TOPIC 1: Conceptual

Overview of Nursing
Health Assessment

 NURSING PROCESS is the

cornerstone of the Nursing
Profession.
Lydia Hall originated the term
Nursing Process in 1955.
It is a systematic, organized
manner of providing goaloriented and humanistic
care that is both efficient and
effective.

Nursing Process is organized

and systematic because it is
composed of six sequential
and interrelated steps,
namely: ASSESSMENT,
DIAGNOSIS, OUTCOME
IDENTIFICATION,
PLANNING,
IMPLEMENTATION AND
EVALUATION.

It is goal oriented because of

the ff:
1.The plan is implemented in
consideration to the unique
needs and concerns of the
individual patient.
2.It is individualized.
3.It involves aspect of human
dignity.

It is efficient because it is
relevant to the needs of the
patient.
It is effective because it
utilizes resources wisely in
terms of human, time and
cost resources.

ASSESSME
NT
EVALUATIO
N
IMPLEMENT
ATION

INDIVIDUAL
FAMILIES
COMMUNITI
ES

DIAGNOSIS

OUTCOME
IDENTIFICATI
ON

I. ASSESSMENT. Is collecting,
validating, organizing and recording
data about the patients health
status.
Purpose- To establish a data base.
Activities during assessment:
1. Collecting Data- This involves
gathering information about the
patient, considering the physical,
psychological, emotional,
sociocultural

And spiritual factors that may

affect his/ or her health status.
Types of Data:
a. Subjective (Symptoms).
Those that can be described only
by the person experiencing it.
e.g. vertigo (dizziness), tinnitus
(ringing in the ears), anorexia
(loss of appetite), pain, thirst,
nervousness.

b. Objective data (Signs).

Those that can be observed and
measured.
e.g. pallor (paleness), diaphoresis
(excessive sweating), jaundice,
reddish urine, body temperature
of 37 degree centigrade.
Methods of Collecting Data:
a. Interview. It is planned,
purposeful conversation.

e.g. collection of data for

health history.
admission of pt in the
hospital.
b. Observation.
e.g. use of senses, use of
units of measure, physical
examination, interpretation of
lab results.

Sources of Data:
1.Primary Source- patient.
2.Secondary Source- family
members, friends, significant
others, patients record or
chart, health team members.

2. Verifying/ Validating Data.

Making sure your information is
accurate.
Eg. The patients urine is dark in
color. This may indicate
dehydration or the patient may had
taken certain medication or food.
To validate if the patient is
dehydrated ask if the pt was
vomiting or having inadequate
fluid intake.

If no data supports
dehydration ask if the pt has
been taking medications like
rifampicin w/c make cause the
urine to orange in color.
II. Diagnosing. Is the clinical act of
identifying health problems. To
diagnose in nursing means to
analyze assessment information
and derive meaning from this
analysis.

Purpose. To identify the patients

health care needs and to prepare
diagnostic statements.
Nursing Diagnosis. Is a statement
of patients potential or actual
alteration in health status.
It uses either the PRS/PES
FORMAT:
P- roblem
R- elated to factors
S- igns and symptoms

P- roblem
E- tiology
S- igns and symptoms
ACTIVITIES during Nsg. Dx
1. Organizing Data. Cluster
facts into groups of info.
e.g. Data about patients
nutritional status.

Subjective
data:
I have no
appetite to eat
Foods and fluids
tastes bitter
I feel weak &
easily get tired
I feel dizzy most
of the time

Objective
data:
Weight loss of
10 lbs in a
week
Pallor
Poor skin turgor
Unable to
perfrom ADL

2. Compare data gathered during

assessment against standards
(accepted norms, measures, or
patterns for purposes of
comparison)
e.g. The standard color of skin is
pink.
The standard rbc level is 5 million.
The standard pulse rate of and
adult is 60-100 bpm.

3. Analyzing data after

comparing with standards.
E.g. Passage of frequent watery
stools may lead to dehydration
and loss of electrolytes like
potassium and sodium.
Pallor, dyspnea, weakness, fatigue,
RBC count of < 5 million cells, and
Hgb of less thant 10 g/dl may
signify inadequate oxygenation.

4. Identify gaps and

inconsistencies in data.
E.g. Patient claims she is gaining
too much weight but actually,
she is underweight.
5. Determine the patients
health problems, health
risks, and strengths.
E.g. inadequation nutrition,
inadequate oxygenation.

6. Formulate the nursing

diagnosis.
E.g. Fluid volume deficit related to
frequent passage of watery stools.
Alteration in nutrition: less than
body requirements related to poor
appetite.
Inadequate oxygenation related to
poor oxygen- carrying capacity of
the blood.

Comparison of Correct and

Incorrect Nsg. Dx
1. Correct: Acute pain related
to physical exertion.
Incorrect: Acute pain related
to myocardial infarction.
2. Correct: Ineffective
breathing pattern related to
increased airway secretions.

Incorrect: Ineffective breathing

pattern related to pneumonia.
III. Outcome Identification.
Refers to formulating and
documenting measurable, realistic,
patient focused goals.
Purposes:
To provide individualized care.
To promote patient and significant
others participation.
To plan care that is realistic and
measurable.

Activities During Outcome

Identification:
1. Establish priorities.
A priority is something that takes
precedence in position, deemed to
be the most important among
several items.
Priority setting is a decisionmaking process that ranks the
order of nursing diagnoses in terms
of importance to the client.

Priority setting involves the

following:
a.Life threatening conditions should be
given highest priority, e.g. difficulty in
breathing, chest pain, hemorrhage,
suicidal tendencies.
b.Use the principles of ABC (airway,
breathing, circulation) Airway is
given the highest priority.
c.Use the Maslows Hierarchy of
Needs. Physiologic needs are given
the highest

Priority. E.g. attend first to patient

who is vomiting before a patient who
is anxious.
d. Consider something that is very
important to the patient like pain.
e. Patients who are unstable are given
priority first against those who are
stable. E.g. attend first to a patient
who has fever rather than the
patient who is scheduled for physical
therapy in the afternoon.

f. Consider the amount of time,

materials, equipment, required to
care for patients. E.g. attend to
the patient who requires dressing
change for post-op wound before
attending to a patient who
requires health teachings and is
ready to be discharged late in the
afternoon. Health teaching
requires more time and should not
be done in a hurried manner.

g. Actual problems take precedence

over potential concerns. E.g. fluid
volume deficit (actual problem)
should be given priority before high risk
for infection (potential problem).
h. Attend to the patient before the
equipment. E.g. assess the patient first
before checking contraptions like IV,
urinary catheter, drainage tubes.
i. Do assessments before
implementation, e.g. when a patient
complains of pain,

Check for location, severity, etc. and

check vital signs before administering
an analgesic.
Nursing Diagnoses are classified
as high priority, medium priority,
and low-priority.
- High priority Nsg. Dx. are those
w/c are potentially life threatening
and require immediate action:
Impaired gas exchange, ineffective
breathing pattern, self- directed risk
for violence.

- Medium priority Nsg. Dx.- are

those that could result in unhealthy
consequences, such as physical or
emotional impairment, but are not
life threatening. E.g. fatigue,
activity intolerance, ineffective coping.
- Low- priority Nsg. Dx.- involve
problems that usually can be resolved
easily with minimal interventions and
are unlikely to cause significant
dysfunction. Eg. Sensation of hunger
in a patient who is

NPO, in preparation of a diagnostic

procedure, minimal pain on the third
postop day related to ambulation.
2. Establishing patient goals and
outcome criteria.
A patient goal is an educated guess,
made as a broad statement, about
what the patients state will be after
the nursing intervention is carried out.
Behavioral goals are written to
indicate a

desired state. They contain an action

verb and a qualifier that indicate the
level of performance that needs to be
achieved.
Examples of Behavioral verbs used
in Patient goals are as follows:
Explain
Distinguish
Classify
ListIdentify
Demonstrate
Verbalize Perform Use
The qualifier is a description of the
parameter for achieving the goal.

Examples: Ambulates safely with oneperson assistance.

Demonstrates signs of sufficient rest
before surgery
States the importance of adopting
appropriate health nursing
maintenance behaviors.
Goals may be short-term or long-term.
Short-term goals (STG) can be met
in a relatively short period (within days
to

Less than a week). Long-term

goals can be requires more time
(within weeks to months).
Outcome criteria are specific,
measurable, realistic statements
of goal attainment. Outcomecriteria are written in a manner
that they answer the questions:
who, what actions, under
what circumstances, how
well, and when.

Therefore a well stated outcome

criteria are as follows:
S- mart
M- easurable
A- ttainable
R- ealistic
T- ime- framed

Example of goals and outcome

criteria are as follows:
Goal: The patient will report a
decreased anxiety level regarding
surgery.
Outcome Criteria: During health
teaching, the patient discusses
fears and concerns regarding
surgical procedure.
After health teaching, the patient
verbalizes decreased anxiety.

IV. Planning. Involves determining

beforehand the strategies or
course of actions to be taken
before implementation of nursing
care. To be effective, involve the
patient and his family in planning.
Purposes:
To identify the patients goals and
appropriate nursing interventions.
To direct patient care activities.

To promote continuity of care.

To focus charting requirements.
To allow for delegation of specific
activities.
Activities During Planning
1. Planning nursing interventions
-To direct activities to be carried out in
the implementation phase.
- Nursing interventions are any
treatment, based upon clinical
judgement and knowledge, that a nurse
performs to

enhance patient outcomes. They

are used to monitor health status;
prevent , resolve, or control a
problem; assist with activities of
daily living (ADLs); promote
optimum health and independence.
Nursing interventions are also
called nursing orders.
Nursing interventions/ collaborative
activities that nurses carry out to
provide patient care.

2. Writing a nursing care plan of care.

The nursing care plan of care is written
summary of the care that patient is to
receive. It is the blueprint of the
nursing process.
The plan of care is nursing centered.
This is essential to identify the scope
and depth of the nursing practice. By
focusing on the treatment of human
responses to actual or potential
health problems, the nurse remains in
the nursing practice

domain.
The plan of care is a step-by-step
process. This is evidenced by the
following.
Sufficient data are collected to
substantiate nursing diagnoses.
At least one goal must be stated for
each nursing diagnosis.
Outcome criteria must be identified for
each goal.
Nursing interventions must be
specifically

designed to meet the indentified

goal.
Each intervention should be
supported by a scientific rationale.
The scientific rationale is the
justification or reason for
carrying out the intervention.
Evaluation must address whether
each goal was completely, partially
met or completely unmet.

NANDA- NORTH AMERICAN NURSING

DIAGNOSIS ASSOCIATION has
accepted list of nursing diagnoses. List in
priority order. Use the diagnostic label
and related to, followed by
manifested by (supporting defining
characteristics).
V. Implementation. Is putting the
nursing care plan into action.
Purpose. To carry out planned nursing
interventions to help the patient attain
goals and achieve optimal level of
health.

Activities:
Reassessing. To ensure prompt
attention to emerging problems.
Set priorities. To determine the order
in w/c nursing interventions are carried
out.
Perform nursing interventions.
These may be independent,
dependent, or interdependent/
collaborative measures.
Record actions. To complete nursing
interventions, relevant documentation

must be done.
NOTE: Something not written is
considered not done.
Requirements of implementation.
1.Knowledge. Includes intellectual
skills like problem- solving, decision
making and teaching.
2.Technical skills. To carry out
treatments and procedures.
3.Communication skills. Use verbal
and

Non verbal communication to carry

out planned nursing interventions.
4. Therapeutic Use of Self. It is
being willing and being able to care.
VI. Evaluation. Is assessing the
patients response to nursing
interventions and then comparing
the response to predetermined
standards and outcome criteria.
Purpose. To appraise the extent to
which

Goals and outcome criteria of

nursing care have been achieved.
Activities:
Collect data about the clients
response.
Compare the patients response to
goals and outcome criteria.
The four possible judgments that
may be made are as follows:
The goal was completely met.

 The goal was partially met.

The goal was completely unmet.
Ne problems or nursing diagnoses
have developed.
Analyze the reasons for the outcomes.
Modify care plan as needed.
Characteristics of Nursing Process
Problem oriented. It is comparable
with scientific problem solving
approaches.

 Goal oriented.
Orderly, planned and step by step.
Open to accepting new
information during its application.
It is flexible to meet the unique needs
of client, family, group or community
(dynamic).
Interpersonal. It requires that the
nurse communicates directly and
consistently with the patient.
Permits creativity, cyclical.

 Universal. It involves the

individual, families and
communities.
TYPES OF DATA:
a. SUBJECTIVE DATA
symptoms; covert data
b. OBJECTIVE DATA signs;
overt data (use your senses)
VITAL SIGNS TPRB & Pain
LAB TEST RESULTS

c. CONSTANT DATA dont

change over time (e.g. race or
blood type)
d. VARIABLE DATA change
quickly, frequently, or rarely (e.g.
BP, age)

Critical Thinking in Relation to

Health Assessment
Definition:
a purposeful, goal-directed
thinking process that strives to
problem solve patient care issues
through the use of clinical
reasoning (Estes, 2010)

Purpose:
To establish potential strategies to
assist patients in reaching their
desired health goals
Components of Critical Thinking
(in relation to health assessment)
1. Interpretation of situations
requires the nurse to decode hidden
messages, clarify the meaning of the
information, and categorize the
information.

Example: A patient may claim to

be seeking health care for a bad
cough and cold, but actually may
be concerned about whether the
cough is a sign of lung cancer.
2. Analysis the nurse examines
the ideas and data that were
presented, identifies any
discrepancies, and reflects on
the reason for the discrepancies.

Example: A patient may complain

of insomnia but upon questioning
reveals that he or she sleeps 6
hours at night and takes a 2-hour
nap each afternoon.
3. Inference speculates, derives
or reasons a specific premise based
on information and assumptions
obtained from patient; drawing
conclusions based from a level
of knowledge and experience

Example: If a patient complains of

an exacerbation of asthma every
morning, the nurse can inquire
about a history of heartburn or
GERD. An experienced nurse
would make the association
between these causative factors.
4. Explanation requires that the
conclusions drawn from the
inferences are correct and can be
justified.

Example: GERD as a
contributing factor of asthma is
well documented in the literature;
there is a documented scientific
link between GERD and asthma.
5. Evaluation examines the
validity of the information and
hypothesis that leads to a final
conclusion that can be
implemented.

Example: The nurse assesses a 5year-old child with cystic fibrosis

who is experiencing labored
breathing and wheezing. Based on
findings, the nurse implements a
nebulizer treatment, postural
drainage and chest physiotherapy.
6. Self-regulation the nurse
reflects on the critical thinking skills
w/c were employed and determines
w/c techniques were effective and
which are

problematic.
Example: After interviewing the
patient, the nurse reflects on
whether leading, biased, or
judgmental questions were posed
to the patient. The nurse might
also reflect on the use of openended questions and
effectiveness of an interpreter.

The Client in the Context of

Culture, Spirituality and
Family
Health assessment involves
assessment of the individual as a
whole. When you look at a client,
you need to see the client in
contexts that affect the client
(and that the client affects in
return). The client is not an
isolated individual.

Culture
the totality of socially transmitted
behavioral patterns, arts,
beliefs, values, customs,
lifeways, and all other products
of human work and thought
characteristic off a population or
people that guide these
worldview and decisionmaking
(Purnell and Paullanka)

 Characteristics of Culture
It is LEARNED. - transmitted from
generation to generation through
socialization and life-experiences.
It is SHARED. shared to others
through interaction and socialization
It is associated with ADAPTATION
TO THE ENVIRONMENT. The
group changes to improve its ability
to survive as environmental
circumstances change.

It is UNIVERSAL.
Cultural and Biological
Variations affect physical
assessment
Within a culture, there are
VARIATIONS of beliefs and
practices, and these variations are
considered normal.
BIOLOGIC VARIATIONS also exists
among cultures, and these are also
considered normal.

For example, heights and weights may

vary significantly, yet the variations
are normal. Only the extremes of
height and weight are considered
abnormal.
Why variations?
VARIATIONS DUE TO GENETICS
AND ENVIRONMENT (nature vs.
nurture)
Mutations occur in genes, and
interbreeding groups whose members
mate mostly within the group develop

distinct biological characteristics.

Gene variations cause obvious
differences such as eye color, and
genetic diseases as trisomy 1.
In a particular race, members share
some distinct biologic
characteristics. However, genetic
variations do not necessarily occur
together, and when looking
worldwide, most characteristics vary
from high frequency to low frequency
across a continuum.

Example: Blonde hair has a high

frequency in northern Europe and
hair tends to become increasing
darker as you move south and east.
SELECTED PHYSICAL VARIATIONS
RELATED TO HUMAN VARIATION
The physical variations (resulting from
genetic or cultural behaviors) are
included directly in the normal and
abnormal findings discovered during
the assessment process that includes:

1. SURFACE VARIATION
example is SECRETIONS. A
variation exists among cultures
in terms of the number of
apocrine and eccrine sweat
secretions and the aprocrine
secretions of ear wax.
Sebacious gland activity and
secretions do not show
significant variation.

Examples:
Eskimos noted to sweat less on
their trunks and extremities but
sweat more on faces than
Caucasians due to adaptation.
This allows thermoregulation
without dampening clothes.
Asians and Native Americans
have fewer functioning apocrine
glands than do most Cuasians and
blacks.

 Asians and Native Americans

85% have dry ear wax
Caucasians (97%) and Blacks
(99%) - have wet ear wax
Reasons for this genetic
variation are thought to
include climate and disease
susceptibility. For instance,
women with dry ear wax have
a lower incidence of breast
cancer.

2. ANATOMIC VARIATION
Example (variation in lower extremity
venous valves):
Black Africans noted to have fewer
valves in the external iliac veins but
many more valves lower in the leg than
Causcasians thus there is lower
prevalence of varicose veins in
blacks.
3. DEVELOPMENTAL VARIATION
Maturity differences appear to be
related to both genetics and
environment.

Example:
African American infants and children
end to be ahead of other American
groups in motor development.
4. BIOCHEMICAL VARIATION AND
DIFFERENTIAL DISEASE
SUSCEPTIBILITY
Examples of these conditions are drug
metabolism differences, lactose
intolerance, and malaria-related
conditions, such as sickle cell disease.

Example:
North and Central European
ancestry lactose intolerant
Mediterranean and Africa
malaria-related conditions
Cultural competence
Definition: a dynamic and
reflective process of becoming
culturally competent
5 CONSTRUCTS:

1. CULTURAL DESIRE. This refers to the

motivation to want to engage in
intercultural encounters and to acquire
cultural competence.
2. CULTURAL AWARENESS. This refers
to the deliberative, cognitive process in
which the healthcare provider becomes
appreciative and sensitive to the values,
beliefs, life ways, practices and problemsolving strategies of a clients culture.
It involves SELF-EXAMINATION and

IN-DEPTH EXPLORATION of ones

own cultural background
Stages of Cultural Awareness are:
UNCONSCIOUS INCOMPETENCE
not aware that one lacks cultural
knowledge; not aware that cultural
differences exists.
CONSCIOUS INCOMPETENCE
aware that one lacks knowledge about
another culture; aware that cultural
differences exist but not knowing what
they are or

how to communicate effectively

with clients with different
cultures.
CONSCIOUS COMPETENCE
consciously learning about the
clients culture and providing
culturally relevant interventions;
aware of differences; able to
have effective transcultural
transactions

 UNCONCIOUS COMPETENCE
able to automatically provide
culturally congruent care to client
from a different culture; having
much experience with a variety
of cultural groups and having an
intuitive grasp of how to
communicate effectively in
transcultural encounters)

3. CULTURAL KNOWLEDGE. This

refers to the process of seeking
and obtaining a sound educational
foundation concerning the various
worldviews of different cultures.
4. CULTURAL SKILL. This refers to
the ability to collect relevant
cultural data regarding the clients
health history and presenting
problem as well as accurately
performing a physical assessment.

5. CULTURAL ENCOUNTERS. This

refers to the process that allows the
healthcare provider to engage directly
in face-to-face interactions with clients
from culturally diverse backgrounds.
Spirituality
RELIGION the doing
SPIRITUALITY the search for
meaning and purpose, seeking to
understand and to relate to the sacred

Role of family in Illness:

The culture (belief systems and
others) in which the family operates
and the specific culture developed
within the family unit interact to
form a context for the client.
The familys beliefs about health,
illness and related behaviors and the
meaning health and illness have for
the family tends to affect each
members behaviors.

Example: Mr. Thomas drinks

excessively. He also smokes and
eats whatever he wants (high-fat,
calorie-rich diet). His risks for
cardiovascular disease are very
high. Why does he not maintain a
preventive lifestyle? His family
believes that men are strong and
that it is assign of weakness to
practice preventive care.

---END---