HEALTH ASSESSMENT / BSN

S.Y. ‘24 - ‘25 | SEM 2 Q3 | Dra. April Monilla JANNELLA Q. ZULUETA

– SEM 2 Q3 WEEK 1 –
1.2 TYPES OF ASSESSMENT
1 NURSING PROCESS
1.​ INITIAL ASSESSMENT - Performed within a
➢​ Systematic, rational method of planning and specified time after admission to a healthcare
providing individualized nursing care. agency.
➢​ Origin: 2.​ PROBLEM FOCUSED - Ongoing process
○​ Hall (1995) integrated with nursing care.
○​ Johnson (1959) 3.​ EMERGENCY - During any physiologic crisis of
○​ Orlando (1961) the patient.
○​ Weidenbach (1963) 4.​ TIME-LAPSED REASSESSMENT - Several
➢​ Series of phases to describing the practice of months after assessment.
nursing

1.3 COMPONENT OF NURSING

PURPOSE ASSESSMENT
➢​ Identify the client’s health status and actual or
➢​ Client’s perceived needs
potential healthcare problems or needs
➢​ Health problems
➢​ Establish plans to meet the identified needs.
➢​ Related experience
➢​ Deliver specific nursing interventions to meet
➢​ Health practices, values, and lifestyle
those needs.

JOINT COMMISSION NURSING PRACTICES

ADPIE
➢​ ASSESSMENT - collect data, organize data, Each client should have A licensed practical nurse
validate data, and document data. an initial nursing (LPN) may gather the data
➢​ DIAGNOSIS - Analyze data and identify health assessment consisting of but the registered nurse
problems, risks, and strengths. Formulate a history and physical (RN) is responsible for
diagnostic statement. examination performed care and must assess the
➢​ PLANNING - Prioritize problems or diagnoses, and documented within data determining the
formulate goals or desired outcomes, and 24 hours of admission as needs of the client.
select nursing interventions. Write nursing an inpatient
intervention.
➢​ IMPLEMENTATION - Reassess the client,
determine the nurse's need for assistance, and
implement the nursing intervention. Supervise TYPES OF DATA
delegated care and document nursing
activities. SUBJECTIVE DATA OBJECTIVE DATA
➢​ EVALUATION - Collect data related to
outcomes, compare data with outcomes, and ➢​ Symptoms or ➢​ Signs or overt
relate nursing actions to client goals or covert data data
outcomes. Draw conclusions about the ➢​ Apparent only to ➢​ Detectable by
problem status and continue to modify or the affected an observer
terminate the client’s care plan. individual ➢​ Can be
➢​ ➢​ Can be described measured or
or verified only by tested against
1 ASSESSMENT that individual an accepted
➢​ Systematic and continuous collection, ➢​ Client’s sensations, standard
organization, validation, and documentation of feelings, values, ➢​ Can be seen,
data. beliefs, and heard, felt or
➢​ A continuous process carried out during the perceptions of smelled and
nursing process personal health. obtained by
➢​ Focus on a client’s responses to a health observation and
problem physical
➢​ Vary according to the purpose, timing, time examination.
available, and client status.

PPT | LECTURE | HEALTH ASSESSMENT MC 3 SEM1 Q2 REVIEWER PAGE 1

@wonrika
 HEALTH ASSESSMENT / BSN
S.Y. ‘24 - ‘25 | SEM 2 Q3 | Dra. April Monilla JANNELLA Q. ZULUETA

➢​ restating> increases the chance of changing

1.4 TYPES OF ASSESSMENT the original meaning
5.​
1.​ COMPLETE (TOTAL HEALTH) DATABASE - 2.0 DIAGNOSING
Complete history and full physical examination
2.​ FOCUSED / PROBLEM CENTERED DATABASE ➢​ The second phase of the nursing process is
- For limited or short-term problem “mini” where nurses use critical thinking skills to
database - smaller in scope and more targeted interpret assessment data and identify client’s
3.​ FOLLOW-UP DATABASE - “what change has strengths and problems.
occurred?” “is the problem getting better or DIAGNOSING
worse?” “which coping strategies are used?” ➢​ refers to the reasoning process
4.​ EMERGING DATABASE - an urgent, rapid DIAGNOSIS
collection of crucial information. Complied ➢​ a statement or conclusion regarding the nature
concurrently with lifesaving measures of a phenomenon.
DIAGNOSTIC PROCESS
➢​ Contains a diagnostic phrase or diagnostic
1.5 SOURCES OF DATA label followed by an etiology phrase
➢​ Client support people ➢​ Diagnostic phrase or label> statement of the
➢​ Client records client’s problem
➢​ Healthcare professionals ➢​ etiology> casual relationship between the
➢​ Literature client’s problem or risk factors.

1.6 DATA COLLECTION METHOD 2.1 NURSING DIAGNOSIS

OBSERVING ➢​ Fulfills the need for a standardized nursing

➢​ Gather data using senses; vision, smell, language to describe client problems
hearing, touch conscious, deliberate skill. ➢​ Helps define the scope of nursing practice>
INTERVIEWING describing conditions the nurse can
➢​ Planned communication or conversation with independently treat
a purpose ➢​ Highlights critical thinking and
EXAMINING decision-making
➢​ Systematic data collection method that uses ➢​ Provides consistent and universally
observation to detect health problems understood terminology
➢​ Its domain includes only those health states
where nurses are educated and licensed to
1.7 ORGANIZING & VALIDATING DATA treat
➢​ Is a judgment made only after thorough,
ORGANIZING
systematic data collection.
➔​ Uses a written (or electronic) format tha
organizes the assessment data systematically
➔​ Nursing history 2.2 DIAGNOSTIC PROCESS
➔​ Nursing assessment
➔​ Nursing database ➢​ Uses the critical thinking skills of analysis and
VALIDATING synthesis
➔​ Act of “double checking” or verifying data to CRITICAL THINKING
confirm that it is accurate and factual ➔​ An individual reviews data and considers
explanation before forming an opinion
ANALYSIS
1.7 DOCUMENTING DATA ➔​ Separation into components (deductive
reasons)
➢​ The nurse records client data
STEPS:
➢​ Accurate documentation
1.​ Analyzing data
➢​ Data are recorded in a factual manner and are
2.​ Identifyin health problems, risks and strengths
not interpreted by the nurse
3.​ Formulating diagnostic statements
➢​ Records subjective data in the client’s own
words, using quotation marks

PPT | LECTURE | HEALTH ASSESSMENT MC 3 SEM1 Q2 REVIEWER PAGE 2

@wonrika
 HEALTH ASSESSMENT / BSN
S.Y. ‘24 - ‘25 | SEM 2 Q3 | Dra. April Monilla JANNELLA Q. ZULUETA

ANALYZING DATA 2.4 FORMULATING DIAGNOSTIC

STATEMENTS
Compare Cluster the Cues Identify Gaps
Data Against and BASIC TWO-PART STATEMENTS
Standards Inconsistencies
BASIC TWO-PART STATEMENT
Standard or Determining Inconsistencies
norm is a whether any are conflicting PROBLEM RELATED TO ETIOLOGY
generally patterns are data
accepted present, whether Constipation Related to Prolonged
measure, the data laxative use
rule, model represent
or pattern isolated Anxiety Related to Threat to
incidents, and physiologic
whether the data integrity:
are significant. possible cancer
diagnosis
Involves making All
inferences about inconsistencies
the data must be clarified BASIC THREE-PART STATEMENTS
before a valid PROBLEM - Statement of the client’s response
pattern can be ETIOLOGY - Factors contributing to or probable cause
established of the responses
SIGNS & SYMPTOMS - Defining characteristics
Growth and Process of Measurement manifested by the client
development determining the erro,
BASIC THREE-PART STATEMENT
pattern, relatedness of expectations and
normal vital facts inconsistent or PROBLEM RELATED ETIOLOGY AS SIGNS &
signs, unreliable TO MANIFESTED
BY
SYMPTOMS

laboratory reports
values Impair Related Feelings As Hyperse
ed to of manifest nsitivity
sellf rejection ed by to
estee by criticism;
2.3 IDENTIFYING HEALTH PROBLEMS, m husband states “I
RISKS & STRENGTHS dont
know if I
IDENTIFYING HEALTH PROBLEMS, RISKS
an
➢​ Identify problems that support tentative manage
actual risk and potential diagnosis by
➢​ Determine whether the client’s problem is myself”
a nursing diagnosis, medical, or a rejects
collaborative diagnosis. positive
IDENTIFYING HEALTH PROBLEMS, RISKS feedbac
➢​ Establishes the client’s strengths, k
resources, and abilities to cope.
➢​ The client can develop a more
well-rounded self-concept and self-image
➢​ Can be an aid in mobilizing health and
regenerative processes.

PPT | LECTURE | HEALTH ASSESSMENT MC 3 SEM1 Q2 REVIEWER PAGE 3

@wonrika
 HEALTH ASSESSMENT / BSN
S.Y. ‘24 - ‘25 | SEM 2 Q3 | Dra. April Monilla JANNELLA Q. ZULUETA

➢​ Word the diagnosis specifically and precisely

to provide direction for planning nursing
2.5 GUIDELINES FOR WRITING DIAGNOSTIC intervention
STATEMENTS
CORRECT STATEMENT INCORRECT STATEMENT
➢​ State in terms of a problem, not a need.
CORRECT STATEMENT INCORRECT STATEMENT Alteration in mucus Alteration in mucus
membrane integrity membrane integrity
Alteration in fluid volume Fluid replacement (need) related to decreased related to noxious agent
(problem) related to fever related to fever salivation secondary to (vague)
radiation of the neck
(specific)
➢​ Word the statement so that it is legally
advisable
➢​ Use nursing terminology rather than medical
CORRECT STATEMENT INCORRECT STATEMENT
terminology to describe the client’s response
Altered skin integrity Altered skin integrity CORRECT STATEMENT INCORRECT STATEMENT
related to immobility ( related to improper
legally acceptable) positioning (implies legal Potential for altered Potential for pneumonia
liability) respiratory status related (medical terminology)
to an accumulation of
secretions in lungs
➢​ Use nonjudgemental statement (nursing terminology)
CORRECT STATEMENT INCORRECT STATEMENT
➢​ Use nursing terminology rather than medical
Impaired spirituality Impaired spirituality terminology to describe the probable cause of
related to the inability to related to strict rules the client’s response
attend church services necessitating church
secondary to immobility attendance (judgmental) CORRECT STATEMENT INCORRECT STATEMENT
(non-judgment)
Potential for altered Potential for altered
respiratory status related respiratory status related
➢​ Make sure that both element of the statement to an accumulation of to emphysema (medical
do not say the same thing secretions in lungs terminology)
CORRECT STATEMENT INCORRECT STATEMENT (nursing terminology)

Potential for altered skin Altered skin integrity

integrity related to related to ulceration of
immobility sacral area (response
and probable cause are
the same)
3.0 PLANNING
➢​ Be sure that cause and effect are correctly ➢​ An intentional systematic phase of the
stated (i.e. the etiology causes the problem or nursing process
puts the client at risk for the problem) ➢​ Involves decision-making and
CORRECT STATEMENT INCORRECT STATEMENT problem-solving
➢​ Refers to the client’s assessment data and
Pain: severe headache Pain related to headache diagnostic statements for direction in
related to avoidance of formulating client goals and designing the
narcotics due to fear of nursing interventions.
addiction
NURSING INTERVENTION
➔​ Any treatment based upon clinical
judgment and knowledge that a nurse
performs to enhance the patient.

PPT | LECTURE | HEALTH ASSESSMENT MC 3 SEM1 Q2 REVIEWER PAGE 4

@wonrika
 HEALTH ASSESSMENT / BSN
S.Y. ‘24 - ‘25 | SEM 2 Q3 | Dra. April Monilla JANNELLA Q. ZULUETA

PLANNING
3.4 GUIDELINES FOR WRITING NURSING
➔​ Input from the client and support person is
CARE PLANS
essential.
➔​ Nurses do not plan for the client but DATE & SIGN THE PLAN
encourage the client to participate actively ➢​ The date is essential for evaluation,
to the extent possible. review, and future planning
➢​ Nurse signature> accountability to the
client and nursing profession
3.1 TYPES OF PLANNING
USE CATEGORY HEADINGS
1.​ INITIAL PLANNING - initiated as soon as ➢​ Nursing diagnosis
possible after the initial assessment ➢​ Goals or desired outcomes
2.​ ONGOING PLANNING - as nurses obtain ➢​ Nursing intervention and evaluation
new information and evaluate the client’s USE STANDARDIZED, APPROVED MEDICAL
responses to care they individualize the SYMBOLS & KEYWORDS
initial care.
3.​ DISCHARGE PLANNING - process and BE SPECIFIC
planning for needs after discharge ➢​ e.g. write down specific times during the
24hrs period

3.3 DEVELOPING NURSING CARE PLANS REFER TO PROCEDURE BOOKS OR OTHER

SOURCES OF INFORMATION
➢​ e.g. see procedure book for tracheostomy
INFORMAL NURSING CARE PLAN care.
➢​ Strategy to action that exists in the nurse’s TAILOR THE PLAN TO THE UNIQUE
mind CHARACTERISTICS OF THE CLIENT
➢​ e.g. Mrs. Phan is very tired. I will need to ➢​ Ensure that the client’s choices such as
reinforce her teaching after she is rested preferences about the times of care and
FORMAL NURSING CARE PLAN the methods used are included
➢​ Written or computed guide that organizes
information about the client’s care ENSURE THAT THE NURSING PLAN
STANDARDIZED CARE PLAN INCORPORATES PREVENTIVE AND HEALTH
➢​ Tailored to meet the unique needs of a MAINTENACE ASPETCS AS WELL AS
specific client - needs that are not RESTORATIVE ONES
addressed by the standardized plan.
ENSURE THAT THE PLAN CONTAINS ONGOING
ASSESSMENT OF THE CLIENT
CARE PLANS
➢​ Include the actions nurses must take to INCLUDE COLLABORATIVE AND COORDINATION
address the client’s nursing diagnoses and ACTIVITIES IN THE PLAN
produce the desired outcome
➢​ Decide which of the client’s problems INCLUDE A PLAN FOR THE CLIENT’S
need individualized plans DISCHARGE AND HOME CREDIT
➢​ Which problems can be addressed by
standardized plans and routine care
➢​ Write individualized desired outcomes and
nursing interventions

PPT | LECTURE | HEALTH ASSESSMENT MC 3 SEM1 Q2 REVIEWER PAGE 5

@wonrika
 HEALTH ASSESSMENT / BSN
S.Y. ‘24 - ‘25 | SEM 2 Q3 | Dra. April Monilla JANNELLA Q. ZULUETA

➢​ Date nursing interventions on the care

3.4 THE PLANNING PROCESS
plan when they are written and review
regularly at intervals that depend on the
SETTING PRIORITIES individual’s needs
➢​ High priority > life-threatening problems ○​ Intensive care unit - plan of care
➢​ Medium priority > Health threatening will be continually monitored and
problems revised
➢​ Low priority > requires only minimal ○​ Community clinic - weekly or
nursing support biweekly reviews may be indicated
➢​ Time element - when, how long, and how
FACTORS TO CONSIDER WHEN SETTING often the nursing action is to occur
PRIORITIES ➢​ Signature of the nurse > accountability
➢​ Client’s health values and beliefs and legal significance
➢​ Client’s priorities
➢​ Resources available to the nurse and
client
➢​ The urgency of the health problem 4.0 IMPLEMENTING
➢​ Medical treatment plan
➢​ Doing and documenting the activities that
ESTABLISHING CLIENT GOALS OR OUTCOMES are the specific nursing actions needed to
➢​ Describe in terms of observable client carry out the interventions
responses ➢​ The nurse performs or assigns the nursing
➢​ What the nurse hopes to achieve by activities for the interventions that were
implementing the nursing intervention. developed.
➢​ Goals - broad statements about the ➢​ Conclude the implementing step >
client’s status recording nursing activities and the
➢​ Outcomes - more specific observable resulting client responses
criteria used to evaluate whether the goals ➢​ Coordination of care
have been met ➢​ Health teaching and health promotion
. ➢​ Consultation
SELECTING NURSING INTERVENTIONS AND
ACTIVITIES
➢​ Actions that a nurse performs to achieve 4.1 PROCESS OF IMPLEMENTING
client goals
1.​ Reassessing the client
➢​ Should focus on eliminating or reducting
2.​ Determining the nurse’s need for
the etiology of the nursing diagnosis
assistance
➢​ If changing the etiologic factors is not
3.​ Implementing the nursing interventions
possible > treat the signs and symptoms
4.​ Supervising the assigned care
➢​ Focus on measures to reduce the client’s
5.​ Documenting nursing activities
risk factors

4.2 IMPLEMENTING THE NURSING

TYPES OF NURSING INTERVENTION
INTERVENTIONS
1.​ Independent interventions
2.​ Dependent intervention
• Base nursing interventions on scientific
3.​ Collaborative intervention
knowledge, nursing research, and professional
standards of care (evidence-based practice)
WRITING INDIVIDUALIZED NURSING
when these exist
INTERVENTION

PPT | LECTURE | HEALTH ASSESSMENT MC 3 SEM1 Q2 REVIEWER PAGE 6

@wonrika
 HEALTH ASSESSMENT / BSN
S.Y. ‘24 - ‘25 | SEM 2 Q3 | Dra. April Monilla JANNELLA Q. ZULUETA

• Clearly understand the nursing interventions ○​ status of goal achievement

to be implemented and question any that are ○​ client's self-care abilities with
not understood regard to following up core
• Adapt activities to the individual client
• Implement safe care ➢​
• Provide teaching, support and comfort
• Be holistic
• Respect the dignity of the client and enhance 4.5 EVALUATION PHASE
the client's self-esteem
Collecting data related to the desired outcomes
• Encourage clients to actively participate in
➢​ Collecting data related to the desired
implementing the nursing interventions
outcomes
○​ Did the client improve or
deteriorate compared to the
4.0 EVALUATING presisus evaluation?
➢​ to judge or to appraise
➢​ planned, ongoing, purposeful activity in ➢​ Comparing the data with the desired
which clients and healthcare outcomes
professionals determine ○​ What improvements have been
➢​ the client's progress towards made in client care
achievement of goals or outcomes
➢​ effectiveness of the nursing care plan ➢​ Relating nursing activities to outcomes\
➢​ conclusions drawn determine whether ○​ Have the nursing interventions
the nursing interventions should be resulted in the attainment of
terminated, continued or changed outcomes
➢​ sixth standard of the ANA Standards of
Practice "the registered nurse evaluates ➢​ Drawing conclusions about the problem
progress towards attainment of status
outcomes” ○​ What outcomes have been
attained?

➢​ Continuing, modifying, or terminating the

4.4 EVALUATION nursing care plan
○​ What changes are needed in the
➢​ Evaluation is done while or immediately plan of care to attain outcomes?
after Implementing a nursing order
➢​ enables the nurse to make an
on-the-spot modifications
➢​ Evaluation performed at specified
intervals
○​ shows the extent of progress
towards achievement of goals or
outcomes
○​ enables to correct any
deficiencies and modify the care
plan as needed
➢​ Evaluation continues until the client
achieves the health goals or is
discharged from nursing care
➢​ Evaluation at discharged

PPT | LECTURE | HEALTH ASSESSMENT MC 3 SEM1 Q2 REVIEWER PAGE 7

@wonrika
 HEALTH ASSESSMENT / BSN
S.Y. ‘24 - ‘25 | SEM 2 Q3 | Dra. April Monilla JANNELLA Q. ZULUETA

➢​ Sign
5.0 HEALTH HISTORY ○​ abnormality that can be detected
in physical examination or in
laboratory studies
➢​ collect subjective data
➢​ forms the database when combined with ➢​ Symptom
the objective data ○​ the subjective sensation that the
➢​ provides a comprehensive portrait of the person feels from the disorder
patient's past and present health
➢​ Component: ➢​ replaced with "reason for seeking
○​ Biographic Data care”
○​ Reason for Seeking Care (Chief ➢​ enclosed in quotation marks to indicate
Complaint) the person's exact words
○​ Present health or history of
present illness
○​ Current medication
○​ Family history PRESENT HEALTH / HISTORY OF
○​ Review of Systems PRESENT HEALTH
○​ Functional assessment of ➢​ For the Well Person
activities of daily living (ADLs) ○​ short statement about general
state of health

BIOGRAPHIC DATA ➢​ For the ill Person

○​ chronological record of the
• Name reason for seeking care, from the
• Address and phone number; email address time the symptom first started
• Age and Birthdate until the present
• Birthplace
• Gender
• Marital Status
• Race, Ethnic Origin
• Occupation CHARACTERISTICS OF THE SYMPTOMS
• Language and Communication Needs • Location
• Character
• Severity
SOURCES OF HISTORY • Timing (Onset, Duration, Frequency)
• Setting
• Record who furnishes the information • Aggravating or Relieving Factors
• Judge how reliable the information seems • Associated Factors
■ same answers with questions that are • Patient's Perception
rephrased
• Note any special circumstances ●​ P: Provocative and Palliative
■ use of an interpreter ●​ Q: Quality or quantity
●​ R: Region of radiation
●​ S: Severity Scale
●​ T: Timing (Onset, Duration, and
REASONS FOR SEEKING CARE (CHIEF Frequency)
COMPLAINT) ●​ U: Understand the patient's perception
brief spontaneous statement in the patient's of the problem
own words that describes the reason for the
visit

PPT | LECTURE | HEALTH ASSESSMENT MC 3 SEM1 Q2 REVIEWER PAGE 8

@wonrika
 HEALTH ASSESSMENT / BSN
S.Y. ‘24 - ‘25 | SEM 2 Q3 | Dra. April Monilla JANNELLA Q. ZULUETA

❖​ Skin
PAST HEALTH HISTORY ➢​ History of skin disease, change in
pigmentation, texture or color,
➢​ Childhood Illness change in a mole, excessive
➢​ Accidents or Injuries dryness, sweating, pruritus, hair
➢​ Serious or Chronic Illness growth, and distribution
➢​ Hospitalizations
➢​ Operations ❖​ Hair
➢​ Obstetric History ➢​ Recent loss, change in texture,
➢​ Last Examination Date Nail: change in shape, color or
➢​ Allergies brittleness

❖​ Head
PAST HEALTH HISTORY ➢​ any unusual or frequent
headache, head injury, dizziness,
➢​ Current Medications
vertigo
○​ Prescription, Over the Counter,
Herbal Remedies
❖​ Eyes
○​ Vitamins, Birth Control Pills,
➢​ Difficulty with vision, eye pain,
Aspirin and antacids
diplopia, redness or swelling.
○​ Name, Dose, Frequency, Use
watery discharge, glaucoma,
and Duration
cataract, photophobia, itching
○​ Ensures evaluation of
medications taken by the patient
❖​ Ears
by the physician
➢​ Earaches, infections, discharge
○​ Medication Reconciliation
and its characteristics, tinnitus,
■​ Comparison of a list of
vertigo
current medication with
the previous list
❖​ Nose and Sinuses
➢​ discharge and its characteristics,
any unusually frequent or severe
FAMILY HISTORY colds, sinus pain, nasal
❖​ age and health or age and cause of obstruction, nosebleeds,
death of relatives allergies, change in the sense of
❖​ prolonged contact with any smell
communicable diseases
❖​ family history of heart disease, high ❖​ Mouth and Throat
blood pressure, stroke, diabetes, blood ➢​ mouth pain, frequent sore throat,
disorders, cancer, anemia, arthritis, bleeding gums, tootache,
allergies, obesity, seizure, tuberculosis lesion in the mouth and tongue,
❖​ pedigree or genogram dysphagia, hoarseness, altered
taste

REVIEW OF SYSTEMS
❖​ General Overall Health State
➢​ Present weight, fatigue,
weakness or malaise, fever,
chills, sweatss or night sweats

PPT | LECTURE | HEALTH ASSESSMENT MC 3 SEM1 Q2 REVIEWER PAGE 9

@wonrika