NCM 101 - Health Assessment: Topic Outline
NCM 101 - Health Assessment: Topic Outline
NCM 101 - Health Assessment: Topic Outline
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
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
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
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
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
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
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
Lecturers: Ms. Stella Pinote, RN, MN; Mrs. Emma Dotillos RN, MN 8