1. University of the E ast
RAMON MAGSAYS AY MEMORIAL MEDICAL CENTER INC
College of Nursing
Aurora Blvd., Quezon City
Nursing Health Assessment
Course Description:
The course deals with the concept, principles and techniques
of history tak ing using various tools, physical examination (head to
toe), ps ycho-social assessment and interpretation of laboratory
findings to arrive at s nursing diagnosis on the client across the
lifespan in varied settings.
Number of Units: 2 units Lecture
1 unit Related Le arning Experience (RLE)
Number of c ontacts hours per semester : 36 lecture hours
(including e-learning), 51 RLE hours
Terminal Competency :
At the end of the course and given simulated and actual
conditions / situations, the students will be able to:
1. Differentiate normal from abnormal findings
2. Utilize concepts, principles, techniques and appropriate
assessment tools in the assessment of individual client with
varying age group and development.
Pre-requisite: All first semester subjects
I. Conceptual overview of Nursing Health Assessment
A. Nursing Process in Nursing Health As sessment
B. Elements of Nursing Health Assessment
1. Purpose
2. Nursing health assessment components
2.1 Subjective data
2.2 Objective data
C. Nurse’s Role in Health Assessment
D. Person as a Bio-psycho-socio-spiritual Being
E. Critical Thinking in Health Assessment
II. Guidelines in Conducting Health Assessment
1. Preparing the Patient
2. Preparing the Equipment
3. Preparing the Environment
4. Preparation of the Nurse
5. Ethico-legal Considerations
6. Termination Phase
7. Aftercare Implementation
8. Documentation
III. Nursing Health History
A. Guidelines
1. Nursing Interview phases
1.1 Introductory phase
1.2 W orking phase
1.3 Summary and Clos ure Phase
2. Communication Techniques

2. B. Collecting Subjective Data
1. Health Histor y
1.1 Biographical Data
1.2 Chief Complaints
1.3 Present Health History
1.4 Past Health History
1.5 Family History
1.6 Ps ychosocial History
1.7 Activities of Daily Living
1.8 Review of S ystems
2. Functional Assessment
2.1 Gordon’s Functional Health Pattern
2.2 Katz Index of Independence
2.3 Barthel Index
IV. Objective Assessment
A. Guidelines
1. Nursing Interview phases
a. Introductory phase
b. W orking phase
c. Summary and Clos ure Phase
2. Communication Techniques
B. Objective Assessment
1. Vital S igns
2. Guidelines on Phys ical Assessment
2.1 Required diagnostic skills
a. Inspection
b. Palpation
c. Percussion
d. Auscultation
2.2 Equipment
3. General Survey
3.1 General Appearance
3.2 Mental Status
3.3 Mobilit y of Client
3.4 Behavior of Client
4. Physical Assessment
4.1 Skin, Hair, Nails
4.2 Head and Neck
4.3 Thorax and Lungs
4.4 Heart
4.5 Breast and Axillae
4.6 Abdomen
4.7 Female and Male Genitalia
4.8 Anus, Rectum, and Prostate
5. Diagnostic Procedures
5.1 Invasive
5.2 Non-invasive
5.3 Laboratory Tests
a. Blood
b. Urine
c. Stool
d. Sputum
e. X-ra y

3. 6. Collaborative Assessment
a. Nutrition
b. Activity and Rehabilitation
c. Treatment
d. Medication
V. Focused Assessment
A. Neurologic Assessment
1. Health history
2. Objective Assessment
B. Respiratory Assessment
1. Health history
2. Objective Assessment
C. Cardiac Assessment
1. Health history
2. Objective Assessment
D. GIT Assessment
1. Health history
2. Objective Assessment
E. Urinar y Assessment
1. Health history
2. Objective Assessment
F. Reproductive Assessment
1. Health history
2. Objective Assessment
G. Pediatric Assessment (across lifespan)
1. Health assessment
2. Objective assessment
C. Physiologic Assessment
1. Pain Assessment
1.1 PQRST
1.2 COLD SPA
2. Nutritional Assessment
2.1 Nutritional Histor y
2.2 Anthropometric Measurements
- Height
- W eight
- Body Mass Index (BMI)

4. Health Assessment Requirements
(Forms, Laboratory/Diagnostic Tools, & Equipment):
 Pen & Pencil
 Note pad and Paper
 Watch w ith second hand
 Stethoscope(P A kit)
 Sphygmomanometer(PA kit)
 Penlight (PA kit)
 Reference/Sample Chart
 Digital Thermometer (P A kit)
 Cotton Balls(PA kit)
 Disinfectant Solution (e.g. Alcohol) (PA kit)
 Tongue depressor(PA k it)
 Ruler or tape measure(PA k it)
 Tuning Fo rk (PA k it)
 Safety pins/paper clip(PA kit)
 Gloves and Lubricant(PA k it)
 Reflex Hammer(PA k it)
 Cotton Applicator(PA k it)
 Soap & Towel(PA kit)
 Snellen’s chart/Jaeger’s chart
 Taste and Smell Testers
 Opthalmoscope
 Otoscope
 W heel chair
 Guard/Gait Belt
 Hospital Charts with Forms
 Hospital Forms
 Laboratory and Diagnostic Results Forms
Reference:
Bates, B., Bick ley, L. (2005). Guide to Physical Examintation &
History Taking (8 t h ed.), Lippincott Company: Philadelphia and
Toronto
Cox, C., (2004), Physical Assessment for Nurses , Black well
Publisher Ltd.
Potter, P.,& Perry, A., (2004). Fundamentals of Nursing (6th ed.),
Mosby’s Inc.
Kozier B., E rb, G., Berman, A., & Snyder, S., Fundamentals of
Nursing Concepts, Process and Practice (8 t h ed.) Pearson
Education, New Jersey
Prepared by:
Peter Elmer Bondad, RN, MSN