Dr. Gerald B. Fiel, RN, MAN-MSN.

Clinical Instructor
Christ The King College

Contact number : +639569068801

Email address: geraldfiel52290@gmail.com
 NEW NORMAL CASSROOM RULES

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 NEW NORMAL CASSROOM RULES

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Do you want to become an effective & efficient NURSE?

START NOW!!
 EXPECTATION
FIRST YEAR
GRADUATION

PRAY
HAVE FUN
CONFIDENCE
BASIC
KNOWLEDGE
100%
DECIDED
GRADING SYSTEM
I. INTRODUCTION TO HEALTH ASSESSMENT
A. Overview of the NURSING PROCESS
• The nursing process is a systematic, rational method of
planning and providing nursing care.

Systematic – It is done according to a fixed plan or system

Rational – Based on or in accordance with scientific reason
or logic
Purpose of the NURSING PROCESS
• Identify a client’s health care status if it is Actual or Potential.

Actual health problem – A client problem that is present at the time of

nursing assessment
Potential health problem – A problem that may occur because of
presence of some risk factors.
• To establish plans to meet the identified needs of the clients.

• To deliver specific nursing interventions to address the needs of our

clients.
Characteristics of a NURSING PROCESS

• A regular repeated event or sequence of events (cycle).

• It is dynamic.

• Client centered.

• An adaptation of problem solving & system theory.

• Decision making is a major key.

• Interpersonal & collaborative.

Phases of the NURSING PROCESS

•Assessing - Collecting, organizing, validating, and documenting

client data.

Purpose : To establish a database about the client’s response to

health concerns or illness and the ability to manage health care
needs
•DIAGNOSING - Analyzing and synthesizing data

Purpose: To identify client strengths and health problems that

can be prevented or resolved by collaborative and independent
nursing interventions To develop a list of nursing an collaborative
problems
•PLANNING - Determining how to prevent, reduce, or resolve the
identified priority client problems; how to support client strengths; and
how to implement nursing interventions in an organized,
individualized, and goal-directed manner

Purpose: To develop an individualized care plan that specifies

client goals/desired out- comes, and related nursing
interventions
•IMPLEMENTING - Carrying out (or delegating) and documenting
the planned nursing interventions

Purpose: To assist the client to meet desired goals/ outcomes;

promote wellness; prevent illness and disease; restore health;
and facilitate coping with altered functioning.
•EVALUATING - Measuring the degree to which goals/outcomes
have been achieved and identifying factors that positively or
negatively influence goal achievement

Purpose: To determine whether to continue, modify, or

terminate the plan of care
One single word could save a Precious life
NURSING ASSESSMENT
ASSESSMENT
• At the end of this session, level 1 will be able to understand the
following concepts.

1. Definition of nursing assessment.

2. Characteristics of nursing assessment
3. Role of the nurse during nursing assessment
4. Examples of nursing assessment
5. Nursing assessment activities
6. Collection of Data (Sources and Type)
7. Types of Assessment
What is Assessment?
• Is the systematic and continuous collection, organization, validation,
and documentation of data (information).

• Is the first and most critical phase of the nursing process. If data
collection is inadequate or inaccurate, incorrect nursing judgments
may be made that adversely affect the remaining phases of the process:
diagnosis, planning, implementation, and evaluation.
CHARACTERISTICS
q Continuous process carried out during all phases of the nursing
process.
q It is focus on a client’s responses to a health problem.
- Client perceived needs
- Health problems
- Related experience
- Health practices
- Values
- Lifestyles
OUR FUNCTIONS
ü Should be a critical thinker
ü Main responsible for the care and must assess the data determining the needs
of the client.
ü Responsible for the collection of comprehensive data
ü To maintain Data Privacy
ü Identify barriers of communication
ü Responsible for the development of clients plan of care
 EXAMPLES OF ASSESSMENT

- Establishing Baseline data

- Obtain a nursing health history.
- Conduct Physical Assessment.
- Review Client records.
- Review nursing literature
- Consult support persons.
- Consult health professionals
•Update data as needed
•Organize Data
•Validate data
•Communicate/document data
STEPS OF HEALTH ASSESSMENT

• Data collection - the process of gathering information about a client’s

health status.
• Validation of Data
• Documentation of Data
How to prepare?
• Review client’s medical record.
• Know client’s basic biographical data ( age, sex, religion, educational
level and occupation)
• Know client’s current symptoms, past health history, family history,
lifestyles and practices.
• Avoid premature judgments.
• Educate yourself about the condition.
• Reflect on your own feelings.
• Prepare the materials necessary for assessment
Data collection
• DATA : A medical information of our client which maybe relevant to
decisions about current or future health or illness.
• DATABASE- It contains all the information about a client; it includes
the nursing health history, physical assessment, primary care
provider’s history, and physical examination, results of laboratory and
diagnostic tests, and material contributed by other health personnel.
• Data collection SHOULD be systematic & continuous to prevent
omission of significant data and reflect a client’s changing health
status.
SOURCES OF DATA
• PRIMARY/DIRECT - The client is the primary source of
data
• SECONDARY/INDIRECT- Family members or other
support persons, other health professionals, records and
reports, laboratory and diagnostic analyses, and relevant
literature
• Secondary source should be validated if possible
TYPES OF DATA

• SUBJECTIVE DATA – Also known as symptoms or covert data

- Apparent only to the person affected and can be described or verified
only by that person.
- It includes client’s sensation, feelings ,values ,beliefs, atittude and
perception of personal health status and life situation.

Example:
Verbalization of itchiness, pain or expression of feelings.
• OBJECTIVE DATA – Also known as signs or overt data.
• are detectable by an observer or can be measured or tested against
an accepted standard.
Examples of objective data
• They can be seen, heard, felt, or smelled, and they are obtained by
observation or physical examination. For example, a discoloration of the skin
or a blood pressure reading is objective data. During the physical
examination, the nurse obtains objective data to validate subjective data and
to complete the assessment phase of the nursing process.
• Constant data is information that does not change over time such as race or
blood type. Variable data can change quickly, frequently, or rarely and include
such data as blood pressure, level of pain, and age.
Types of Assessment

• INITIAL ASSESSMENT
• PROBLEM-FOCUSED ASSESSMENT
• EMERGENCY ASSESSMENT
• TIME-LAPSED REASSESSMENT
ABCDE Approach
• Airway (Airway obstruction)
• Breathing (Respiratory distress)
• Circulation (Shock)
• Disabilty (Level of consciousness)
• Exposure (Skin problems)
R
O •Collects data in a systematic and
L ongoing process
E •Involves the patient, family, other health
care providers, and environment, as
O appropriate, in holistic data collection
F •Prioritizes data collection activities
based on the patient’s immediate
N condition, or anticipated needs of the
U patient or situation
R •Uses appropriate evidence-based
S assessment techniques and instruments
E in collecting pertinent data
S
R
O • Uses analytical models and problem-solving tools
L • Synthesizes available data, information, and
E knowledge relevant to the situation to identify patterns
and variances
O • Documents relevant data in a retrievable
F format(ANA,2010,p.21) Standard 2 states, “The
registered nurse analyzes the assessment data to
N determine the diagnoses or issues. To accomplish this,
U the registered nurse:
R • Derives the diagnosis or issues based on assessment
S data
E
S
R
O
L
E •Validates the diagnoses or issues with the
client, family, and other healthcare
O providers when possible and appropriate
F

N •Documents diagnoses or issues in a manner

U that facilitates the determination of the
R expected outcomes and plan (ANA, 2010,
S p. 22)
E
S
IV . STEPS OF HEALTH ASSESSMENT

A. Collection of Subjective Data through interview and Health history

INTERVIEW : A communication process in nursing

Focuses:

- Establishing rapport and a trusting relationship with the client to elicit

accurate and meaningful information
- Gathering information on the client’s developmental, psychological,
physiologic, sociocultural, and spiritual statuses to identify deviations
that can be treated with nursing and collaborative interventions or
strengths that can be enhanced through nurse–client collaboration.
PHASES OF THE INTERVIEW
First Phase: Pre-introductory Phase

Activities:
- Reviewing Medical Record
- Nurse endorsement
- Other healthcare team endorsement
Purpose: To know the baseline data of the patient.

Example:
- The client has difficulty hearing in one ear
- The client religion, culture and beliefs
- The client health condition (infectious or not,
etc)
PHASES OF THE INTERVIEW

Second Phase: Introductory Phase

Activities ( Client should be Comfortable and has privacy)

- Self-introduction
- Patient awareness ( Purpose, types of questions, reasons of taking
notes)
- Data Privacy Act
- Develop trust and rapport
PHASES OF THE INTERVIEW

Third Phase: Working Phase

Activities:
- Collection of the following
1. Biographic data
2. Reasons for seeking care
3. History of present health concern
4. Past health history
5. Family history
6. Review of body systems for current health problems
7. Lifestyle and health practices
8. Developmental level
- Listens, observes cues, uses critical thinking skills to interpret and validate
information received from the client
- Nurse collaboration
PHASES OF THE INTERVIEW

Fourth Phase: Summary and Closing Phase

Activities:

- Summary of the information collected

- Validates problems and goals with the client
- Discusses possible plans to resolve the problem (nursing
diagnoses and collaborative problems)
- Entertain questions from the client