FHARDINA LEIGH D.

YAP BSN 1-B HEALTH ASSESSMENT LECTURE

HEALTH ASSESSMENT - Know Verbal and nonverbal
Cephalocaudal Assessment – communication
medical term for head-to-toe - Establish trust and mutual respect
assessment
 When administering abdominal Ethical Skills
pain, the first thing that we should - Being responsible and accountable
consider as our first step is - Become an advocate to your patient
assessment.  If you know that the doctor’s
Assessment – (vital signs, stabilizing order is wrong for the welfare of
the patient) the patient, DON’T DO IT
- is a process of collecting, validating,  A nurse should be the protector
and clustering data. of patient
Cognitive Skills – needed for critical
thinking, and decision making. 4 TYPES OF ASSESSMENT
Critical Thinking – not just doing but Initial Comprehensive Assessment
asking “why?” - Collection of subjective data about
Problem Solving – select the best skill client/patient’s perception about
that suites your patients need their body
Reflexive Thinking – you automatically - As well as objective data gathered
make decision and do things quickly during the step by step
Hit or Miss Thinking – trial – error
approach Ongoing or Partial Assessment
 make independent nursing - Data collection after the
intervention before you refer to a comprehensive assessment
doctor  Ward
Critical Thinking Approach –  Still ongoing treatment of the
scientific method – involves identifying patient that needs an
a problem and collecting supporting assessment
data Focused or Problem-Oriented
Intuition – develops through Assessment
experience - this assessment should only be
- how “expert” nurse solve problem concerning on the specific health
Psychomotor skills – needed to concern of the patient.
perform the 4 techniques of physical Emergency Assessment
assessment (Inspection, Palpation, - very rapid assessment that doesn’t
Percussion, and Auscultation) need a chain of long assessment to
 All parts of the body should be diagnose the patient.
inspected by the IPPA method  Choking, cardiac arrest,
except for the abdomen drowning
 For abdomen inspection, the
physical inspection should be in ROLE OF NURSE AND
order of IAPP (Inspection, ASSESSMENT
Auscultation, Palpation, Percussion) Nursing Assessment
- We should assess the bowel sound - Diagnose and treat human
Affective/Interpersonal Skills responses to actual or potential
- Needed to practice the “art” in health problem
nursing
- Improves physiological,
- Caring, therapeutic nurse-patient
psychological, cultural,
relationship
development, and spiritual
FHARDINA LEIGH D. YAP BSN 1-B HEALTH ASSESSMENT LECTURE
Medical Assessment  Don’t describe what your
- Diagnose and treat diseases patient’s looks when writing a
- Makes physiological and data
psychological development only × An old man that is sad looking
Observation
MEDICAL TERMS - Observation by the use of 5 senses
(sight, hearing, smell, taste, touch)
Dyspnea – an uncomfortable Physical Assessment
abdominal awareness of breathing. - Collection of client’s data base from
Dyspneic – a person who is suffering a physical examination
from dyspnea - Help assess the patient’s health
Apnea – patients that stops breathing status
for short periods during sleep - Technique of IPPA
Apneic – breathing that stops from any  Pain can be subjective or
cause objective.
Bradypnea – breathing slowly than  Subjective data: “I am in pain”
normal  Objective data: “the pain scale
Tachypnea – rapid or increased is 8/10”
breathing than normal Documentation ALWAYS PRIORITIZE
Febrile – fever; hyperthermia: 36.5 SOAPIE METHOD
above S – Subjective A – AIRWAY
Afebrile – absence of fever; O – Objective
hypothermia: 34 below A – Assessment B – BREATHE
P – Plan
I – Intervention C – CIRCULATION
TYPES OF DATA
Subjective Data E – Evaluation
- Symptoms of the patient
- What the patient’s feel and speak
Objective Data
- Signs
- Observation by the use of 5 senses
(sight, hearing, smell, taste, touch)
- What is done and said by a health
practitioner
Primary Data
- Anything from what the patient’s
said
Secondary Data
- Other people or health care
provider said, family, physician
Interview
- Structured communication intended
to obtain subjective data
- Needs a good interpersonal
communication
- Be emphatic
- Maintain neutral and non-
judgmental positional