Julaili, Rada J.

BSN I – C
Sample Health Problems:
NCM 101j - Health Assessment  You are doing blood pressure screening at a health
center. You take the blood pressure of a middle-aged
THE NURSING PROCESS AND THE ASSESSMENT man. Your reading is 170/100.
PROCESS  You are working in the emergency department (ED)
Nursing is the diagnosis and treatment of human when a father comes in with his 9-year-old daughter.
responses to actual or potential health problems. Diagnosis and He states that she fell off her bike and hit her head but
treatment are achieved through a process, called the nursing did not lose consciousness. But she has a terrible
process, that guides nursing practice. headache and feels sick.
 You are making a postpartum follow-up visit to the
DEFINITION home of a young mother who had her first baby 2 days
 Nursing process: ago.
o systematic rational method of planning and
providing nursing care ASSESSMENT
o cyclical, that its components follow a logical  Systematic and continuous data collection,
sequence, but not more than one component organization, validation and documentation of
may be involved at one time data(information) as compared to what is standard
PURPOSE OF NURSING PROCESS norm.
 To identify a client’s status and actual or potential  It is a continuous process
health care problems or needs  All phases of nursing process depend on the accurate
 To establish plans to meet the identified needs, and complete collection of date
 To deliver specific nursing interventions to meet those
needs PURPOSE OF ASSESSMENT
CHARACTERISTICS OF THE NURSING PROCESS  Establish a data base
Dynamic and cyclic  Identify health promoting behaviors
■ Patient centered  Identify actual and/ potential health problems
■ Goal directed
■ Flexible TYPES OF ASSESSMENT
■ Problem oriented  Initial assessment
■ Cognitive  Problem focused assessment
■ Action oriented  Emergency assessment
■ Interpersonal  Time lapsed assessment
■ Holistic
■ Systematic  INITIAL ASSESSMENT
o It is done within specified time after admission
NURSING PROCESS to hospital
 Assessment o Purpose: To establish a complete data base
 Nursing Diagnosis for problem identification, reference and
 Planning future comparison
 Implementation o (Eg. Admission assessment)
 Evaluation
 PROBLEM FOCUSED ASSESSMENT
COMMUNICATION o Ongoing process integrated with nursing care
 Communication is a process of sharing o Purpose: To determine the status of specific
information and meaning, of sending and problem identified in an earlier assessment
receiving messages. The messages we o (Eg: Assessment of client’s fluid intake and
communicate are both verbal and non-verbal. urinary output in an ICU)
 Nonverbal Messages
o Nonverbal behavior is an important source of  EMERGENCY ASSESSMENT
data. message being sent is more accurate o During any physiologic and psychologic crisis
than the verbal one. of the client
o Nonverbal behavior includes vocal cues or o Purpose: To identify the threatening problem
paralinguistic, action cues or kinetics, object and to identify new and overlooked problem
cues, personal space, and touch. For o Eg: Rapid assessment of person’s airway and
example, a patient who tells you he is having breathing status and circulation during a
“crushing pain” should look like he is having cardiac arrest
“crushing chest pain.” His nonverbal behavior
should be consistent with he is telling you. So  TIME LAPSED REASSESSMENT
you would expect the tone in his voice to o Several months after initial assessment
convey “crushing pain” as he is clutching his o Purpose: To compare the client’s current
chest. status to baseline data previously obtained
 Verbal
o Vocal cues describe the quality of your voice COLLECTION OF DATA
and its inflections, tone, intensity, and speed  Is the process of gathering information about client’s
when speaking. health status. It includes the health history, physical
o These voice characteristics usually reflect examination, results of laboratory and diagnostic tests,
underlying FEELINGS. and material contributed by other health personnel.
TYPE OF DATA
1. SUBJECTIVE DATA VALIDATION OF DATA
o referred to as symptoms or covert data, are The information gathered during the assessment is
clear only to the person affected and can be “double-checked” or verified to confirm that it is
described only by that person. accurate and complete.
o Eg: itching, pain and feeling of worry
DOCUMENTATION OF DATA
2. OBJECTIVE DATA To complete the assessment phase, the nurse records
o referred to as signs or overt data, are client data. Accurate documentation is essential and
detectable by an observer or can be should include all data collected about the client’s
measured or tested against an acceptable health status.
standard. They can be seen, heard, felt or
smelled and they are obtained by observation NURSING DIAGNOSIS
or physical examination.  Is the second stage of nursing process. In this phase,
o Eg: discoloration of the skin or a blood nurses use critical thinking skills to interpret
pressure reading assessment data to identify client’s problem.
 North American Diagnosis Association (Nanda) define
SOURCES OF DATA or refine nursing diagnosis.
1. PRIMARY:
o it is the direct source of information. The client DEFINITION
is the primary source of data.  Nursing Diagnosis:
2. SECONDARY: o A clinical judgement concerning a human
o it is the direct source of information. all response to health conditions/life processes
sources other than the client are considered or a vulnerability for that response, by an
secondary sources. Family members, health individual, family, group or community”
professionals, records and reports, laboratory STATUS OF NURSING DIAGNOSIS
and diagnostic results are secondary The status of nursing diagnosis are actual health
sources. promotion and risk
1. An Actual diagnosis is a client problem that is present
METHODS OF DATA COLLECTION at the time of the nursing assessment.
The methods used to collect data are observation, interview 2. A health promotion diagnosis relates to client’s
and examination. preparedness to improve their health condition.
 Observation: it is gathering by using the senses.  A risk nursing diagnosis is a clinical judgement that a
Vision, smell, and hearing are used. problem does not exist, but the presence of risk factors
 Interview: An interview is planned communication or a indicates that problem may develop if adequate care is
conversation with a purpose. not given.
TWO APPROACHES TO INTERVIEW
 Directive interview is highly structured and COMPONENT OF NANDA NURSING DIAGNOSIS
directly ask questions. The nurse controls the 1. The problem and its definition
interview. 2. The etiology
 Non Directive interview or rapport building 3. The defining characteristic
interview and the nurse allows the client to control
the interview. 1) The problem statement describes the client’s health
problem.
STAGES OF INTERVIEW 2) The etiology component of a nursing diagnosis
An interview has three major stages: identifies causes of the health problem.
1. The opening or introduction 3) Defining characteristics are the cluster of signs and
2. The body or development symptoms that indicate the Presence of health
3. The Closing problem.

EXAMINATION FORMULATING DIAGNOSTIC STATEMENT

The physical examination is a systematic data The basic three-part nursing diagnosis statement is
collection method to detect health problems. To called the PES format and includes the following:
conduct the examination, the nurse uses techniques 1) Problem(P): statement of the client’s health problem
of: 2) Etiology (E): causes of the health problem
 Inspection 3) Signs and symptoms (S): defining characteristics
 Palpation manifested by the client.
 Percussion
 Auscultation NURSING DIAGNOSIS MEDICAL DIAGNOSIS
Statement of nursing Is made by a physician.
VALIDATING ORGANIZING AND PRIORITIZING DATA judgement that made by
nurse, by their education,
ORGANIZATION OF DATA experience and expertise
The nurse uses a format that organizes the are licensed to treat.
assessment data systematically. This is often referred
to as nursing health history or nursing assessment
form.
 Describe the human Refers to disease process.  Comparing the data with desired outcomes
response to an illness or a  Continuing, modifying or terminating the nursing care
health problem. plan
May change as the client’s May change as the client’s HEALTH HISTORY
responses change. responses change.  Is the collection of data regarding client’s health in
Ineffective breathing pattern Asthma chronological order
Activity intolerance Cerebrovascular accident
Acute pain Appendicitis PURPOSE AND TYPES OF HEALTH HISTORY
Disturbed body image Amputation  Provide subjective database.
 Identify patient strengths.
 Identify patient’s health problems., both actual and
PLANNING potential. Identify supports.
 Identify teaching needs.
 Involves decision making
 Identify referral needs.
 It is the process of formulating goals and designing the
nursing intervention required to prevent, reduce or
MEDICAL VS NURSING HISTORY
eliminate the client’s health problems.
 Physicians diagnose and treat illness.
 Nurses diagnose and treat the patient’s response to a
TYPES OF PLANNING
health problem.
1. Initial planning- done after the initial assessment
2. Ongoing planning-continuous planning
3. Discharge planning-needs after discharge
SETTING THE SCENE AND COMPONENTS OF HEALTH
HISTORY
SETTING PRIORITIES
Key points to remember when obtaining health history
 The nurse begins planning by deciding which nursing 1) Listen to what your patient is telling you both verbally
diagnosis requires attention first, which second and so
and non-verbally.
on.
2) Don’t rush. Allow enough time to obtain the data.
 Nurses frequently use Maslow’s hierarchy of needs
3) Ensure confidentiality
when setting priorities.
4) Provide a private, quite comfortable environment.
5) Avoid interruptions.
ESTABLISHING DESIRED OUTCOMES/CLIENT GOALS
6) Tell your patient how long the interview will tke and why
After, establishing priorities, the nurse set goals for
you need to ask these questions.
each nursing diagnosis. Goals may be short term or 7) Do not be so concerned about completing forms that
long term. you neglect the patient.
8) Start with what the patient perceives as the problem
NURSING INTERVENTION 9) Use an open ended question to elicit the patient's
A nursing intervention is any treatment, that a nurse perspective
performs to improve patient’s health. 10) Attend to any acute problems, such as pain, before
obtaining a detailed history.
TYPES OF NURSING INTERVENTION 11) Remember that quality is more important than the
1. Independent interventions are those activities that quantity of information obtained.
nurses are licensed to initiate on the basis of their
knowledge and skills. COMPONENT OF HEALTH HISTORY
2. Dependent interventions are activities carried out 1. Biographic data
under the orders or supervision of a licensed physician. 2. Reason for seeking health care
3. Collaborative interventions are action the nurse 3. Present/current Health History
carries out in collaboration with other health team 4. Past health history
members. 5. Family history
WRITING INDIVIDUALIZED NURSING INTERVENTIONS 6. Review of system
 After choosing the appropriate nursing interventions, 7. Socio economic history
the nurse writes them on the care plan.
 Nursing care plan is a written or computerized BIOGRAPHICAL DATA
information about the client’s care  Patient’s name, address, phone number, contact
person, age/birth date, place of birth, gender, race,
IMPLEMENTATION religion, marital status, educational level, occupation,
Consist of doing and documenting the activities.
and social security number/health insurance.
The process of implementation includes: CURRENT HEALTH STATUS
 Implementing the nursing interventions Patient is Maria dele Cruz, age 42, married, mother of
 Documenting the nursing activities three, full-time teacher. Usual state of health good. Has
yearly physical with pelvic examination and dental
EVALUATION examination. Last eye examination 1 year ago.
Is a planned, ongoing purposeful activity in which he Expresses concern regarding family history of hypertension and
nurses determines ovarian cancer.
1. Client’s progress toward achievement of ■ Usual state of health.
goals/outcomes and ■ Any major health problems.
2. Effectiveness of the nursing care plan ■ Usual patterns of healthcare.
EVALUATION INCLUDES: ■ Any health concerns.
 o Perform a symptom analysis for any positive symptom For example, a patient with right lower
that your patient reports. quadrant pain cannot have appendicitis
o PQRST provides key questions that will give you a if his or her appendix has been
good overview of any symptom. removed, but pain may be caused by
o Additional questions to ask to provide a thorough adhesions.
analysis of any presenting symptom: Serious Injuries History of serious injuries (fractures,
head injuries with loss of
■ Precipitating/Palliative Factors consciousness, motor vehicle
Ask: What were you doing when the problem started? accidents, burns, or lacerations) may
Does anything make it better, such as medications or relate to current promusculoskeletal
certain positions? Does anything make it worse, such problems or scars. blem or explain
as movement or breathing? findings during physical examination.
■ Quality/Quantity For example, past motor vehicle
Ask: Can you describe the symptom? What does it feel accident (MVA) may cause lingering
like, look like, or sound like? How often are you
experiencing it? To what degree does this problem Lack of immunization may explain
affect your ability to perform your usual daily activities current problem. Consider patient’s
■ Region/Radiation/Related Symptoms age: Ask if children have had the
Ask: Can you point to where the problem is? Does it following immunizations: measles,
occur or spread anywhere else? (Take care not to lead mumps, rubella, chickenpox, hepatitis
your patient.) Do you have any other symptoms? B, diphtheria, tetanus, polio, and
(Depending on the chief complaint, ask about related Haemophilusinfluenzae B (HIB). Ask
symptoms. For example, if the patient has chest pain, older adults if they have had a
ask if she or he has breathing problems or nausea.) pneumococcal vaccine (Pneumovax)
■ Severity and influenza (flu shot). If not
Ask: Is the symptom mild, moderate, or severe? vaccinated against tuberculosis (TB),
Grade it on a scale of 0 to 10, with 0 being no symptom ask about last purified protein derivative
and 10 being the most severe. (Grading on a scale (PPD) test. Consider where patient
helps lives:
objectify the symptom.) In the United States, people are not
■ Timing routinely immunized against TB, but in
Ask: When did the symptom start? How often does it other countries where incidence of TB
occur? How long does it last? is high, bacille Calmette-Guérin (BCG)
vaccine may be used.
Medications Medications may be causing current
PAST HEALTH HISTORY problem. For example, over-the-
The past health history assesses: counter (OTC) medication may be
o childhood illnesses, Hospitalizations, surgeries, interacting with a prescribed
serious injuries adult medical problems (including medication, causing adverse effects
serious or chronic illnesses), immunizations, allergies, or negating desired effects. Allows you
medications, recent travel, and military service. to assess patient’s understanding of
her or his medications, which may
PURPOSE identify teaching needs. Ask about
 to identify any health factors from the past that may prescribed and OTC medications,
have a direct relationship to your patient’s current including vitamins, supplements, and
health status. For example, a history of rheumatic fever herbs. Obtain name of medication,
as a child may explain mitral valve disease as an adult. dose, frequency, and last time taken.
Recent Travel May identify exposure to health
DATA SIGNIFICANT/CONSIDERATION hazards and explain presenting
Childhood Positive history of mumps, chickenpox, symptoms (e.g., traveler’s
Illnesses rubella, frequent ear infections, Diarrhea, covid).
frequent streptococcal infections or Military Service Recent or past military service may
sore throats, rheumatic fever, scarlet identify exposure to health hazards. For
fever, pertussis, or asthma may have a example, exposure to Agent Orange
direct link to current health problem during Vietnam War is risk factor for
(e.g., history of chickenpox explains cancer, and exposure to chemical
current shingles). toxins during Operation Desert Storm is
Hospitalizations Previous hospitalizations may have a risk factor for later health problems.
direct link to current problem or provide
clues to preexisting problems. Knowing FAMILY HISTORY
name of hospital and dates facilitates  Provides clues to genetically linked or familial diseases
record retrieval. Ask about that may be risk factors for your patient.
hospitalizations for both physical and  Ask about the health status and ages of your patient’s
psychological problems. family members. Family members include the patient,
Surgeries Knowing past surgical procedures may spouse, children, parents, siblings, aunts and uncles,
rule out certain problems or explain and grandparents. Ask about genetically linked or
others. common diseases, such as heart disease, high blood
pressure, stroke, diabetes, cancer, obesity, bleeding
 disorders, tuberculosis, renal disease, seizures, or Ears Last hearing test, difficulty hearing,
mental disease. If the patient’s family members are sensitivity to sounds, ear pain,
deceased, record the age and cause of death. drainage, vertigo, ear infections,
ringing, fullness in ears, ear wax
FAMILY HISTORY BY LISTING FAMILY MEMBERS problems, use of hearing aids, ear-
Patient: Age 37, alive and well care habits, such as use of cotton-
Spouse: Age 40, divorced, alcoholism tipped swabs.
Daughter: Age 12, alive and well Nose and Sinuses Nosebleeds, broken nose, deviated
Son: Age 8, alive and well septum, snoring, postnasal drip,
Brother: Age 32, alive and well runny nose, sneezing, allergies, use
Sister: Age 30, alive and well of recreational drugs, difficulty
breathing through nose, problem
with ability to smell, pain over
sinuses, sinus infections.
REVIEW OF SYSTEM Mouth and Throat Sore throats, streptococcal
 To obtain the current and past health status of each infections, mouth sores, oral herpes,
system bleeding gums, hoarseness,
 To identify health problems that your patient may have changes in voice quality, difficulty
failed to mention previously. Remember, if your patient chewing or swallowing, changes
has an acute problem in one area, every other body in sense of taste, dentures and
system will be affected, so look for correlations as you bridges, description of dental health,
proceed with the ROS. dental surgery, last dental
 Perform a symptom analysis for every positive finding examination, dental hygiene
and determine the effect of and the patient’s response patterns.
to, this symptom. Provides clues to health promotion Respiratory Breathing problems; cough; sputum
activities for each particular system. Identify health (color and amount); bloody sputum;
promotion activities and provide instruction as needed shortness of breath (SOB) with
 As you proceed with the ROS, consider any prescribed activity; noisy respirations such as
or over-the-counter medications your patient is taking wheezing (as is seen with asthma);
and how they affect every system. This may help pneumonia; bronchitis; tuberculosis
explain some of your findings. (TB); last chest x-ray and results;
purified protein derivative (PPD) and
AREA/SYSTEM ASK ABOUT results; history of smoking.
General Health Unusual problems or symptoms, Cardiovascular awakening at night with SOB; dizzy
Survey fatigue, exercise intolerance, spells; cold or numb hands and feet;
unexplained fever, night sweats, color changes in hands and feet;
weakness, difficulty doing activities pain in legs while walking; swelling
of daily living (ADLs), number of of extremities; hair loss on legs;
colds or illnesses per year. sores that do not heal; results of
Integumentary Skin diseases, such as psoriasis, electrocardiogram, if ever done.
itching, rashes, scars, sores, ulcers, Breasts Breast masses, lumps; pain,
warts, and moles; changes in skin discharge, swelling; changes in
lesions; skin reaction to hot and cold. breast or nipples; cystic breast
Changes in hair texture, baldness, disease; breast cancer; breast
usual patterns of hair care (e.g., surgery, reduction, enhancements;
shampooing, coloring, permanents). breast self-examination (BSE)
Changes in nails (e.g., color, texture, (when and how); date of last clinical
splitting, cracking, breaking); usual breast examination; date of last
patterns of nail care (e.g., use of mammogram, if ever done.
polish, acrylic nails). Gastrointestinal Loss of appetite; indigestion;
Head and Neck Headaches; lumps; scars; recent heartburn; gastroesophageal reflux
head trauma, injury, or surgery; disease (GERD); nausea; vomiting;
history of concussion or loss of vomiting blood; liver or gallbladder
consciousness; dizzy spells; disease; jaundice; abdominal
fainting; stiff neck; pain with swelling; regular bowel patterns;
movement of head and neck; changes in bowel patterns; color of
swollen glands, nodes, or masses. stool; diarrhea; constipation;
Eyes Wearing glasses or contact lenses, hemorrhoids; weight changes; use
visual deficit, last eye examination, of laxatives and antacids; date and
last glaucoma check, eye injury, results of last fecal occult blood test,
itching, tearing, drainage, pain, if ever done.
floaters, halos, loss of vision or parts Genitourinary Pain on urination; burning;
of fields, blurred vision, double frequency; urgency; dribbling;
vision, colored lights, flashing lights, incontinence; hesitancy; changes in
light sensitivity, twitching, cataracts urine stream, color of urine; history
or glaucoma, eye surgery, retinal of urinary tract infections, kidney
detachment, strabismus, or infections, kidney disease, kidney
amblyopia. stones, frequent nighttime urination.
Female Reproductive Menarche; description of cycle; last NURSING HEALTH ASSESSMENT
menstrual period; painful
menstruation; excessive bleeding; PHYSICAL ASSESSMENT
irregular menses; bleeding between Complete PHYSICAL ASSESSMENT
periods; last Pap test and results;  General Survey
satisfaction with sexual  Vital Sign Measurement
performance; painful intercourse;  Assessment of Height and Weight
use of contraceptives; history of  Physical Examination of all structures, organs and
sexually transmitted disease (STD); body systems
knowledge of prevention of STDs
including human immunodeficiency FOCUSED PHYSICAL ASSESSMENT
virus (HIV); infertility problems;  Zeros in the acute problem (unstable, time constraint)
obstetrical history including
pregnancies, live births, EXAMINATION EQUIPMENT PURPOSE
miscarriages, abortions. All Gloves and gown Protect examiner
Male Reproductive Lesions; discharge; pain on examinations in any part
urination; painful intercourse; Vital Signs Sphygmomanometer Measure diastolic
prostate or scrotal problems; history and systolic blood
of STDs, infertility problems, pressure
impotence, or sterility; satisfaction Thermometer Measure body
with sexual performance; knowledge temperature
of prevention of STDs including HIV; Watch with Take heart rate,
use of contraceptives; frequency second hand pulse rate
and technique for testicular self-
Pain rating scale Determine
examination, if ever done; date and
perceived pain
results of last prostate examination,
level
if ever done.
Nutritional Skinfold calipers Measure skinfold
Musculoskeletal Fractures, sprains, muscle cramps,
status thickness of
pain, weakness, joint swelling,
subcutaneous
redness, limited range of motion,
tissue
joint deformity, noise with
Flexible tape Measure mid arm
movement, spinal deformities, low
measure circumference
back pain, loss of height,
Skin-marking pen Mark
osteoporosis, degenerative joint
measurements
disease, or rheumatoid arthritis;
impact on ability to do ADLs; use of Platform scale with Measure height
calcium supplements. height attachment and weight
Neurological Loss of consciousness; fainting; Skin, hair and Examination light, Provide adequate
seizures; head injury; changes in nail penlight lighting
cognition or memory; hallucinations; Mirror Client’s self-
disorientation; speech problems; examination of
sensory disturbances such as the skin
numbness, tingling, or loss of Metric ruler Measure size of
sensations; motor problems; skin lesions
problems with gait, balance, or Magnifying glass Enlarge visibility
coordination; and impact on ability to of lesion
do ADLs. Wood’s light Test for fungus
Endocrine Endocrine disorders such as thyroid Braden scale Predict one’s risk
disease or diabetes; unexplained to develop
changes in weight or height; pressure sore
increased thirst, hunger, or urination; Head and neck Stethoscope Auscultate the
heat and cold thyroid
Immune/Hematologic Anemia, bleeding disorders; Small cup of water Help client
recurrent infections; cancers; HIV; swallow
fatigue; blood transfusion; bruising; Eye Penlight Test pupillary
allergies; unexplained swollen examination constriction
glands. Snellen E chart Test distant
vision
Newspaper Test near vision
Opaque card Test for
strabismus
Ophthalmoscope View the red
reflex and
examine retina of
the eye
Ear Tuning fork Test for bone and
examination air conduction of
sound
 Otoscope View the ear Tongue depressor Test for gag
canal and reflex and rise of
tympanic uvula
membrane Tuning fork Vibratory
Thoracic and Stethoscope Auscultate breath sensation
lung sounds Male genitalia Gloves and water- Promote comfort
examination and rectum soluble lubricant for client
Metric ruler and skin Measure Penlight Scrotal
marking pen diaphragmatic illumination
excursion Specimen card Detect occult
Mouth, throat, Penlight Provide light to blood
nose and sinus view the mouth Female Vaginal speculum Inspect cervix
and the throat genitalia and and water- soluble through dilatation
4 x 4 small gauze Grasp tongue to rectum lubricant of the vaginal
pad examine mouth canal
Tongue depressor Depress tongue Bifid spatula, Obtain
to view throat, endocervical broom endocervical
check looseness swab and cervical
of teeth view scrape and
cheeks and vaginal pool
check strength of sample
tongue Large swabs Vaginal
Otoscope with wide View internal examination
tip attachment nose Liquid pap medium Pap smear
Heart and neck Stethoscope Auscultate heart Specimen card Detect occult
vessel sounds blood
Two metric rulers Measure jugular
venous pressure
Peripheral Sphygmomanometer Measure blood
vascular and stethoscope pressure and
auscultate
vascular sounds
Flexible metric Measure size of
measuring tape extremities for
edema
Tuning fork Detect vibratory
sensation
Doppler ultrasound Detect pressure
and weak pulses
Abdominal Stethoscope Detect bowel
sounds
Flexible metric Measure size and
measuring tape and mark the area of
skin marking pen percussion of
organs
Two small pillows Place under
knees and head
to promote
relaxation of
abdomen
Musculoskeletal Flexible metric Measure size of
examination measuring tape extremities
Goniometer Measure degree
of flexion and
extension of
joints
Neurologic Cotton-tip applicator Test taste/smell
perception
Objects to feel Test for stereo
gnosis
Reflex hammer Test deep tendon
reflexes
Cotton ball and clip Test for light,
sharp and dull
touch