2 Semester SY 2018-2019
2 Semester SY 2018-2019
SY 2018-2019
NCM-101
HEALTH ASSESSMENT
Objectives :
1. Explain ways in which nurses use critical thinking.
2. Identify the steps of the nursing process
3. Discuss the importance of the nursing process as it relates
to client care
4. Relate how nurses implement
each step of the nursing process
What Is the Nursing Process?
Definition:
*systematic problem-solving process that guides all nursing
actions
*an approach used to identify, prevent and treat actual or
potential health problems and promote wellness.
*way to plan, implement and evaluate care for individuals,
families, groups and communities.
Purpose:
To help the nurse provide goal-directed client-centered care
STEPS IN NURSING PROCESS:
1. Assessment
2. Nursing Diagnosis
3. Planning
4. Implementation
5. Evaluation
STEPS IN NURSING PROCESS:
1. Assessment -involves the systemic collection of Patient
data.(collect data, validate data, organize data, document data)
Data Collection
a. subjective & objective data
b. Nursing history( Biographic data, current physical
&emotional complaints, past medical history, past and current
ability to perform ADL’S, socio-economic factors)
c. Physical Assessment.
d. Review of lab &Diagnostic test results.
e. Review other available Health Information.
.
STEPS IN NURSING PROCESS:
Validation of data:
Validation is the act of "double-checking“ or verifying data to
confirm that it is accurate and factual
Organization of data
The nurse uses a written or computerized format that organizes
the assessment data systematically. The format may be modified
according to the clients physical status.
Documenting data:
The nurse records clients data. Accurate documentation is
essential and should include all data collected about the clients
health status. Data are recorded in a factual manner and not
interpreted by the nurse.
STEPS IN NURSING PROCESS: 1. Assessment
.
STEPS IN NURSING PROCESS:
2. Nursing Diagnosis- is a clinical judgment about individual, family, or
community responses to actual or potential health problems/life processes.
Nursing diagnoses provide the basis for selection of nursing interventions to
achieve outcomes for which the nurse is accountable (NANDA, 1997).
Three components:
*Label an actual or potential health problems that Nursing care can affect.
*Related factors- Factors that may precede, contribute to or be associated with the
human response.
*Evidence – Signs symptoms that point to the Nursing Diagnosis.
TYPES OF NURSING DIAGNOSIS
a. Actual Diagnosis: An actual diagnosis is a statement about a health problem
that the client has, and could benefit from nursing care.
b. Risk diagnosis is a statement about a health problem that the client doesnt
have yet, but is at a higher than normal risk of developing in the near future.
STEPS IN NURSING PROCESS:
2.Nursing Diagnosis
.
STEPS IN NURSING PROCESS:
When determining whether a goal has been achieved, the nurse can draw one
of the three possible conclusions:
A. The goal was met, that is the client response is the same as the desired
outcomes.
B. The goal was partially met, that is either a short term goal was achieved but
the long term was not, or the desired outcome was only partially attained.
A physical examination is performed for all age group in health care setting.
Assessing a client is a major component of nursing care. It is the picture of
the client’s physiological functioning ,combined with a health and
psychosocial assessment that forms a data base for decision making.
Chief Complaint(s)
• one or more symptoms or concerns causing the
patient to seek care.
Complete Health History
History of Present Health concerns
• Mnemonic: COLDSPA
• Character: describe the sign or symptom; how does it feel, look, sound,
smell, and so forth?
• Onset: when did it begin?
• Location: where is it?, does it radiate
• Duration: how long does it last?
• Severity: how bad is it?
• Pattern: what makes it better? what makes it worse?
• Associated Factors: what other symptom occur with it?
Complete Health History
History of Present Health concerns
• Mnemonic: PQRST
P – provocative or palliative
Q – quality or quantity
R – region or radiation
S – severity
T - timing
Complete Health History
History of Present Health concerns
Seven attributes of a symptom
1.Location- where is it? Does it radiate?
2. Quality- What is it like?
3. Quantity or severity- how bad is it? ( for pain- ask for a rating scale of 1-
10)
4. Timing- When does it start? How long does it last? How often does it come?
5. Setting in which it occurs- Include environmental factors, personal activities,
emotional reactions, or other circumstances that may have contributed to the
illness
6. Remitting or exacerbating factors- Does anything make it better or worse
7. Associated manifestations- Have you noticed anything else that accompanies
it?
Complete Health History
III. Past History
Medical Immunizations
Surgical Mental and
Hospitalization Emotional Health
Outpatient care Allergies
Childhood Illnesses Substance use
Complete Health History
IV. Family History
Immediate Family Genogram
Extended Family
• reveals risk factors for certain diseases
(Diabetes, hypertension, cancer, mental illness).
• Use genogram
Complete Health History
V. Psychosocial History
Occupational History Family
Education Social Structure
Financial Background Self concept
Economic concerns
Roles and Relationships
Complete Health History
Lifestyle and health practices profile
Include:
• nutritional habits, activity and exercise patterns
,• sleep and rest patterns
,• use of medications, & substances
• self-concept & self-care activities
• social and community activities,
• relationships,
• values and belief system,
• education and work,
• stress level and coping style, and
• environment.
Complete Health History
Social data
• include family relationships, ethnic and educational
background, economic status, home and neighborhood
conditions.
Psychological data
• information about the client’s emotional state.
Pattern of health care
• includes all health care resources: hospitals, clinics,
health centers, family doctors.
Developmental level