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NCM 101 - Health Assessment: Topic Outline

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NCM 101 - HEALTH ASSESSMENT

Transcribed by: Irah Mylene Del Castillo BSN 1A


Date: February 10, 17, 2022

TOPIC OUTLINE
I. Conceptual Overview of
Nursing Health Assessment
A.
Assessment
B. Critical Thinking in
Health Assessment
C. The Client in Context
Culture, Spirituality, &
Family

NURSES ROLE IN HEALTH ASSESSMENT

Assessment
I. CONCEPTUAL OVERVIEW OF NURSING HEALTH
ASSESSMENT - The gathering of
- Effective nursing care begins with an accurate & physiological, psychological, sociocultural,
holistic health assessment. developmental, & spiritual status.
- Purpose: to collect subjective & objective data
Assessment

- is the first and most critical step of the nursing functioning in order to make a professional
process, and accuracy of assessment data clinical judgment.
affects all other phases of the nursing process. 4 TYPES OF NURSING ASSESSMENTS
THE NURSING PROCESS Name Description
Phase Title Description 1. Initial Comprehensive - Collection of subjective
I Assessment Collecting subjective & Assessment
objective data. perception of all body
parts or systems, past
II Diagnosis Analyzing subjective &
health hx & lifestyle &
objective data to make a
health practices plus
professional judgement.
gathering of objective
III Planning Determining outcome
data during a step-by-
criteria & developing a
step physical
plan.
examination.
IV Implementation Carrying out the plan.
V Evaluation Assessing whether Insights/Examples: Regardless of who collects the
outcome criteria have data, it is important to always have comprehensive
been met & revising the assessment when the client enters the facility. The
plan as necessary. reason for this is to establish BASELINE DATA.

Lecturers: Ms. Stella Pinote, RN, MN; Mrs. Emma Dotillos RN, MN 1
NCM 101 - HEALTH ASSESSMENT
Transcribed by: Irah Mylene Del Castillo BSN 1A
Date: February 10, 17, 2022

2. Ongoing or Partial - Data collection after Obtain & organize materials needed for
Assessment comprehensive assessment
assessment.
- Any problems that were
initially detected in the
re FOUR MAJOR STEPS OF HEALTH ASSESSMENT
reassessed in less-depth 1. Collecting of - Data w/c include sensations or
to determine any major Subjective Data symptoms, feelings, perceptions,
changes from the preferences, beliefs, ideas,
baseline data. values, & personal information
Insights/Examples: This is to check if the patient has that can be elicited & verified
any new/other problems. Example: A client is only by the client.
admitted with a lung cancer, so you as a nurse, is - Method used to obtain data:
required to conduct a frequent assessment on the client interview.
respiratory rate, lung sound, oxygen saturation of the MAJOR AREAS of Subjective Data:
patient. a. Biographical information
3. Focused or Problem- - Thorough assessment b. Physical symptoms related to each body part
Oriented Assessment of a particular client or system
problem & does not c. Past health history
cover areas not related d. Family history
to the problem. e. Health & lifestyle practices
Insights/Examples: If only a 2. Collecting of - Directly obtained by the
Objective Data nurse/examiner through
other body parts. observation & PE.
4. Emergency - Very-rapid assessment - Observed by family or SOs
Assessment performed in life- about the client.
threatening situations -
(e.g. choking, drowning). IPPA (Inspection, Palpation,
- An immediate diagnosis Percussion, Auscultation) - the
is needed to provide four physical exam techniques.
prompt treatment. MAJOR AREAS of Objective Data:
Insights/Examples: a. Physical characteristics (e.g. skin, color, &
Breathing, Circulation). posture).
b. Body functions (e.g. HR, RR)
-Normal HR 60-100 bpm
PREPARING FOR THE ASSESSMENT -Normal RR 12-20cpm
Gathering information (e.g. biographical data c. Appearance
such as age, sex, religion, occupation, & d. Behavior
important documented information) before e. Measurements (e.g. ht., wt.)
actually meeting the client. f. Lab results
Keep an open mind and avoid premature 3. Validation of - The process of confirming or
judgment that may alter your ability to obtain Data verifying that the subjective data
accurate data. ssume. & objective data you have
gathered are reliable & accurate
diagnosis. Make sure infos came from px. as well as complete.

Lecturers: Ms. Stella Pinote, RN, MN; Mrs. Emma Dotillos RN, MN 2
NCM 101 - HEALTH ASSESSMENT
Transcribed by: Irah Mylene Del Castillo BSN 1A
Date: February 10, 17, 2022

METHODS of Validation: and self-corrective thinking.


a. Recheck your own data. - Creative Thinking is a major component of critical
b. Clarify data w/ the client (ask additional thinking.
questions).
- Goal directed thinking that leads to better solutions by
c. Verify w/ another HC professional.
using new ideas or methods.
d. Compare objective from subjective findings.
4. Documentation - Primary reason: to provide the
of Data HC team w/ a data base that UNIVERSAL INTELLECTUAL STANDARDS FOR
becomes the foundation of care CRITICAL THINKING
for the client. - Are standards which must be applied to
- Helps to identify health thinking whenever one is interested in
problems, formulate nursing checking the quality of reasoning about a
diagnoses & plan. problem, issue, or situation.
Database: provides information 1. Clarity - Understandable; the meaning can
to the entire health care team. be grasped.
Sample questions to improve clarity:
- Could you elaborate further on that point?
- Could you express that point in another way?
ASSESSMENT
- Could you give me an example?
1. Past - Assessment is an integral part of
2. Accuracy - Free from errors and distortion;
nursing ever since the days of
True.
Nightingale.
Sample questions to improve accuracy:
- Nurses relied on their natural senses.
- Is that really true?
- They had lesser knowledge in health
- How could we find out if that is true?
assessment.
3. Precision - Exact to the necessary level of
2. Present - Role of nurses in health assessment is
detail.
more prevalent today.
Sample questions to improve precision:
- Depth & scope of nursing assessment
- Could you give more details?
has expanded due to advances in
- Could you be more specific?
medical knowledge & technology.
4. Relevance - Relating to the matter at hand.
3. Future - Increased specialization & diversity of
assessment skills. Sample question to improve relevance:
- - How is that connected to the question?
who have strong assessment & client 5. Depth - Containing complexities and
teaching abilities. multiple interrelationships.
Sample questions to improve depth:
- How does your answer address the
CRITICAL THINKING IN HEALTH ASSESSMENT complexities in the question?
- Is that dealing with the most significant
Critical Thinking factors?
- A purposeful mental activity (problem-solving & - COLDSPAA (Character, Onset, Location,
Duration, Severity, Pattern, Associated
decision-making) that guides beliefs & actions.
Factors/Patterns/How it Affects the pt)
-

- Is self-directed, self-disciplined, self-monitored,

Lecturers: Ms. Stella Pinote, RN, MN; Mrs. Emma Dotillos RN, MN 3
NCM 101 - HEALTH ASSESSMENT
Transcribed by: Irah Mylene Del Castillo BSN 1A
Date: February 10, 17, 2022

6. Breadth - Encompassing multiple viewpoints. THE CLIENT IN CONTEXT-CULTURE, SPIRITUALITY &


Sample questions to improve breadth: FAMILY
- Do we need to consider another point of
view? Context & Health
- Is there another way to look at this question?
7. Logic - The parts make sense together, no Health assessment involves assessment of the
contradictions. individual as a whole.
Sample questions to improve logic: The individual is part of a cultural context, a
- Does this really make sense? family context, a spiritual context, & a
- Does that follow what you said? community context, all of which affect the
8. Fairness - Justifiable, not self-serving or one-
sided.
Sample questions to improve fairness: DEFINITION OF TERMS
- Do I have a vested interest in this issue? Culture The totality of socially transmissible
- Am I sympathetically representing the behavioral patterns, arts, beliefs,
viewpoints of others? values, customs, lifeways, and all
other products of human work and
thought characteristic of a
CLINICAL APPLICATION population or people that guide
You are conducting an initial comprehensive their worldview and decision
assessment of a 25-year-old female client who has making (Purnell & Paulanka, 2003).
been admitted with severe pain in her abdomen. Subculture Composed of people who have a
During the assessment she informs you that she is distinct identity and yet are related
being treated for a stomach ulcer. She also tells you to a larger cultural group.
that she has a migraine and has been taking aspirin to Race The classification of people
control it. She is afraid that she may have taken too according to shared biologic
much aspirin. She appears pale, and upon examining characteristics, genetic markers or
her, you note that the pain is originating around the features.
stomach area. Acculturation The process where people adapt to
or borrow traits from another
How should you categorize the information provided culture.
by the client into subjective and objective data? Culture Shock A disorder that occurs in response
to
Subjective Data: She is being treated for a stomach transition from one cultural setting
ulcer; she has a migraine and has to
been taking aspirin to control it; another.
she is afraid that she may have Stereotyping Assuming all members of a culture
taken too much aspirin. or ethnic groups are alike.
(verbal complaints of px) Ethnocentrism The tendency to view your own way
Objective Data: She appears pale; pain is of culture as the most desirable,
originating around the stomach acceptable, or best, and to act in a
area. superior manner toward other
cultures.

Lecturers: Ms. Stella Pinote, RN, MN; Mrs. Emma Dotillos RN, MN 4
NCM 101 - HEALTH ASSESSMENT
Transcribed by: Irah Mylene Del Castillo BSN 1A
Date: February 10, 17, 2022

Cultural The tendency to impose your Health Practices:


Imposition beliefs, values, and patterns of - Acupuncture (needles)
behavior on individuals from - Medicinal herbs
another culture. - Ventosa (cupping)
- Acupressure/massage

CHARACTERISTICS OF CULTURE Korean - Similar cultural characteristics


with the Chinese.
Learned Transmitted from generation to
- Touching someone s head is
generation; learned through life
considered disrespectful.
- Culture-bound syndrome: hwa-
Shared By all members of the group.
byung (a mental illness common
Adapted As environmental circumstances change,
in married, middle-aged women;
the group changes to improve its ability to
triggered by life crises).
Survive.
Dynamic Is ever changing. Middle - Men & women do not shake
Eastern hands, touch each other or go
together in public, unless they
THE ROLE OF CULTURE IN ILLNESS are married or belong to the
Culture- Are culturally-defined conditions same immediate person
Bound which may have no equivalent from considered family.
Syndromes a biomedical/scientific perspective. - Physically robust person
Examples: Panuhot, among the Cebuanos; considered healthy.
Empacho, among the Hispanic Americans - Culture is male-dominated.
- HC provider should only be of the
same sex.
MAJOR CULTURAL GROUPS - Culture is highly influenced by
Chinese - Eye contact may be considered Islamic religion.
disrespectful. - Culture bound syndrome: Zar
- Hesitant to ask questions; (apathy & withdrawal believed to
nodding may not mean be caused by spirit possession).
agreement.
- Respect elders & authority Hispanic - Tend to be verbally expressive,
figures. American yet values confidentiality
- (sensitive to open discussions
interpreted as disrespect for regarding sex).
others. - Believes illness to be caused
- Touching is unacceptable with either by the supernatural, as a
members of the opposite sex. punishment from God or as an
- Female clients usually prefer a imbalance between the caliente
female care provider. & frio forces.
- Family involvement in care is
preferred. Health Practices:
- Health beliefs: illness is an - when ill, first seeks advice from
imbalance between yin (cold older women in family
foods) and yang (hot foods). - then goes to either an 3jerbero
(specializes in the use of herbs)

Lecturers: Ms. Stella Pinote, RN, MN; Mrs. Emma Dotillos RN, MN 5
NCM 101 - HEALTH ASSESSMENT
Transcribed by: Irah Mylene Del Castillo BSN 1A
Date: February 10, 17, 2022

curandero/curandera Cultural Competence


(holistic healer).
- if no relief, may go to a physician - refers to an ability to interact effectively with
people of different cultures
Culture Bound Syndromes:
- mal ojo (evil eye)
- empacho (ball of food) - become sensitive to nonverbal cues
- susto (soul loss following & communication.
extreme fright) - engage in many direct cultural
- caida dela mollera (depressed encounters
fontanelle due to improper - appreciate differences, but build on
handling of infant) similarities
African Culture Bound Syndromes: - stereotyping
American - voodoo illness (as a result of - personalizing all perceived negative
witchcraft) communication
- falling out (sudden collapse, - judging others based on your
fainting or blacking out; normal personal values & rules
reaction)
Filipino - Spirituality
before discussing more serious
- A search for meaning & purpose in life, w/c
matters.
- Respect the elderly & people
older than you. to the sacred.
- Sex & socioeconomic status too - Spiritual assessment will help the nurse address
personal to discuss. -being.
- Expressing pain or crying is a sign
Religion
of weakness (esp. among males)
- Refers to rituals, practices, & experiences
Cultural Beliefs: involving a search for the sacred (God, Allah)
- believes that illness may be that are shared within a group.
caused by evil spirits; may see - Formal, organizes, ritualistic & group-oriented.
folk/faith healers.
- Each religion has different views on health.
Health Practices: MAJOR WORLD RELIGIONS AND THEIR HEALTH
- flushing (stimulating BELIEFS
perspiration) Buddhism - Prayer & meditation are used
- protection (use of amulets, for cleansing & healing.
religious medals, pictures, - Death is associated with rebirth
statues). into another form
(reincarnation).
Culture Bound Syndromes: - Many are strict vegetarians.
- Panuhot CLINICAL APPLICATION
- Nabuyagan A nurse is caring for a Chinese patient who was
- Pasmo admitted for a liver problem. When the breakfast meal
- Kabuhi tray was served, your patient called your attention and

Lecturers: Ms. Stella Pinote, RN, MN; Mrs. Emma Dotillos RN, MN 6
NCM 101 - HEALTH ASSESSMENT
Transcribed by: Irah Mylene Del Castillo BSN 1A
Date: February 10, 17, 2022

. It is contrary Christianity - Jesus Christ is the savior &


to my Buddhist beliefs to eat these hard- miracles can,happen through
prayers.
- Extreme unction for the dying
protein is too low due to your condition. Eggs are rich (pahilugan; ask for the priest to
pray for the dying).
- Emergency baptism for
te? Justify. dying/dead newborns.
- It is inappropriate. Nurses and other Judaism - Restrictions related to work on
healthcare professionals should respect a (Jews) holy days are removed to save
a life.
other foods that are rich in protein such as - Psalms & last prayer of
broccoli, spinach, and etc. confession (vidui) are held at
Hinduism - Illness is a result of past & bedside.
current life actions (karma). - At death, arms are NOT
- The right hand is seen as holy; crossed & any clothing or
thus eating & interventions bandages should be buried
needs to be with the right hand with the person.
to promote clean healing. - Diet: no mixing of meat &
- Many but not all are dairy; Kosher laws include
vegetarians; NO BEEF special slaughter & food
Islam - Prayer occurs 5 times per day: handling; unleavened bread
at dawn/sunrise, noon, only during Passover week.
afternoon, sunset, & evening. - Religious person: Rabbi
- Prayers are done facing the CLINICAL APPLICATION
East on a rug; it is preceded by You are caring for a dying Jewish patient, One day,
washing hands & feet. when you were doing your morning rounds, the
- Ladies are not to view men
other than their husbands,
naked. until noon.
- All outcomes in life are seen as
predetermined by Allah.
- It is important for dying clients - You can offer your presence as a nurse, but be
to face East & die facing East. transparent that you do not share the same
- beliefs. It might strengthen your nurse-patient
relationship.
- Consumption of pork & alcohol
- Prohibits consumption storage
is prohibited (but allowed to
Witness & transfusion of blood.
eat beef)
Mormon & - Prohibits alcohol, coffee, tea,
- Ramadan: month of fasting;
Seventh and tobacco, smoking.
refraining from eating,
Day - No pork for seventh day
drinking, having sex & indulging
Adventist Adventist and no foods that
in anything in excess or ill-
turns red like shrimps and
natured from dawn
crabs
until sunset
-

Lecturers: Ms. Stella Pinote, RN, MN; Mrs. Emma Dotillos RN, MN 7
NCM 101 - HEALTH ASSESSMENT
Transcribed by: Irah Mylene Del Castillo BSN 1A
Date: February 10, 17, 2022

FAMILY
- Consists of individuals YOU consider to be
your significant others.
The Role of Family in Illness
-
related behaviors, and the meaning of health
and illness have for the family tend to affect

- Family assessment is IMPORTANT.


Holistic Nursing
- Nursing which recognizes the biophysical &
spiritual dimensions of persons; recognizing
that individuals are unitary wholes whose
lives are intertwined with family, culture &
environment.
CLINICAL APPLICATION
You are assessing a female client who has come to the
hospital for infertility treatment. During the initial

a shaman to treat his wife along with the attending


physician. He also adds that they have always
consulted a shaman for illnesses.

How would you respond to this request?


-
request. If they are more comfortable with

that will be given to the client. Again, always


respect

Lecturers: Ms. Stella Pinote, RN, MN; Mrs. Emma Dotillos RN, MN 8

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