changes in your life in last year or two?
Crisis?
• Who is most helpful in talking things over? Available
to you now?
• Tense or relaxed most of the time? When tense, what
helps?
• Use any medications, drugs, alcohol to relax?
• When (if) there are big problems in your life, how do
you handle them? Most of the time, are these ways
successful?
VALUE/BELIEF PATTERN

Describes the patterns of values,

beliefs (including spiritual), and
goals that guides the client’s
choices or decisions.
VALUE/BELIEF PATTERN
History (subjective data):
• Generally get things you want from life?
• Important plans for future?
• Religion important to you? f appropriate - Does
this help when difficulties arise?
• If appropriate – will being here interfere with any
religious practices?
• Health beliefs/values?
 COMPLETE
HEALTH HISTORY
8 Sections of a Complete Health History

• Biographic data
• Reasons for seeking health care (Chief Complaint)
• History of present health concern
• Past health history
• Family health history
• Review of systems for current health problems
• Lifestyle and practices profile
• Developmental level
8 Sections of a Complete Health History

• Biographic data
• Reasons for seeking health care (Chief Complaint)
• History of present health concern
• Past health history
• Family health history
• Review of systems for current health problems
• Lifestyle and practices profile
• Developmental level
BIOGRAPHIC DATA

• Includes information that identifies the client

– E.g. name, address, phone number, gender etc.

– Source of data:
• Client or significant others
 REASON(S) FOR SEEKING HEALTH CARE

• Also known as Client’s Chief Complaint (CC)

• We aim to determine the following:

– What brought the client to seek health care
– The feelings of the client about seeking health care

• Can be assessed by asking the following questions:

– “What is your major health problem or concerns at this time?”
– "How do you feel about having seeking health care?”
 “What is your major health problem or
concerns at this time?”

• Assist the client to focus on his most significant concern

• Other questions like, “ Why are you here?” and “How

can I help you?” can also be asked

– Reminder: use holistic approach in phrasing questions,

draw out concerns that are beyond just a physical
complaint and address other associated factors like stress
or lifestyle changes
 "How do you feel about having seeking
health care?”

• Encourages the client to discuss fears or feelings

about having to seek health care advice.

• May help in determining descriptions of past

experiences—both positive and negative—with
other health care worker
HISTORY OF PRESENT HEALTH CONCERN

• takes into account several aspects of client’s

current health concern

• includes questions that provide detailed

descriptions of the client’s health problem
Encourage the client to explain:

• health problem or symptom focusing on onset, progression

and duration
• signs and symptoms and related problems
• what the client perceives as causing the problem/symptom
• what makes the problem worse
• what makes the problem better
• which treatments have been tried
• what effect the problem has had on daily life
• what is the client’s ability to provide self-care
TIP: USE MNEMONICS

• To gather a comprehensive history of present concern as a nurse

you may use the following mnemonic to organize data:

• PQRST or COLDSPA
Precipitating factors (What
brought about the pain? What
do you do to be relieved?)
Quality/character (What the
pain feels like? Piercing?
Scalding? Crushing?
Unbearable? Killing? Intense?,
How does it look like?)
Region/Radiation (Where do
you feel the pain?)
Severity (Use rating scale 0-
10/ 1-10)
Time/duration ( How long it
lasts?)
Character (how does it feel, look,
smell, sound?)
Onset (When did it begin: is it better,
worse, or same since it began?)
Location/radiation (Where is it?
Does it radiate?)
Duration (How long it lasts? Does it
recur?)
Severity (use rating scale)
Pattern (What makes it better,
worse?)
Associated factors (What other
symptoms do you have with it? Will
you be able to continue doing your
work or other activities ?)
 PAST HEALTH HISTORY

• elicit data related to the client’s strengths and

weaknesses in his health history
– Physical, social, emotional or spiritual
• may also include trends of unhealthy
behaviors
– Vices or lack of physical activity
• data obtained in this section aids the nurse
to identify risk factors that stem from
previous health problems (risk factors may
be to the client or significant others)
Past Health History
includes questions about...
• birth, growth and development
• childhood diseases
• immunizations
• allergies
• previous health problems
• hospitalizations and surgeries
• pregnancies
• births
• previous accidents and injuries
• pain experiences
• emotional or psychological problems
 FAMILY HEALTH HISTORY

• focuses on health problems that seem to run

in families or those that are genetically
based
• should include as many genetic relatives as
the client can recall
• include maternal and paternal grandparents,
aunts and uncles on both sides, parents,
siblings and the client’s children
 FAMILY HEALTH HISTORY
• drawing a genogram helps to organize and illustrate the client’s family
history
• use a standard format
• provide a key for the entries
– female relatives: circle
– male relatives: square
– deceased relative: marking an X in the circle or square and listing the age
at death
– cause of death noted inside a parenthesis e.g. (heart failure )
– AW (Alive and well) should be placed next to the age
– Straight or vertical lines to denote relationship
– Horizontal doted line to indicate client’s spouse
– Vertical dotted line to indicate adoption
Functional Assessment of Newborns,
Infants & Children, Adults/Elderly
• Newborn (APGAR Scoring & anthropometric
measurements)
• Infants & Children (MMDST & some major
developmental milestones)
• Adults/Elderly (PADC, Lawton Scale for IADL,
KATZ index of independence on ADL, Barthel
Index)
Initial Newborn Assessment...Apgar
Scoring
• provides numeric indicator of newborn’s physiologic
capacity to adapt to extra-uterine life
• assessed at 1 and at 5 minutes after delivery
• each of the five aspects is assigned a maximum score
of 2
• maximum achievable total score is 10
• score under 7 suggests that the baby is having difficulty
• score under 4 indicates that the baby’s condition is
critical
• those with very low scores require special resuscitative
measures and care
Initial Newborn Assessment...Apgar
Scoring

Sign Score: 0 Score: 1 Score: 2

Heart Rate absent slow (below over 100/min

100/min)
Respiration absent slow, irregular, regular rate,
hypoventilation good lusty cry
Muscle Tone flaccid some flexion of active
extremities movements/flexi
on
Reflex Irritability no response crying, some crying, coughing
motion/grimace
Color Blue (cyanotic), pink body, blue pink body, pink
pale hands & feet extremities
Initial Newborn
Assessment...Anthropometric
Measurements

• weight
• length
• head and chest circumference
Newborn’s Anthropometric
Measurements...weight
• at birth most babies weigh from 2.7 to 3.8 kg (Kozier et
al)...2500 to 4000 g (Weber & Kelly)
• just after birth, newborns lose 5% to 10% of their birth
weight because of fluid loss (normal)
• regains birth weight in about 1 week
• at 5 to 6 months, infants usually reach twice their birth
weight
• by age 12 months, infants weight is usually 3 times their
birth weight
• weigh the newborn unclothed using a newborn scale
Newborn’s Anthropometric
Measurements...length

• average length varies

• female babies are usually smaller in length than
male babies
• rate of increase in height/length is largely
influenced by the baby’s size at birth and by
nutrition
• measure the newborn from head-to-heel (from
the top of the head to the base of the heels)

84
Newborn’s Anthropometric
Measurements...head & chest
circumference
• normal head circumference (normocephaly) should be assessed in
relation to chest circumference
• chest circumference of the newborn is usually less than the head
circumference by about 2.5 cm (1 in)
• as the infant grows, chest circumference becomes larger than the
head circumference
• at about 9 or 10 months, head and chest circumferences are almost
the same
• after 1 year of age, chest circumference is larger
• a newborn’s head circumference is measured around the skull
above the eyebrows
• measure chest circumference by placing tape measure at nipple line
and wrap it around the newborn
Developmental Screening Test

86
 Developmental Assessment of Infants
and Children...MMDST

• adopted from Denver Developmental Screening

Test (DDST)
• a screening tool to identify developmental delays
among children from birth to 6 years of age
• intended to estimate the abilities of a child
compared to those of an average group of
children of the same age
• not a test of intelligence
Developmental Assessment of Infants
and Children...MMDST

•four main areas of development are screened:

1. personal-social
2. fine-motor adaptive
3. language
4. gross motor
Developmental Assessment of Infants and
Children...MMDST
• personal-social – tasks which indicate the child’s
ability to get along with people and to take care of
himself
• fine motor adaptive – tasks which indicate the
child’s ability to see and use his hands to pick up
objects and to draw
• Language – tasks which indicate the child’s ability
to hear, follow directions and to speak
• Gross motor – tasks which indicate the child’s
ability to sit, walk and jump
Assessment of Infants and
Children...Immunization Status
• Immunization – the process by which resistance to
an infectious disease is produced or augmented

• Types of Immunity:
1. active immunity – acquired when a person
produces antibody in response to an antigen
Types of Immunity...continued

• Active Immunity can either be:

a. natural - exposure and/or recovery from an
infection

b. artificial - acquired through the injection of a small

amount of attenuated (weakened) or dead
organisms (vaccines) or modified toxins from the
organism (toxoids) into the body.

91
Types of Immunity...continued

• Passive Immunity – a resistance of the body to

an infection in which the host receives natural
(from the mother to her unborn child through
placental transfer) or artificial antibodies
produced by another source/host.
Assessment of Infants and
Children...Immunization Schedule (Based on EPI,
2010)
Schedule/Child’s Age Vaccines

At Birth BCG1 and Hepatitis B1

1 and a half month/6 weeks DPT1, OPV1, Hepatitis B2

after birth
2 and a half months/10 weeks DPT2, OPV2
after birth
3 and a half months/14 weeks DPT3, OPV3, Hepatitis B3
after birth
***6 months ***Give Vitamin A

9 months Anti-Measles Vaccine +

Vitamin A
Assessment of Infants and
Children...Immunization Status
• A child’s immunization status can be categorized
as:
incompletely immunized
completely immunized
fully immunized

***based on child’s age

Assessment of a Pregnant Woman

• estimating delivery date (EDC/EDD)

• estimating gestational age (AOG/age of gestation
• maternal assessment (history)
Assessment of a Pregnant
Woman...Estimating Delivery Date

• Nagel’s Rule: subtract 3 months from the first day

of the last menstrual period (LMP) and add 7 days.
Ex: LMP= Oct. 5, 2010
Oct. 5 – 3months= July 3(because Aug. & July have
31 days) thus,
EDD= July 3+7days=July 10, 2011
Assessment of a Pregnant
Woman...Estimating Age of Gestation

• through LMP
• using McDonald’s Rule
fundal height in cm x 2/7 = AOG in months
fundal height in cm x 8/7 = AOG in weeks
Assessment of a Pregnant
Woman...Maternal History

• age
• family history
• pregnant woman’s medical history
• pregnant woman’s past obstetric history
• pregnant woman’s present obstetric history
Assessment of a Pregnant
Woman...Maternal History
• age as a risk factor: very young; older women
• family history: congenital disorders, multiple
pregnancies, DM, heart disease, hypertension,
mental retardation
• woman’s medical history: menarche, childhood
diseases, major illnesses, surgery, blood
transfusion, drug sensitivity, urinary infections,
heart disease, diabetes, hypertension, endocrine
disorders, anemia, use of contraceptives, drug
abuse, alcohol and tobacco use
Assessment of a Pregnant Woman...Maternal
History

• past obstetric history – previous pregnancies

(gravida) and deliveries (parity), types of
deliveries, multiple births (multipara), abortions,
maternal, fetal and neoatal complications,
perceptions of past pregnancies, labor and
delivery
Assessment of a Pregnant
Woman...Maternal History
• present obstetric history
gravidity, parity
LMP
EDD
signs and symptoms of pregnancy
rest and sleep patterns
activity and employment, if any
sexual activity
diet history, eating pattern, weight loss, weight
gain
Assessment of a Pregnant
Woman...Maternal History

• psychosocial status – emotional changes client is

experiencing, reactions to the present pregnancy
(including her family’s response), support system
Assessment of an Elderly Client

• differentiate findings that result from the usual

“wear and tear”/degenerative processes and
those that indicate pathologic process

• “frail elderly”– vulnerability of aged people to be

in poorer health, to have more chronic
disabilities and to function less independently
Assessment of an Elderly Client

• symptoms of a disease may be more subtle in

advanced age
• changes in functional abilities may herald the
occurrence of a potential health problem
• recognizing changes in functional ability is often
crucial for prompt and accurate management of
both acute and chronic illness in an elderly
Assessment of an Elderly Client

• geriatric syndromes – the unique way in which a disease

presents in a frail elderly. These syndromes include:
• sleep disorders
• problems with eating or feeding
• incontinence (bladder and bowel)
• confusion
• evidence of falls
• skin breakdown
Determining Functional Status of an Elderly

• functional assessment – an evaluation of the

person’s ability to carry out the basic self-care
activities of daily living (ADLs) such as bathing,
eating, grooming and toileting
• functional assessment also includes those activities
necessary for well-being and survival as an
individual in a society (instrumental activities of
daily living
Determining Functional Status of an
Elderly

• Instrumental Activities of Daily Living (IADL) –

focus primarily on household chores, mobility-
related activities (ex. shopping and
transportation) and cognitive abilities (ex. money
management, making decisions affecting basic
safety and social needs) )...see display 30-8 on
page 820 of your book by Weber & Kelly
Determining Functional Status of an
Elderly

• Katz Activities of Daily Living – a commonly

used tool for measuring the ability to perform
basic personal tools such as bathing, dressing,
toileting, transferring and eating... see display 30-7
on page 819 of your book by Weber & Kelly
Goal of Elderly Assessment

• the ultimate goal of elderly assessment and

intervention should be to empower clients to
maintain the relationships, activities and events that
elderly clients find meaningful

• elderly assessment may not be focused on disease

prevention as it is on minimizing the disability
associated with chronic illness and preventing
complications and exacerbations of chronic
maladies
Common Laboratory Exams

• Complete Blood Count (CBC)

• urinalysis
• stool exam
• blood chemistry
Common Laboratory Exams...CBC

• one of the most frequently ordered blood tests

• uses venous blood
• measures important blood components
• hemoglobin
• hematocrit
• erythrocyte (RBC)
• leukocyte
• red blood cell (RBC) indices
• differential white cell count
Common Laboratory Exams...Blood
Chemistry
• a test performed on blood serum (the liquid portion
of the blood); may provide valuable diagnostic cues
• in addition to serum electrolytes (a screening test
for electrolytes and acid-base imbalances),
common blood chemistry examinations include
certain enzymes that may be present in the blood
(lactic dehydrogenase (LDH), creatinine kinase
(CK), aspartate aminotransferase (AST), alanine
aminotranferase (ALT), serum glucose, cholesterol,
triglycerides
Common Laboratory
Exams...Urinalysis
• determines urine composition and possible abnormal
components (glucose, ketones, proeins, blood)
• collecting urine specimens for a number of tests
• clean voided specimens – routine urinalysis
• clean-catch or midstream urine specimens – urine
culture
• timed urine specimens – for a variety of tests that
depend on the client’s specific health problem
• ***urine specimen collection may require collection
via straight catheter insertion
Common Laboratory Exams...Stool
Exam
• can provide information about a client’s health
condition
• reasons for testing feces include:
1. to determine the presence of occult (hidden)
blood; also known as guaiac test
2. to analyze for diatary products and digestive
secretions
3. to detect presence of ova and parasites
4. to detect the presence of bacteria or viruses
Concepts 1

References:
1. Health Assessment in Nursing 3rd Edition by Janet Weber
& Jane Kelley
2. Fundamentals of Nursing 7th Edition by Barbara Kozier et
al
3. Fundamentals of Nursing 6th Edition by Patricia Potter &
Ann Griffin Perry

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