HEALTH ASSESSMENT PRELIMS

nursing

art of applying science in a humanitarian way to care for people

nursing process

organizational framework for nursing practice

nursing plans and provide care

problem → nursing care

components of nursing process

Assessment

Diagnosis

Planning

Implementation

Evaluation

Assessment

1. collection

2. organization

3. validation

4. documentation

of data

Purpose of assessment

1. establish patient data base

2. basis of nursing care

3. clinical judgement in the form of diagnosis

4. plan and implement nursing interventions

5. standards for evaluation of nursing care outcome

types of assessment

initial (admission)

focus/problem-focused

time-lapsed/ ongoing

emergency

steps of assessment

1. collection of data

   1. subjective

   2. objective

2. validation of data

3. organization of data

4. recording/documentation of data

types of data

subjective

objective

data collection methods

observing

interviewing

examining

health assessment

complete health history

physical assessment

Assessment techniques

inspection - visual

palpation - light, deep

percussion - direct, indirect, blunt

auscultation - listening

percussion sounds

resonance - hollow

hyper resonance - booming

tympany - drum (stomach)

dullness - thud (dense: liver, spleen, bladder)

flatness - extremely dull (very dense: muscle, bone)

stethoscope side and for

diaphragm - high-pitched (heart, lungs, abdomen)

bell - low-pitched sounds (blood vessels)

sources of data

primary - patient, if unstable

secondary - family members, significant other, medical records, diagnostic procedures, health professionals, etc.

validation of data is

double checking

maslow’s hierarchy of needs

body system model aka

medical model/review of systems

purpose of health history

patient’s symptoms and how they developed

health history includes

biographic data

chief complaint

present health status
current lifestyle

past health history

family history

psychosocial status

review of systems