SlideShare una empresa de Scribd logo
1 de 39
Kimberly Carillo, RN
Kristine Mae Fernandez, RN
Regeine Tepanero, RN
After 2 hours and 30 minutes of interactive class
discussion and film showing, the graduate school
students of MAN 211c will be able to:
Define the Nursing Health History
Identify the purpose of the Nursing Health History
Differentiate Subjective Data and Objective Data
Utilize the guidelines in obtaining nursing history when
doing the Interview
Identify the components of the nursing history
Demonstrate the Skills used in Physical Examination
...the systematic collection of subjective data (stated by
the client) and objective data (observed by the nurse)
used to determine a client's functional health pattern
status.
...these data assist the nurse in identifying nursing
diagnoses and/or collaborative problems.
Characteristic Subjective Objective
Description Data elicited & verified
by the client
Data directly or indirectly
observed through
measurement
Sources Client
Family & Significant
Others
Client Records
Other Health Care
Professionals
Observations & PA
findings of the nurse or
other health care
professionals
Documentation of
assessments made in
client record
Observations made by
the client’s family or
significant others
Characteristic Subjective Objective
Methods used to obtain
data
Client Interview Observation and Physical
Examination
Skills needed to obtain
data
Interview
Therapeutic
communication skills
Caring ability
Empathy
Listening Skills
Inspection
Palpation
Percussion
Auscultation
Examples “ I have a headache”
“Hindi ako gutom”
Respirations 16 cpm
BP 180/100, apical pulse
80, irregular
X-ray film reveals
fractures
 Phases of the Nursing Interview
 Specific Communication Techniques
Nursing Interview
...is a communication process that focuses on the client's
developmental, psychological, physiological,
sociocultural and spiritual responses that can be
treated with nursing and collaborative interventions.
Introductory
Phase
Working
Phase
Summary/
Closing
Phase

Introduce yourself & your role

Explain purpose of interview

Explain the purpose of note-taking, confidentiality
and type of questions to be asked.

Provide comfort, privacy and confidentiality.
Introductory Phase

Facilitate clients comments about major biographical
data, reason for seeking health care, and functional
health pattern responses.

Use critical thinking skills to:

listen for and observe cues

interpret and validate information received from the
client

Collaborate with client to identify problems and
goals

The approach for facilitation may either be free-
flowing or structured depending on time and data
needed
Working Phase

Summarize information obtained from working
phase

Validate problems and goals with the client

May discuss possible plans to resolve the problems
identified

Allow the client time to express feelings, concerns
and questions.
Summary/ Closing Phase
 Types of Questions to use
 Types of Statements to use
 Helpful Hints
 Communication Styles to Avoid
 Specific Age Variations
 Emotional Variations
 Use open-ended questions (What, How, Which)
 Use close-ended questions in obtaining facts on
specific information
 Use a laundry list (scrambled words) approach to
obtain specific answers
 Explore all data that deviate from normal with the
following questions:
 “What alleviates or aggravates the problem?
 “How long has it occurred?”
 “How severe is it?”
 “Does it radiate?”
 “When does it occur?”
 Rephrase or repeat your perception of the client’s
response to reflect or clarify information shared
 Encourage verbalization of client by saying “Yes, ” or
“I agree,” or nodding
 Describe what you observe in the client
 Accept the client; display a non-judgmental attitude
 Use silence to help both you and the client reflect
and reorganize thoughts
 Provide client with information as questions and
concerns arise
 Excessive/Insufficient eye contact
 Doing other things while taking history
 Biased or Leading questions
 Relying on memory to recall information
 Recording all the details
 Rushing the Client
 Reading questions from history form
 For ages from birth up to 14 years old clients history
should be validated for reliability with the
responsible SO.
 Assess hearing acuity; with loss, speak slowly, face
the client, and speak on the side on which hearing is
more adequate.
 Speak loudly only if with hearing deficit
 Use direct eye contact
 Angry Client:
 Approach in a calm, reassuring, in-control manner.
 Allow ventilation of client’s feelings
 Avoid arguing and provide personal space
 Anxious Client:
 Approach with simple and organized information
 Explain your role and purpose
 Manipulative Client
 Provide structure and set limits
Client Profile
Developmental
History
Gordon’s
Functional
Health Patterns
History of
Present Illness
Past Health
History
Review of
Systems
Physical
Assessment
Client Profile
The purpose of the client profile is to
determine biographical client data and to
obtain an overview of past and present
medical diagnoses and treatment that may
alter a client’s response.
Developmental History
The purpose of the developmental history
is to determine the physical, cognitive, and
psychosocial development to assess
developmental delays.
Gordon’s Functional Health Patterns
a guide for establishing a comprehensive
nursing data base. These 11 categories
make possible a systematic and
standardized approach to data collection,
and enable the nurse to determine the 11
aspects of health and human function.
History of Present Illness
a framework for approaching patient
complaints in a problem oriented fashion.
The patient initiates this process by
describing a symptom. It falls to you to
take that information and use it as a
springboard for additional questioning
that will help to identify the root cause of
the problem.
Past Health History
Patient’s other Health Problems aside
from his/her chief complaint
Review of Systems
To better define the likely causes of a
presenting symptom
(Meaning it’s highly subjective)
Physical Assessment
Uses 4 Basic Techniques for Assessment:
Inspection
Palpation
Percussion
Auscultation
Marjorie Gordon (1987) proposed functional health
patterns as a guide for establishing a comprehensive
nursing data base. These 11 categories make possible a
systematic and standardized approach to data
collection, and enable the nurse to determine the
following aspects of health and human function:
Health Perception and Health Management.
Data collection is focused on the person's perceived
level of health and well-being, and on practices for
maintaining health. Habits that may be detrimental to
health are also evaluated, including smoking and
alcohol or drug use. Actual or potential problems
related to safety and health management may be
identified as well as needs for modifications in the
home or needs for continued care in the home.
Nutrition and Metabolism
Assessment is focused on the pattern of food and fluid
consumption relative to metabolic need. The adequacy
of local nutrient supplies is evaluated. Actual or
potential problems related to fluid balance, tissue
integrity, and host defenses may be identified as well as
problems with the gastrointestinal system.
Elimination.
Data collection is focused on excretory patterns (bowel,
bladder, skin). Excretory problems such as
incontinence, constipation, diarrhea, and urinary
retention may be identified.
Activity and Exercise.
Assessment is focused on the activities of daily living
requiring energy expenditure, including self-care activities,
exercise, and leisure activities. The status of major body
systems involved with activity and exercise is evaluated,
including the respiratory, cardiovascular, and
musculoskeletal systems.
Cognition and Perception.
Assessment is focused on the ability to comprehend and use
information and on the sensory functions. Data pertaining to
neurologic functions are collected to aid this process.
Sensory experiences such as pain and altered sensory input
may be identified and further evaluated.
Sleep and Rest.
Assessment is focused on the person's sleep, rest, and
relaxation practices. Dysfunctional sleep patterns,
fatigue, and responses to sleep deprivation may be
identified.
Self-Perception and Self-Concept.
 Assessment is focused on the person's attitudes toward
self, including identity, body image, and sense of self-
worth. The person's level of self-esteem and response to
threats to his or her self-concept may be identified.
Roles and Relationships.
Assessment is focused on the person's roles in the world
and relationships with others. Satisfaction with roles,
role strain, or dysfunctional relationships may be
further evaluated.
Genogram - A genogram is a pictorial display of a
person's family relationships and medical history.
Sexuality and Reproduction.
Assessment is focused on the person's satisfaction or
dissatisfaction with sexuality patterns and reproductive
functions. Concerns with sexuality may he identified.
Coping and Stress Tolerance.
Assessment is focused on the person's perception of stress
and on his or her coping strategies Support systems are
evaluated, and symptoms of stress are noted. The
effectiveness of a person's coping strategies in terms of stress
tolerance may be further evaluated.
Values and Belief.
Assessment is focused on the person's values and beliefs
(including spiritual beliefs), or on the goals that guide his or
her choices or decisions.
Overview of Skills
Inspection
Palpation
Percussion
Auscultation
Inspection
•Definition:
•Inspection is using the senses of vision, smell, and hearing to
observe the condition of various body parts, including any
deviations from normal.
•Technique:
•Expose the parts being observed while keeping the rest draped
•Always look before touching
•Use good lighting
•Provide warm room for examination
•Observe color, size, location, texture, symmetry, odors and
sounds.
Inspection
Palpation
Percussion
Auscultation
Inspection
Palpation
•Definition:
•Is touching and feeling body parts with your hands to determine
the following characteristics:
•Texture
•Temperature
•Moisture
•Motion
•Consistency of structures
Inspection
Palpation
•Technique:
•Examiner’s fingernails should be short
•Most sensitive parts of the hand should be used to detect various
sensations
•Fingertips: Fine discriminations, pulsations
•Palmar Surface: Vibratory sensations (e.g. thrills, fremitus)
•Dorsal Surface: Temperature
•Light palpation precedes deep palpation
•Tender areas are palpated last
Inspection
Palpation
Percussion
Auscultation
Percussion
Auscultation
•Definition:
•Is tapping a portion of the body to elicit tenderness or sounds
that vary with the density of underlying structures.
•Technique:
•Direct Percussion: To elicit tenderness or pain
•Indirect Percussion: To elicit one of the following sounds over the
chest or abdomen:
Percussion
Auscultation
•Technique: (cont’d)
•Resonance: Heard over part air and part solid
•Hyperresonance: Heard over mostly air
•Tympany: Heard over air
•Dullness: Heard over more solid tissue
•Flatness: Heard over very dense tissue
Inspection
Palpation
Percussion
Auscultation
Auscultation
•Definition:
•Is listening for various breath, heart, vasculature, and bowel
sounds using a stethoscope.
•Technique:
Purpose Technique
Diaphragm To detect high-
pitched sounds
Press firmly on body
part
Bell To detect low-pitched
sounds
Press lightly over
body part
Inspection
Palpation
Percussion
Auscultation

Más contenido relacionado

La actualidad más candente

Note nursing as a profession 1
Note nursing as a profession   1Note nursing as a profession   1
Note nursing as a profession 1Babitha Devu
 
Nursing records & reports
Nursing records & reportsNursing records & reports
Nursing records & reportsjasleenbrar03
 
Roles and Responsibility of Community Health Nurse
Roles and Responsibility of Community Health NurseRoles and Responsibility of Community Health Nurse
Roles and Responsibility of Community Health NurseThomaskutty Saji
 
FUNCTIONS & QUALITIES OF COMMUNITY HEALTH NURSE
FUNCTIONS & QUALITIES OF COMMUNITY HEALTH NURSEFUNCTIONS & QUALITIES OF COMMUNITY HEALTH NURSE
FUNCTIONS & QUALITIES OF COMMUNITY HEALTH NURSEMAHESWARI JAIKUMAR
 
Family health nursing process
Family health nursing processFamily health nursing process
Family health nursing processJose Anilda
 
Illness and illness behavior, impact on patient& family
Illness and illness behavior, impact on patient& familyIllness and illness behavior, impact on patient& family
Illness and illness behavior, impact on patient& familyArifa T N
 
Introduction of medical surgical nursing
Introduction of medical surgical nursingIntroduction of medical surgical nursing
Introduction of medical surgical nursingSanjaiKokila
 
Legal issues in nursing
Legal issues in nursingLegal issues in nursing
Legal issues in nursingRuppaMercy
 
Health assessment of Patient ppt
Health assessment of Patient  pptHealth assessment of Patient  ppt
Health assessment of Patient pptMathew Varghese V
 
Uses of computer in nursing
Uses of computer in nursing Uses of computer in nursing
Uses of computer in nursing Monika Devi NR
 
admission procedure in nursing
admission procedure in nursingadmission procedure in nursing
admission procedure in nursingANILKUMAR BR
 
Nursing Audit
Nursing AuditNursing Audit
Nursing AuditNc Das
 
Discharge of a patient
Discharge of a patientDischarge of a patient
Discharge of a patientNursing Path
 
Role of nurse in medical surgical setting
Role of nurse in medical surgical setting Role of nurse in medical surgical setting
Role of nurse in medical surgical setting RakhiYadav53
 
Trend and issues of nursing and role of nurse
Trend and issues of nursing and role of nurse   Trend and issues of nursing and role of nurse
Trend and issues of nursing and role of nurse ramracer99
 
Unit2 nursing as a profession .
Unit2 nursing as a profession .Unit2 nursing as a profession .
Unit2 nursing as a profession .SHINY GEORGE
 
Introduction to nursing
Introduction  to  nursingIntroduction  to  nursing
Introduction to nursingMaghan Das
 

La actualidad más candente (20)

Note nursing as a profession 1
Note nursing as a profession   1Note nursing as a profession   1
Note nursing as a profession 1
 
Nursing records & reports
Nursing records & reportsNursing records & reports
Nursing records & reports
 
Roles and Responsibility of Community Health Nurse
Roles and Responsibility of Community Health NurseRoles and Responsibility of Community Health Nurse
Roles and Responsibility of Community Health Nurse
 
FUNCTIONS & QUALITIES OF COMMUNITY HEALTH NURSE
FUNCTIONS & QUALITIES OF COMMUNITY HEALTH NURSEFUNCTIONS & QUALITIES OF COMMUNITY HEALTH NURSE
FUNCTIONS & QUALITIES OF COMMUNITY HEALTH NURSE
 
Care of terminally ill
Care of terminally illCare of terminally ill
Care of terminally ill
 
Family health nursing process
Family health nursing processFamily health nursing process
Family health nursing process
 
Illness and illness behavior, impact on patient& family
Illness and illness behavior, impact on patient& familyIllness and illness behavior, impact on patient& family
Illness and illness behavior, impact on patient& family
 
Introduction of medical surgical nursing
Introduction of medical surgical nursingIntroduction of medical surgical nursing
Introduction of medical surgical nursing
 
Legal issues in nursing
Legal issues in nursingLegal issues in nursing
Legal issues in nursing
 
Health assessment of Patient ppt
Health assessment of Patient  pptHealth assessment of Patient  ppt
Health assessment of Patient ppt
 
Nursing process
Nursing processNursing process
Nursing process
 
Uses of computer in nursing
Uses of computer in nursing Uses of computer in nursing
Uses of computer in nursing
 
admission procedure in nursing
admission procedure in nursingadmission procedure in nursing
admission procedure in nursing
 
Nursing Audit
Nursing AuditNursing Audit
Nursing Audit
 
Discharge of a patient
Discharge of a patientDischarge of a patient
Discharge of a patient
 
ROLE OF NURSE IN HEALTH CARE
ROLE OF NURSE IN HEALTH CAREROLE OF NURSE IN HEALTH CARE
ROLE OF NURSE IN HEALTH CARE
 
Role of nurse in medical surgical setting
Role of nurse in medical surgical setting Role of nurse in medical surgical setting
Role of nurse in medical surgical setting
 
Trend and issues of nursing and role of nurse
Trend and issues of nursing and role of nurse   Trend and issues of nursing and role of nurse
Trend and issues of nursing and role of nurse
 
Unit2 nursing as a profession .
Unit2 nursing as a profession .Unit2 nursing as a profession .
Unit2 nursing as a profession .
 
Introduction to nursing
Introduction  to  nursingIntroduction  to  nursing
Introduction to nursing
 

Destacado

Chest pain: nursing assessment and management
Chest pain: nursing assessment and managementChest pain: nursing assessment and management
Chest pain: nursing assessment and managementJamie Ranse
 
Nursing Assessment
Nursing AssessmentNursing Assessment
Nursing Assessmentpreet kaur
 
Health & Physical Assessment In Nursing, 3rd edition
Health & Physical Assessment In Nursing, 3rd editionHealth & Physical Assessment In Nursing, 3rd edition
Health & Physical Assessment In Nursing, 3rd editionLearnStressFree
 
Attachment
AttachmentAttachment
Attachmenttoofy208
 
N 295 lecture 5 6 eye and ear student copy
N 295 lecture 5  6 eye and ear student copy N 295 lecture 5  6 eye and ear student copy
N 295 lecture 5 6 eye and ear student copy Elly Hb
 
Percussion and Auscultation of CARDIOVASCULAR system.
Percussion and Auscultation of CARDIOVASCULAR system.Percussion and Auscultation of CARDIOVASCULAR system.
Percussion and Auscultation of CARDIOVASCULAR system.Manoz Marwin
 
Chapter 13 Special Senses
Chapter 13 Special SensesChapter 13 Special Senses
Chapter 13 Special SensesPrincessQiana
 
Neurological assessment
Neurological assessmentNeurological assessment
Neurological assessmentAlbert Balace
 
Basic head to toe assessment
Basic head to toe assessmentBasic head to toe assessment
Basic head to toe assessmentChristi Scott
 
Table of descriptive terms commonly used in charting.
Table of descriptive terms commonly used in charting.Table of descriptive terms commonly used in charting.
Table of descriptive terms commonly used in charting.Raisah Lomangcolob
 

Destacado (20)

Chest pain: nursing assessment and management
Chest pain: nursing assessment and managementChest pain: nursing assessment and management
Chest pain: nursing assessment and management
 
Nursing Assessment
Nursing AssessmentNursing Assessment
Nursing Assessment
 
Health & Physical Assessment In Nursing, 3rd edition
Health & Physical Assessment In Nursing, 3rd editionHealth & Physical Assessment In Nursing, 3rd edition
Health & Physical Assessment In Nursing, 3rd edition
 
Attachment
AttachmentAttachment
Attachment
 
N 295 lecture 5 6 eye and ear student copy
N 295 lecture 5  6 eye and ear student copy N 295 lecture 5  6 eye and ear student copy
N 295 lecture 5 6 eye and ear student copy
 
Percussion and Auscultation of CARDIOVASCULAR system.
Percussion and Auscultation of CARDIOVASCULAR system.Percussion and Auscultation of CARDIOVASCULAR system.
Percussion and Auscultation of CARDIOVASCULAR system.
 
Nursing assessment
Nursing assessmentNursing assessment
Nursing assessment
 
Chapter 13 Special Senses
Chapter 13 Special SensesChapter 13 Special Senses
Chapter 13 Special Senses
 
Ee report rle 6
Ee report rle 6Ee report rle 6
Ee report rle 6
 
audiometry
audiometryaudiometry
audiometry
 
Neurological assessment
Neurological assessmentNeurological assessment
Neurological assessment
 
Aging Process
Aging ProcessAging Process
Aging Process
 
Basic head to toe assessment
Basic head to toe assessmentBasic head to toe assessment
Basic head to toe assessment
 
Eye + ear
Eye + earEye + ear
Eye + ear
 
Assessment of Hearing
Assessment of HearingAssessment of Hearing
Assessment of Hearing
 
Table of descriptive terms commonly used in charting.
Table of descriptive terms commonly used in charting.Table of descriptive terms commonly used in charting.
Table of descriptive terms commonly used in charting.
 
nsg diagnosis
nsg diagnosisnsg diagnosis
nsg diagnosis
 
Nursing assessment
Nursing assessmentNursing assessment
Nursing assessment
 
examination of the eye
 examination of the eye examination of the eye
examination of the eye
 
Musculoskeletal Exam
Musculoskeletal ExamMusculoskeletal Exam
Musculoskeletal Exam
 

Similar a Comprehensive nursing assessment

1.Introduction & interview.pptx
1.Introduction & interview.pptx1.Introduction & interview.pptx
1.Introduction & interview.pptxMustafaALShlash1
 
Prelims-Coverage-for-NCM-101-Lecture.pptx
Prelims-Coverage-for-NCM-101-Lecture.pptxPrelims-Coverage-for-NCM-101-Lecture.pptx
Prelims-Coverage-for-NCM-101-Lecture.pptxZaiSB
 
GORDONS 11 HEALTH FUNCTIONAL PATTERNS.ppt
GORDONS 11 HEALTH FUNCTIONAL PATTERNS.pptGORDONS 11 HEALTH FUNCTIONAL PATTERNS.ppt
GORDONS 11 HEALTH FUNCTIONAL PATTERNS.pptShadrackKoech7
 
Generalist Practice A Presentation on Steps of The Problem-Solv
Generalist Practice A Presentation on Steps of The Problem-SolvGeneralist Practice A Presentation on Steps of The Problem-Solv
Generalist Practice A Presentation on Steps of The Problem-SolvMatthewTennant613
 
1 reflection4reflection (thorax and l
1 reflection4reflection (thorax and l1 reflection4reflection (thorax and l
1 reflection4reflection (thorax and lVivan17
 
NT Nursing Process ,Nursing care plan and Documentation.ppt
NT  Nursing Process ,Nursing care plan and Documentation.pptNT  Nursing Process ,Nursing care plan and Documentation.ppt
NT Nursing Process ,Nursing care plan and Documentation.pptNSHIZIRUNGUMARTIN
 
Chapter002 1
Chapter002 1Chapter002 1
Chapter002 1Ken Woody
 
Chapter002 1
Chapter002 1Chapter002 1
Chapter002 1Ken Woody
 
Chapter002 1
Chapter002 1Chapter002 1
Chapter002 1Ken Woody
 
Chapter002 1
Chapter002 1Chapter002 1
Chapter002 1Ken Woody
 
Physical Assessment including history taking and physical examination
Physical Assessment including history taking and physical examinationPhysical Assessment including history taking and physical examination
Physical Assessment including history taking and physical examinationRamar GURUSAMY
 
Health assessment
Health assessmentHealth assessment
Health assessmentMihir1986
 
American Sentinel N522PE Module Mental Health Assessment Male and Female.pdf
American Sentinel N522PE Module Mental Health Assessment Male and Female.pdfAmerican Sentinel N522PE Module Mental Health Assessment Male and Female.pdf
American Sentinel N522PE Module Mental Health Assessment Male and Female.pdfbkbk37
 
In-Service- Fieldwork II - CRT
In-Service- Fieldwork II - CRTIn-Service- Fieldwork II - CRT
In-Service- Fieldwork II - CRTJenna Bisignano
 
Rationale of psychological testing
Rationale of psychological testingRationale of psychological testing
Rationale of psychological testingDr. Piyush Trivedi
 
MA114 Chapter 22 patient coaching
MA114 Chapter 22 patient coachingMA114 Chapter 22 patient coaching
MA114 Chapter 22 patient coachingBealCollegeOnline
 

Similar a Comprehensive nursing assessment (20)

1.Introduction & interview.pptx
1.Introduction & interview.pptx1.Introduction & interview.pptx
1.Introduction & interview.pptx
 
Prelims-Coverage-for-NCM-101-Lecture.pptx
Prelims-Coverage-for-NCM-101-Lecture.pptxPrelims-Coverage-for-NCM-101-Lecture.pptx
Prelims-Coverage-for-NCM-101-Lecture.pptx
 
Lecture 4 notes
Lecture 4 notesLecture 4 notes
Lecture 4 notes
 
GORDONS 11 HEALTH FUNCTIONAL PATTERNS.ppt
GORDONS 11 HEALTH FUNCTIONAL PATTERNS.pptGORDONS 11 HEALTH FUNCTIONAL PATTERNS.ppt
GORDONS 11 HEALTH FUNCTIONAL PATTERNS.ppt
 
Nursing-process
 Nursing-process Nursing-process
Nursing-process
 
Generalist Practice A Presentation on Steps of The Problem-Solv
Generalist Practice A Presentation on Steps of The Problem-SolvGeneralist Practice A Presentation on Steps of The Problem-Solv
Generalist Practice A Presentation on Steps of The Problem-Solv
 
1 reflection4reflection (thorax and l
1 reflection4reflection (thorax and l1 reflection4reflection (thorax and l
1 reflection4reflection (thorax and l
 
NT Nursing Process ,Nursing care plan and Documentation.ppt
NT  Nursing Process ,Nursing care plan and Documentation.pptNT  Nursing Process ,Nursing care plan and Documentation.ppt
NT Nursing Process ,Nursing care plan and Documentation.ppt
 
Chapter002 1
Chapter002 1Chapter002 1
Chapter002 1
 
Chapter002 1
Chapter002 1Chapter002 1
Chapter002 1
 
Chapter002 1
Chapter002 1Chapter002 1
Chapter002 1
 
Chapter002 1
Chapter002 1Chapter002 1
Chapter002 1
 
Nursing process assessment
Nursing process assessmentNursing process assessment
Nursing process assessment
 
Physical Assessment including history taking and physical examination
Physical Assessment including history taking and physical examinationPhysical Assessment including history taking and physical examination
Physical Assessment including history taking and physical examination
 
Health assessment
Health assessmentHealth assessment
Health assessment
 
American Sentinel N522PE Module Mental Health Assessment Male and Female.pdf
American Sentinel N522PE Module Mental Health Assessment Male and Female.pdfAmerican Sentinel N522PE Module Mental Health Assessment Male and Female.pdf
American Sentinel N522PE Module Mental Health Assessment Male and Female.pdf
 
health assessment for nursing student
health assessment for nursing studenthealth assessment for nursing student
health assessment for nursing student
 
In-Service- Fieldwork II - CRT
In-Service- Fieldwork II - CRTIn-Service- Fieldwork II - CRT
In-Service- Fieldwork II - CRT
 
Rationale of psychological testing
Rationale of psychological testingRationale of psychological testing
Rationale of psychological testing
 
MA114 Chapter 22 patient coaching
MA114 Chapter 22 patient coachingMA114 Chapter 22 patient coaching
MA114 Chapter 22 patient coaching
 

Último

AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxAUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxiammrhaywood
 
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfMaximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfTechSoup
 
3.21.24 The Origins of Black Power.pptx
3.21.24  The Origins of Black Power.pptx3.21.24  The Origins of Black Power.pptx
3.21.24 The Origins of Black Power.pptxmary850239
 
In - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxIn - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxAditiChauhan701637
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxraviapr7
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxheathfieldcps1
 
How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17Celine George
 
UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE
 
What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?TechSoup
 
5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...CaraSkikne1
 
Patterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxPatterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxMYDA ANGELICA SUAN
 
Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.EnglishCEIPdeSigeiro
 
How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17Celine George
 
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxPractical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxKatherine Villaluna
 
CAULIFLOWER BREEDING 1 Parmar pptx
CAULIFLOWER BREEDING 1 Parmar pptxCAULIFLOWER BREEDING 1 Parmar pptx
CAULIFLOWER BREEDING 1 Parmar pptxSaurabhParmar42
 
How to Solve Singleton Error in the Odoo 17
How to Solve Singleton Error in the  Odoo 17How to Solve Singleton Error in the  Odoo 17
How to Solve Singleton Error in the Odoo 17Celine George
 
Diploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdfDiploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdfMohonDas
 
How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17Celine George
 
Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.raviapr7
 
M-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxM-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxDr. Santhosh Kumar. N
 

Último (20)

AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptxAUDIENCE THEORY -- FANDOM -- JENKINS.pptx
AUDIENCE THEORY -- FANDOM -- JENKINS.pptx
 
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdfMaximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
Maximizing Impact_ Nonprofit Website Planning, Budgeting, and Design.pdf
 
3.21.24 The Origins of Black Power.pptx
3.21.24  The Origins of Black Power.pptx3.21.24  The Origins of Black Power.pptx
3.21.24 The Origins of Black Power.pptx
 
In - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptxIn - Vivo and In - Vitro Correlation.pptx
In - Vivo and In - Vitro Correlation.pptx
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptx
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptx
 
How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17
 
UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024UKCGE Parental Leave Discussion March 2024
UKCGE Parental Leave Discussion March 2024
 
What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?
 
5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...
 
Patterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxPatterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptx
 
Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.Easter in the USA presentation by Chloe.
Easter in the USA presentation by Chloe.
 
How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17How to Show Error_Warning Messages in Odoo 17
How to Show Error_Warning Messages in Odoo 17
 
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxPractical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
 
CAULIFLOWER BREEDING 1 Parmar pptx
CAULIFLOWER BREEDING 1 Parmar pptxCAULIFLOWER BREEDING 1 Parmar pptx
CAULIFLOWER BREEDING 1 Parmar pptx
 
How to Solve Singleton Error in the Odoo 17
How to Solve Singleton Error in the  Odoo 17How to Solve Singleton Error in the  Odoo 17
How to Solve Singleton Error in the Odoo 17
 
Diploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdfDiploma in Nursing Admission Test Question Solution 2023.pdf
Diploma in Nursing Admission Test Question Solution 2023.pdf
 
How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17How to Make a Field read-only in Odoo 17
How to Make a Field read-only in Odoo 17
 
Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.Drug Information Services- DIC and Sources.
Drug Information Services- DIC and Sources.
 
M-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxM-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptx
 

Comprehensive nursing assessment

  • 1. Kimberly Carillo, RN Kristine Mae Fernandez, RN Regeine Tepanero, RN
  • 2. After 2 hours and 30 minutes of interactive class discussion and film showing, the graduate school students of MAN 211c will be able to: Define the Nursing Health History Identify the purpose of the Nursing Health History Differentiate Subjective Data and Objective Data Utilize the guidelines in obtaining nursing history when doing the Interview Identify the components of the nursing history Demonstrate the Skills used in Physical Examination
  • 3. ...the systematic collection of subjective data (stated by the client) and objective data (observed by the nurse) used to determine a client's functional health pattern status. ...these data assist the nurse in identifying nursing diagnoses and/or collaborative problems.
  • 4. Characteristic Subjective Objective Description Data elicited & verified by the client Data directly or indirectly observed through measurement Sources Client Family & Significant Others Client Records Other Health Care Professionals Observations & PA findings of the nurse or other health care professionals Documentation of assessments made in client record Observations made by the client’s family or significant others
  • 5. Characteristic Subjective Objective Methods used to obtain data Client Interview Observation and Physical Examination Skills needed to obtain data Interview Therapeutic communication skills Caring ability Empathy Listening Skills Inspection Palpation Percussion Auscultation Examples “ I have a headache” “Hindi ako gutom” Respirations 16 cpm BP 180/100, apical pulse 80, irregular X-ray film reveals fractures
  • 6.  Phases of the Nursing Interview  Specific Communication Techniques
  • 7. Nursing Interview ...is a communication process that focuses on the client's developmental, psychological, physiological, sociocultural and spiritual responses that can be treated with nursing and collaborative interventions.
  • 9.  Introduce yourself & your role  Explain purpose of interview  Explain the purpose of note-taking, confidentiality and type of questions to be asked.  Provide comfort, privacy and confidentiality. Introductory Phase
  • 10.  Facilitate clients comments about major biographical data, reason for seeking health care, and functional health pattern responses.  Use critical thinking skills to:  listen for and observe cues  interpret and validate information received from the client  Collaborate with client to identify problems and goals  The approach for facilitation may either be free- flowing or structured depending on time and data needed Working Phase
  • 11.  Summarize information obtained from working phase  Validate problems and goals with the client  May discuss possible plans to resolve the problems identified  Allow the client time to express feelings, concerns and questions. Summary/ Closing Phase
  • 12.  Types of Questions to use  Types of Statements to use  Helpful Hints  Communication Styles to Avoid  Specific Age Variations  Emotional Variations
  • 13.  Use open-ended questions (What, How, Which)  Use close-ended questions in obtaining facts on specific information  Use a laundry list (scrambled words) approach to obtain specific answers
  • 14.  Explore all data that deviate from normal with the following questions:  “What alleviates or aggravates the problem?  “How long has it occurred?”  “How severe is it?”  “Does it radiate?”  “When does it occur?”
  • 15.  Rephrase or repeat your perception of the client’s response to reflect or clarify information shared  Encourage verbalization of client by saying “Yes, ” or “I agree,” or nodding  Describe what you observe in the client
  • 16.  Accept the client; display a non-judgmental attitude  Use silence to help both you and the client reflect and reorganize thoughts  Provide client with information as questions and concerns arise
  • 17.  Excessive/Insufficient eye contact  Doing other things while taking history  Biased or Leading questions  Relying on memory to recall information  Recording all the details  Rushing the Client  Reading questions from history form
  • 18.  For ages from birth up to 14 years old clients history should be validated for reliability with the responsible SO.  Assess hearing acuity; with loss, speak slowly, face the client, and speak on the side on which hearing is more adequate.  Speak loudly only if with hearing deficit  Use direct eye contact
  • 19.  Angry Client:  Approach in a calm, reassuring, in-control manner.  Allow ventilation of client’s feelings  Avoid arguing and provide personal space  Anxious Client:  Approach with simple and organized information  Explain your role and purpose  Manipulative Client  Provide structure and set limits
  • 20. Client Profile Developmental History Gordon’s Functional Health Patterns History of Present Illness Past Health History Review of Systems Physical Assessment Client Profile The purpose of the client profile is to determine biographical client data and to obtain an overview of past and present medical diagnoses and treatment that may alter a client’s response. Developmental History The purpose of the developmental history is to determine the physical, cognitive, and psychosocial development to assess developmental delays. Gordon’s Functional Health Patterns a guide for establishing a comprehensive nursing data base. These 11 categories make possible a systematic and standardized approach to data collection, and enable the nurse to determine the 11 aspects of health and human function. History of Present Illness a framework for approaching patient complaints in a problem oriented fashion. The patient initiates this process by describing a symptom. It falls to you to take that information and use it as a springboard for additional questioning that will help to identify the root cause of the problem. Past Health History Patient’s other Health Problems aside from his/her chief complaint Review of Systems To better define the likely causes of a presenting symptom (Meaning it’s highly subjective) Physical Assessment Uses 4 Basic Techniques for Assessment: Inspection Palpation Percussion Auscultation
  • 21. Marjorie Gordon (1987) proposed functional health patterns as a guide for establishing a comprehensive nursing data base. These 11 categories make possible a systematic and standardized approach to data collection, and enable the nurse to determine the following aspects of health and human function:
  • 22. Health Perception and Health Management. Data collection is focused on the person's perceived level of health and well-being, and on practices for maintaining health. Habits that may be detrimental to health are also evaluated, including smoking and alcohol or drug use. Actual or potential problems related to safety and health management may be identified as well as needs for modifications in the home or needs for continued care in the home.
  • 23. Nutrition and Metabolism Assessment is focused on the pattern of food and fluid consumption relative to metabolic need. The adequacy of local nutrient supplies is evaluated. Actual or potential problems related to fluid balance, tissue integrity, and host defenses may be identified as well as problems with the gastrointestinal system. Elimination. Data collection is focused on excretory patterns (bowel, bladder, skin). Excretory problems such as incontinence, constipation, diarrhea, and urinary retention may be identified.
  • 24. Activity and Exercise. Assessment is focused on the activities of daily living requiring energy expenditure, including self-care activities, exercise, and leisure activities. The status of major body systems involved with activity and exercise is evaluated, including the respiratory, cardiovascular, and musculoskeletal systems. Cognition and Perception. Assessment is focused on the ability to comprehend and use information and on the sensory functions. Data pertaining to neurologic functions are collected to aid this process. Sensory experiences such as pain and altered sensory input may be identified and further evaluated.
  • 25. Sleep and Rest. Assessment is focused on the person's sleep, rest, and relaxation practices. Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified. Self-Perception and Self-Concept.  Assessment is focused on the person's attitudes toward self, including identity, body image, and sense of self- worth. The person's level of self-esteem and response to threats to his or her self-concept may be identified.
  • 26. Roles and Relationships. Assessment is focused on the person's roles in the world and relationships with others. Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated. Genogram - A genogram is a pictorial display of a person's family relationships and medical history.
  • 27. Sexuality and Reproduction. Assessment is focused on the person's satisfaction or dissatisfaction with sexuality patterns and reproductive functions. Concerns with sexuality may he identified. Coping and Stress Tolerance. Assessment is focused on the person's perception of stress and on his or her coping strategies Support systems are evaluated, and symptoms of stress are noted. The effectiveness of a person's coping strategies in terms of stress tolerance may be further evaluated. Values and Belief. Assessment is focused on the person's values and beliefs (including spiritual beliefs), or on the goals that guide his or her choices or decisions.
  • 30. Inspection •Definition: •Inspection is using the senses of vision, smell, and hearing to observe the condition of various body parts, including any deviations from normal. •Technique: •Expose the parts being observed while keeping the rest draped •Always look before touching •Use good lighting •Provide warm room for examination •Observe color, size, location, texture, symmetry, odors and sounds.
  • 32. Inspection Palpation •Definition: •Is touching and feeling body parts with your hands to determine the following characteristics: •Texture •Temperature •Moisture •Motion •Consistency of structures
  • 33. Inspection Palpation •Technique: •Examiner’s fingernails should be short •Most sensitive parts of the hand should be used to detect various sensations •Fingertips: Fine discriminations, pulsations •Palmar Surface: Vibratory sensations (e.g. thrills, fremitus) •Dorsal Surface: Temperature •Light palpation precedes deep palpation •Tender areas are palpated last
  • 35. Percussion Auscultation •Definition: •Is tapping a portion of the body to elicit tenderness or sounds that vary with the density of underlying structures. •Technique: •Direct Percussion: To elicit tenderness or pain •Indirect Percussion: To elicit one of the following sounds over the chest or abdomen:
  • 36. Percussion Auscultation •Technique: (cont’d) •Resonance: Heard over part air and part solid •Hyperresonance: Heard over mostly air •Tympany: Heard over air •Dullness: Heard over more solid tissue •Flatness: Heard over very dense tissue
  • 38. Auscultation •Definition: •Is listening for various breath, heart, vasculature, and bowel sounds using a stethoscope. •Technique: Purpose Technique Diaphragm To detect high- pitched sounds Press firmly on body part Bell To detect low-pitched sounds Press lightly over body part