MODULE 3: (PART 1)

Steps on Health
Assessment
NCM 101

Name of Student:
Section:
University of San Agustin

Date Started: College of Nursing, Nutrition and Dietetics

Nursing Program

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 NCM 101: HEALTH ASSESSMENT

Introduction
This learning and assessment workbook introduces you to the different steps in the collection of
READ data out of a health assessment.

By the end of this module, the learners will be able to:

 Differentiate subjective and objective data.
 Match methods of data collection to the desired data outcome.
 Outline the contents of the Health History

Data Collection
- Data collection is the process of gathering information about a client’s health status.
Data collection must be both systematic and continuous to prevent the omission of
significant data and reflect a client’s changing health status.

Read about the Collection and Types of Data in any of the resource materials or on the internet.
Provide the definition and at least 3 examples of the following terminologies:
READ
I have read and understood the following resource material / internet site:
Subjective VS. Objective Nursing Data: What’s The Difference. (n.d.).
https://www.nursingprocess.org/subjective-vs-objective-nursing-data.html

QUESTIONS SUBJECTIVE DATA: Subjective nursing data are collected from sources other than the nurse's
observations. This type of data represents the patient's perceptions, feelings, or concerns as
obtained through the nursing interview. The patient is considered the primary source of
subjective data. Other sources, including the patient's family or caregivers, and other members
of the healthcare team, are called secondary sources.

Examples:
 Congestion or Runny Nose
 Level of Consciousness
 Loss of Appetite, Taste or Smell
 Shortness of Breath

OBJECTIVE DATA: Objective data in nursing refers to information that can be measured
through physical examination, observation, or diagnostic testing. Examples of objective data
include, but are not limited to, physical findings or patient behaviors observed by the nurse,
laboratory test results, and vital signs.

Examples:
 Blood Urea and Creatinine Levels
 Blood Pressure and Body Temperature
 Respiratory Rate
 X-Ray or Computed, Tomography (CT) Scans

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Look into this YouTube video: https://youtube.com/watch?v=UWu78KZvj70

Watch until the 3-minute mark and identify and match the data gathered to its type.

LOOK INTO

Subjective Data Objective Data

 History of hypertension and diabetes  Vital signs: BP: 117/78, HR: 67, RR: 22, T:
37.2, Sat: 96%
 According to the patient the is
intermittent and a burning sensation  Physical Examination:

 Reports of nausea without vomiting  General: Alert, oriented, mild distress

due to pain, pale, clammy
 Denies dyspnea, fevers, cough,
 Airway: Speaking in full sentences
congestion, urinary symptoms or
changes of stool.
 Breathing: No significant respiratory
distress, increased respiratory rate
 No record of allergies
 Circulation: Cool and clammy skin,
 With Lisinopril, and Metformin normal pulses, normal capillary refill
medication
 HEENT/Neck: Normal
 A former smoker
 Chest: No pain to palpation, no signs
of trauma

 Heart: RRR; no rubs gallops or murmurs

 Lungs: Clear to auscultation bilaterally,

no rales, rhonchi, or wheezes

 Abdomen: Soft, non-tender, non-

distended, bowel sounds present, no
masses, rigidity, or guarding

Nursing Health History

- a health history is part of the Assessment phase of the nursing process. It consists of
using directed, focused interview questions and open-ended questions to obtain
symptoms and perceptions from the patient about their illnesses, functioning, and life
processes.

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Read about the Components of a Nursing Health History in any of the resource materials or on
the internet.
READ
I have read and understood the following resource material / internet site:

Given the background of Health History taking, conduct an interview session with a family
member or a friend who is experiencing an illness or has a current medical situation and derive
sufficient data for the following:
QUESTIONS

Biographic Data:

Name: Cynthia G. Pianera

Age: 49
Gender: Female
Address: Malusgod, Pototan, Iloilo City
Birthdate: April 3 1973
Religion: Catholic
Birthplace: Iloilo City
Marital Status: Married
Date of Admission: September 9, 2022
Attending Physician: Dr. Liza M. Limsiaco, Dr. Nina Isabela P. Juan Loa, and Dr. Shane Ann S.
Pedragosa
Initial Diagnosis: Severe Anemia, Hypogastric mass
Final Diagnosis: Presence of Hypogastric Mass, Endometrial Cyst, and Thickness of
uterine line, Undergone Total Abdominal Hysterectomy with Bilateral Salpingo-
oophorectomy surgery and Dilation and Curettage procedure.

Chief Complaint or Reason for Seeking Health Care:

History of Present Illness:

Past Health History:

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Family Health History:

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Review of System for Current Health Practice:

Lifestyle and Health Practices:

Knowing the Method of Obtaining Subjective Data, reflect on the following:

SELF
REFLECTION While interviewing a client / patient about their Nursing Health History. What set of
attitude or behaviour did you show to establish rapport?
- Seeking out commonalities really helped me on knowing how to establish rapport. This
is a way of continuing

What difficulties have you encountered in collecting subjective data and how did you
establish to manage these during your interview?
- As the patient experience illness, subjective data signals the nurse about things that
may be problematic for the patient and can also indicate specific patient strengths that could
be useful when communicating with and caring for patient. In order to manage the difficulty, I
will check upon the patient’s health history to have an access on the data needed.

3. As an Augustinian Nursing Student, how would this topic be beneficial to your career
path?

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Thank you for answering the questions of this module with utmost honesty and zeal. Keep in
mind that plagiarism, in any form, is not tolerated with this curriculum. So please note the
READ
source of your answers in the green boxes provided. For book sources: Name of Author and the
Book Name, for internet sources: the website.

You may, print and answer this self-directed module, scan it as PDF and upload on the drop box
in your neolms or super-impose your answers digitally on the spaces provided, save it as PDF
and upload them on the drop box in your neolms.

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