NCM 101 Health Assessment PDF - Conceptual Overview

NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 collecting validating, organizing,...

NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 collecting validating, organizing, and recording data TOPIC OUTLINE ​ Discuss the historical and current evolution of the Nurse’ role I.​ INTRODUCTION TO HEALTH in health assessment. ASSESSMENT IN NURSING ​ Identify and explain the II.​ NURSING: SCOPE AND STANDARDS OF framework for health assessment in PRACTICE nursing. III.​ FACTORS THAT PROMOTES ​ Differentiate between the OPPORTUNITIES THAT CREATE ADVANCE types of assessment used in ASSISTANCE SKILLS nursing(initial, comprehensive, IV.​ FOCUS OF HEALTH ASSESSMENT IN ongoing/partial, NURSING: focused/problem-oriented, and V.​ FRAMEWORK FOR HEALTH ASSESSMENT emergency). IN NURSING: VI.​ 4 TYPES OF ASSESSMENT A. Initial assessment B. Problem-focused assessment Introduction to Health Assessment in C. Emergency assessment Nursing D. Time-lapsed reassessment The American Nurses Association VII.​ 4 STEPS OF HEALTH ASSESSMENT Publication, Nursing: Scope and A. Collection of Subjective data Standards of Nursing Practice defines B. Collection of objective data nursing as: C. Validation of data 1.​ The protection, promotion, and D. Documentation of data optimization of health and abilities VIII.​ PHASES OF NURSING INTERVIEW Your job as nurses is to insure: A.​ INTRODUCTORY PHASE ​ Safety of the client B.​ WORKING PHASE ​ Insure quality care C.​ SUMMARY & CLOSURE 2.​ Prevention of illness and injury IX.​ GORDON'S TYPOLOGY OF 11 3.​ Alleviation of suffering through FUNCTIONAL HEALTH PATTERNS diagnosis and treatment of human X.​ COLLECTING OBJECTIVE DATA responses XI.​ VALIDATING ASSESSMENT DATA 4.​ Advocacy in the care of individuals, XII.​ VALIDATING ASSESSMENT DATA families, communities and populations legend : book- blue; PPT- Black; Audio- Red ANA emphasized on: - Diagnosis and treatment of human Learning Objectives: responses ​ Define and explain the - Accurate client assessments different phases of Nursing Practice. - Effective nursing interventions ​ Describe the Nurse’s role in This 3 of course first you insure your health assessment, including assessment, after insuring your assessment that's the time you can diagnose the client. Not as doctors 1  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 but as nurses. Then you can now You should learn to prioritize data collection. implement because your nursing Because you need to know what is high interventions are in the priority, medium priority and low priority. implementation phase. ​ Uses appropriate evidence-based assessment techniques and instruments in collecting pertinent data. NURSING: SCOPE AND STANDARDS OF PRACTICE Everything that we do, especially the techniques and instruments, have undergone “The registered nurse collects comprehensive studies, added to the professional nursing data pertinent to the patient’s health or standards. Evidence based practice, situation” ngatanan nat nga gin bubuhat medically, all Our role as nurses, if we based on the history based on evidences.Dapat maaram kamo hit of nursing. We are no longer servants to anatomy and, physiology,health assessment, serve, we now are “Thinking Servants”. okay, it already involves the whole body Meaning we are thinking about the welfare system, how your brain works. and the health of others. ​ Uses analytical models and How do you implement of how do you problem-solving tools practice your thinking skills? is by “asking Inin hiya amo na inin gin adman han TFN, questions” because in Nursing health assessment you How will you collect comprehensive data? also incorporate the theoretical model. You ask pertinent questions. ​ Synthesizes available data, information, In nursing assessment you ask questions, not and knowledge relevant to the situation to just ask but also observe the behavior of the identify patterns and variances client. meaning to say scientific an pag analyze han data dre la ky basta basta collect and collect, select and select. TO ACCOMPLISH THIS PERTINENT AND ​ Documents relevant data in a retrievable COMPREHENSIVE DATA COLLECTION, format THE NURSE; Meaning ngatanan nga im gin rerecord gin ​ Collects data in a systematic and fa-file you dont throw it away, because ongoing process there is what we called a nursing health We have standards, we follow steps in history. Nursing health history is the interviewing. And it should be ongoing history taking done by nurses, its the meaning 'continuous'. you have to start and history taking done by the medical you have to end it somehow. professionals you collaborate with each ​ Involves the patient, family, other other kun pareho ba an data nga iyu na health care providers, and environment, as collect, is it reliable?,, you compare. appropriate, in holistic data collection. It involves everyone who is part on the STANDARD 2 STATES, “ THE patients sources. Kun hino man it nag REGISTERED NURSE ANALYZES THE babantay, ASSESSMENT DATA TO DETERMINE THE ​ Prioritizes data collection activities DIAGNOSIS OR ISSUES” based on the patient’s immediate condition, Standard 2. States that the registered or anticipated needs of the patient or nurse analyzes the Assessment data to situation 2  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 determine the diagnosis or issues. Your role ​ Examples of independent nursing here is to make sure that all possible and practice using inspection, palpation, appropriate care will be given to the and auscultation have been patient. recorded in nursing journals since 1901. Some examples reported in ​ Derives the diagnosis or issues the American Journal of Nursing based on assessment (1901-1938) include gastrointestinal ​ Validates the diagnosis or issues palpation, testing eighth cranial with the client, family, and other healthcare nerve function, and examination of providers when possible and appropriate. children in school systems Validation is the sources of the data All you have to remember is that the collected, how reliable is it and how nurses relied on their natural senses. relevant is it to the case of the client. ​ Documents diagnoses or issues in a 1930-1949 manner that facilitates the ​ The American Journal of Public ​ determination of the expected Health documents routine client and outcomes and plan home inspection by public health Then you document, again balik balik inin nurses in the 1930s. nga uupat, you collect you organize you ​ This role of case finding, prevention validate then you document. Your role here of communicable dis-eases, and is to make sure that all possible and routine use of assessment skills in appropriate care would be given to a poor inner-city areas was performed patient. through the Frontier Nursing Service and the Red Cross (Fitzsimmons & Gallagher, 1978) THE NURSE’S ROLE IN HEALTH 1950-1969 ASSESSMENT ​ Nurses were hired to conduct pre-employment health stories and Your assessment, as part of a nursing role, physical examinations for major is now a specialization. companies, such as New York Telephone, from 1953 through 1960 LATE 1800s-EARLY 1900s (Bews & Baillie, 1969; Cipolla & ​ Nurses relied on their natural Collings, 1971) senses; the client's face and body would be observed for "changes in 1970-1989 color, tem-perature, muscle ​ The early 1970s prompted nurses to strength, use of limbs, body output, develop an active role in the and degrees of nutrition, and provision of primary health services hydration" (Nightingale, 1992). and expanded the professional ​ Palpation was used to measure nurse role in conducting health pulse rate and quality and to locate histories the fundus of the puerperal woman (Fitzsimmons & Gallagher, 1978). 3  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 1990-PRESENT FACTORS THAT PROMOTE ​ Over the last 20 years, the OPPORTUNITIES TO NURSES WITH movement of health care from the ADVANCED ASSESSMENT SKILLS: acute care setting to the community ​ Rising educational costs and focus on and the proliferation of primary care that affect the numbers baccalaureate and graduate and availability of medical students. education solidified the nurses' role ​ Increasing complexity of acute care in holistic assessment. ​ Growing aging population with ​ Downsizing, budget cuts, and complex comorbidities restructuring were the priorities of ​ Expanding health care needs of single the 1990s. In turn, there was a parents demand for documentation of client ​ Increasing impact of children and the assessments by all health care homeless on communities providers to justify health care ​ Intensifying mental health issues services. ​ Expanding health service networks ​ In the 1990s, critical pathways or ​ Increasing reimbursement for health care maps guided the client's promotion and preventive care progression, with each stage based services on specific protocols that the nurse was responsible for assessing and vali-dating. ​ Advanced practice nurses have been increasingly used in the 30 hospital as clinical nurse specialists and in the community as nurse practitioners. ​ While state legislators and the American Medical Association struggled with issues of reimbursement and prescriptive Tigamni it assessment an data nga gin cocollect services by nurses, government and is subjective and objective data. Wry na iba. societal recognition of the need for Diagnosis you analyzed han iyo mga data nga greater cost accountability in the gin pan collect Planning, you set goals and health care industry launched the objectives Implementation, carrying out the advent of diagnosis-related groups plan, meaning to say this is your nursing (DRGs) and promotion of health intervention. Evaluation you identify whether or care coverage plans such as health not you're goals or other criteria has been met or maintenance organizations (HMOs) achieved and preferred provider organizations(PPOs). Assessment -​ is the first and most critical phase of the nursing process. 4  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 -​ Inaccurate or incorrect collection of developmental and spiritual data about data or clinical judgements will have an the client. adverse effect in the remaining phases -​ The nurse focuses on how the clients health of the process. status affects activities of daily living -​ Health assessment is more than just (ADLs) and how those (ADLs) affect the gathering information about the health client's health For example: a client with status of the client. It is analyzing and asthma may have to avoid extreme synthesizing those data, making temperatures and may not be able to enjoy judgements about the effectiveness of recreational camping. Walking to work in a nursing interventions, and evaluating smoggy environment may affect this client care outcomes. person's asthma -​ FRAMEWORK FOR HEALTH ASSESSMENT IN NURSING bbb ​ Nursing Health History (subjective data) -​ History of Present Health Concern -​ Personal Health History -​ Family History -​ Lifestyle and Health Practices -​ Each step of the nursing process depends -​ A nursing framework helps to organize on the accuracy of the preceding step. information and promotes the collection of -​ The steps overlap because you may have holistic data, it provides clues that help to to move more quickly for some problems determine human responses than others -​ The arrow between Assessment and Physical Examination Skills(Technique) Evaluation goes in both directions because (objective data) assessment and evaluation are ongoing -​ Inspection processes as well as separate phases. -​ Palpation -​ Percussion FOCUS OF HEALTH ASSESSMENT IN -​ Auscultation NURSING: -​ Objective data, this type of data is the client's medical record, which is the The purpose of a nursing health document that contains information about assessment: what other healthcare professionals -​ Is to collect holistic subjective and observed about the client May also be objective data to determine a client’s observations noted by the family or overall level of functioning to make a significant others of the client professional clinical judgment -​ The nurse collects physiological, psychological, sociocultural, 5  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 4 TYPES OF ASSESSMENT: 3. Focused or Problem-Oriented Assessment 1. Initial Comprehensive Assessment -​ Involves collection of subjective data about -​ lt is performed when a comprehensive the client's perception of his or her health of database exists for a client who comes to all body parts or systems, past health the health care agency with a specific history, family history, and lifestyle and health concern. health practices as well as objective data -​ This does not replace the comprehensive gathered during a step-by-step physical health assessment examination. -​ A focused assessment consists of a -​ The nurse typically collects subjective and thorough assessment of a particular objective data in many settings. client problem and does not addr Depending on the setting, other members specific, uusa la specific hitun nga of the healthcare team may also particular body system. Anything nga iyo participate in various parts of the data na peperform when which the patient collection already complains. Na exist na ha -​ Frequency of Comprehensive assessment pasyente, for example nag complain depending on the clients age, risk factors, hiyan chest pain, tikang hito han health status, health promotions practices pasyente, verbalized iton han pasyente so and lifestyle. that would be your focused problem. An This can be done in any setting, this is a one how do you alligate chest pain? That on one interview with your patient, you would be now your interventions for that include your patient’s perception here. particular focused problem which is the heart, or the chest pain complain by the 2. Ongoing or Partial Assessment patient. So amo iton iyo focus. 4. Emergency Assessment -​ Consists of data collection that occurs after the comprehensive database is established. -​ A very rapid assessment performed in -​ This consists of a mini-overview of the life-threatening situations client's body systems and holistic health -​ Immediate assessment is needed to patterns as a follow-up on health status provide prompt treatment -​ A brief reassessment of the clients body -​ The major and only concern during this systems and holistic health patterns is type of assessment is to determine the performed to detect any new problems. status of the client's life sustaining This is done in a setting of a hospital an physical functions. Natatabo inin ha sulod patient na admit na, it consist of data hit ER, rapid assessment performed in life collected within the comprehensive data threatening conditions. Kailangan hin base or chart of the patient. Dd niyou immediate attention, or any major makukuha an baseline data kikitaon niyo concern is being documented here is kun na improve o na deteriorate ba an documented here in emergency iyo patient. assessment. 6  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 STEPS OF HEALTH ASSESSMENT psychological, physiologic, sociocultural, I.​ Collection of subjective data and spiritual responses that can be II.​ Collection of objective data treated with nursing and collaborative III.​ Validation of data interventions. IV.​ Documentation of data TWO FOCUSES 1. Establishing rapport and a trusting These steps may tend to overlap however it's relationship with the client to elicit accurate very mandatory that you’ll be strictly and meaningful information following these steps. 2. Gathering information on the client's developmental, psychological, physiologic, sociocultural, and spiritual statuses to PREPARING FOR ASSESSMENT identify deviations that can be treated with -​ Review the client's medical record, if nursing and collaborative interventions or available strengths that can be enhanced through -​ Know the client's basic biographical nurse client collaboration. data -​ Use this time to educate yourself about PURPOSE OF THE INTERVIEW the client's diagnoses or tests 1.​ Gather organized, complete and accurate performed. data about the patient's health state, -​ Take a minute to reflect on your own including the description and chronology of feelings regarding any signs and symptoms of illness. -​ Remember to keep an open mind and to 2.​ Establish rapport and trust so the patient avoid premature judgments that may feels accepted and feels free to share all alter your ability to collect accurate relevant data data. 3.​ Teach patients about the health state so -​ your initial encounter with the client. that he/she can participate in identifying -​ Remember to obtain and organize problems and planning for health care. materials that you will need for the 4.​ Build rapport for a continuing assessment nurse-patient therapeutic relationship. 5.​ Begin teaching for health promotion and I.​ COLLECTING SUBJECTIVE DATA disease prevention. Subjective: Are sensation or symptoms, perceptions. Desires, feelings, INTERVIEWING IS FORMING A CONTRACT preferences, beliefs, ideas, values, and ​ Time and place personal information, that can be ​ Introduction of self and brief explanation elicited and verified on the client. of the nurse's role. -​ To elicit accurate subjective data, learn ​ The purpose of the interview to use effective interviewing skills with a ​ How long will it take? variety of clients in different settings ​ Expectation of participation for and of the Key words: verified only by the client. patient ​ Presence of other people (Significant other, NURSING INTERVIEW family members, relatives, Health care -​ a communication process focusing on team) the client's developmental, ​ Confidentiality and cost 7  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 THE PROCESS OF COMMUNICATION SPECIFIC VERBAL COMMUNICATION ​ SENDING(SENDER) TECHNIQUES Verbal Nonverbal TYPES OF QUESTIONS TO USE: ​ RECEIVING(RECEIVER) -​ Use open-ended questions to elicit the client's feelings & perceptions. -​ Use close-ended questions to obtain facts and COMMUNICATION DURING INTERVIEW zero in on specific information. ​ Nonverbal Communication -​ Use a laundry list (scrambled words) approach ❖​ Appearance- how you present to obtain specific answers yourself -​ Explore all data that deviate from normal. ❖​ Demeanor- how you approach your client ❖​ Facial Expression- how you face How to use open ended questions? your client Open-Ended Questions ❖​ Attitude - one most important -​ elicit the client's feelings and perceptions. nonverbal skill to develop as this has -​ They typically begin with the words "how or a huge effect in terms of "what." comfortability of clients towards the -​ An example of this type of question is: healthcare provider. ​ "How have you been feeling lately?" ❖​ Silence- allow you and the client to ​ What brings you to the hospital? reflect and organize thoughts, which ​ You mentioned shortness of breath, tell facilitate more accurate reporting of me more* about it. data collection. ❖​ Listening- the MOST important skill Close-Ended Questions to learn and develop fully in order to -​ Questions to obtain facts and to focus on collect complete and valid data specific information from your client. -​ The client can respond with one or two words. - To listen effectively, you need to The questions typically begin with the words maintain good eye contact, smile "when" or "did." or display an open, appropriate -​ An example of this type of question is: facial expression, and maintain an ​ "When did your headache start?" open body position and open ​ "Have you ever had pain?" mind. ​ "What medications are you presently taking? ​ Nonverbal Communication ❖​ Open-ended Questions Laundry List ❖​ Close-ended Questions -​ provide the client with a list of words to ❖​ Laundry List choose from in describing symptoms, ❖​ Rephrasing conditions, or feelings. ❖​ Well-placed Phrases -​ This laundry list approach helps you to obtain ❖​ Inferring specific answers and reduces the likelihood of ❖​ Providing information the client perceiving or providing an expected answer 8  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 -​ Examples: ​ Is the pain dull, piercing, severe, mild, ​ ADDITIONAL HELPFUL HINTS: tolerable? -​ Accept the client; Display a ​ Does the pain occur, hourly, everyday, nonjudgmental attitude every month? -​ Use silence to help the client & yourself to reorganize thoughts Rephrasing -​ Provide information during the -​ This technique helps to clarify interview as questions or concerns arise. information the client has stated; it also enables you and the client ​ COMMUNICATION STYLES TO AVOID: to reflect on what was said. -​ Excessive/ insufficient eye contact -​ Doing other things while taking the Well-Placed Phrases history -​ The nurse can use this technique -​ Biased/leading questions to encourage client’s -​ Relying on one's own memory verbalization. -​ Rushing the client -​ Listening to what the client is saying and uses “uh-huh”, “yes”, or “I agree” to encourage the PHASES OF THE NURSING INTERVIEW client to continue. I.​ INTRODUCTORY PHASE II.​ WORKING PHASE Inferring III.​ SUMMARY & CLOSURE -​ Using the information or what you’ve observed to form an idea I.​ INTRODUCTORY PHASE or conclusion to the client. -​ Introduce yourself and describe your Providing Information role (RN, Student, etc.) -​ Another important thing to do -​ Address the client with the surname throughout the interview is to -​ Explain the purpose of the interview & provide the client with note-taking information as questions and -​ Provide comfort, privacy, and concerns arise and making sure confidentiality. to answer every questions as you -​ Important for nurses to develop trust can. and rapport SPECIFIC COMMUNICATION TECHNIQUES ​ TYPES OF STATEMENTS TO USE: II.​ WORKING PHASE -​ Rephrase/repeat your perception of the client's response When you -​ Facilitate the client's comments ( conduct and interview, you clarify the about major biographical data, information. reasons for seeking care, history of -​ Encourage verbalization present health concern, past health -​ Describe what you observe in the history, family history, review of body client. health system) 9  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 -​ Use critical thinking skills How do you compare subjective and objective -​ Collaborate with the client to identify data? problems and goals When you describe subjective data it is elicited -​ Approach could either be free-flowing (inaabat ngan gin yayakan han pasyente an ira or more structured. inaabat) and verified by the patient. -​ During the working phase it is here Objective naman directy or indirectly you can now that you practice your see once the patient an iya status, an iya communication skills. You apperance, and the true measurement directly collaborborate and identify the when you take the vital signs. problems of the patient together with the patient and you come up with SOURCES OF DATA goals. 1.​ Client - the primary and the best source of data. If the client is conscious, alert, coherent(nakakayakan), III.​ SUMMARY & CLOSURE oriented to time date and place. -​ Summarize information obtained 2.​ Support people -​ May begin to discuss possible plans 3.​ Client record to resolve problems. 4.​ Health Care Professionals -​ Allow the client time to express 5.​ Literature feelings, concerns, and questions. -​ It is very important on this phase, DATA COLLECTION METHODS all the data you've gathered you 1.​ Observing relate it to the patient.you confirm 2.​ Interviewing everything what you've written 3.​ Examining together with the patient. If you're in doubt you ask the patient again ORGANIZING DATA 1.​ Nursing Conceptual Models 2.​ Wellness Models 3.​ Non-nursing Models 4.​ Body systems model 5.​ Maslow’s Hierarchy of Needs 6.​ Developmental Theories GORDON'S TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERNS this is part of your collection of your subjective and objective data, This was developed in 1982 this pattern as a nursing model standardizes your data collection in practicing the nursing process. “ gin sisimplify ini han pag collect niyo hin data so that you can come up with the correct nursing problem 10  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 or nursing diagnosis. Basically this 11 patterns is your anatomy and physiology. Your body Subjective: systems. The review of systems. ​ Dietary & Fluid intake ​ Condition of the skin 1.​ Health-perception/health ​ Condition of Hair & Nails management pattern. ​ Metabolism 2.​ Nutritional/metabolic pattern. This involves your diet. Mapakiana 3.​ Elimination pattern. kamo, ma’am ano it imo usual nga diet? 4.​ Activity/exercise pattern. Naka pira ka pag inom hin tubig ha usa 5.​ Sleep-rest pattern. ka adlaw. You observe also the skin, is it 6.​ Cognitive/perceptual pattern dry? Or hydrated pa it pasyente? 7.​ Self-perception/self-concept pattern. 8.​ Role/relationship pattern. Objective: 9.​ Sexuality/reproductive pattern. ​ Assess the VS of the client 10.​ Coping/stress-tolerance pattern. For objective are, you check the vital 11.​ Value/belief pattern signs, you weigh the patient. When we say nutrition the body systems involved here are your all body systems. 1.​ HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN 3.​ ELIMINATION PATTERN Subjective: Subjective: ​ Client's perception of health ​ Bowel habits ​ Client's perception of illness ​ Bladder habits ​ Health Management & habits ​ Compliance with prescribed Objective: medications & treatments ​ Abdominal assessment ​ Genitourinary assessment Objective: Physical survey Subjective: The output for this is you write down in You ask here kun anot perception han a paragraph form the before the client client ha iya health. Ex. “maam tim was ill then after being diagnosed with panlawas yana in terms of health ma’am an illness, pero if admitted it pasyente ano man? Maupay ba? Satingin nimo mabutang kamo, before the patient is healthy kaba? Pwd kalat mag rating admitted to the hospital then you scale. Pakiana pa itun anot iya compare now the present condition of perception, you ask questions. Na focus the client. For example: ano ba an iya more in subjective ini ha? Ha objective: bawal habits ngan bladder habits you do your physical survey here. before pa hiya ma admit han maupay Meaning to say mag oobserve la kamo pa an iya lawas. Then you compare now, hin demeanor, anot iya appearance. you also ask for the subjective and Maupay ba hiya mag lakat? When you objective data after magka sakit an call for their attention na bati ba hira? pasyente so that you will know the changes that occurred within the 2.​ NUTRITIONAL-METABOLIC PATTERN patient. 11  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 aborted? both male an female will be 4.​ ACTIVITY-EXERCISE PATTERN asked for contraception. Ex: ma’am, sir, nagamit ba kamo hin family planning? Subjective: ​ Activities of daily living Objective: ​ Leisure activities ​ Breast; Genito-urinary; ​ Exercise routine Abdominal assessment ​ Occupational Activities Physical examination that you would do Ano ba it usual nga mga activities hit is you perform your breast, pasyente ha iya panimalay, ha iya genito-urinary, abdominal assessment. trabaho nag eexerscise ba hiya. So tanan inin ig papakiana niyo, all related 6.​ SLEEP-REST PATTERN to this. Subjective: Objective: ​ Sleep habits ​ Thoracic & lung assessment; ​ Special problems Cardiovascular; Musculoskeletal ​ Sleep Aids For your objective you have your thorax You ask how long does it take for the and lung assessment, cardiovascular, patient to sleep, how would you rate muscular and skeletal system. your quality of sleep? Naka katurog kaba hin 6 - 8 hrs? If its a paediatric 5.​ SEXUALITY-REPRODUCTION PATTERN patient you ask the mother if nacocompleto ba it 10 - 12 hrs nga Subjective: sleep? ​ Female: Menstrual history; Obstetric history Objective: ​ Male/Female: Contraception; ​ Observe appearance Sexual activities (perception); ​ Observe behavior Concerns related to illness; You observe the appearance and the Special problems; History of behavior of the client, the client might sexual abuse look shriveled, uninterested, blank stare. You do not just ask for anything about sexuality. You follow. For example. A 7.​ A. SENSORY-PERCEPTUAL PATTERN female, ma’am kakano an imo last nga regla? So thats pertaining to a Duha ini. 7.A and 7.B. because here you menstrual history of your client. For observe Central nervous system (CNS) obstetric history naman if burod or nanay an imo pasyente or kahuman Subjective: pala panganak it im pasyente. Obstetric ​ Perception of Senses history, Kakano an im last nga ​ Pain assessment panganak,? nakapira ka pag anak?, pira ​ Special aids pa tim anak nga buhi?, tanan ba How to ask?, help the patient describe. nahuman nimo pag burod hin 9 months? Ex. ma’am nakita ka ha akon hin klaro? Pira an namatay? Miscarriage or Dre ba blurry, dre ba masirom? Hini hiya 12  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 ano man ini nga color? So that you can ​ Perception of major roles & assess whether the patient can see or is responsibilities at work not colorblind, o nakabati ba? Sakto ba ​ Perception of major social roles it baton?, you ask questions relating to & responsibilities senses or let the patient describe pain assessment. Objective: ​ Outline a family genogram Objective: ​ Observe your clients family ​ EENT assessment members ​ Cranial nerve assessment an 12 You let them describe their family. cranial nerves Ma’am naukoy kapa ba ha iyo balay? Or may kalugaringon ka na nga gin 7. B COGNITIVE PATTERN uukyan. Here you see the family genogram, for this particular typology Subjective: you include their the family genogram. ​ Ability to understand on page 21. You read. There are legends ​ Ability to communicate there, in male square, female circle, if ​ Ability to remember married straight line if broken line it ​ Ability to make a decision means cohabiting or separated. etc. You ask here the ability to understand, communicate remember and make a 9.​ SELF-PERCEPTION-SELF CONCEPT decision. So gin papa recall la nimo an PATTERN an im pasyente, example. Ma’am nakaka hinumdom kapa ba kun kakano Subjective: an imo last nga kaon? Or you let them ​ Perception of identity read a news paper, or magazine, or let ​ Perception of abilities & them watch a reel then ask then about self-worth kun anot ira reaction. If they could talk ​ Body Image to you on a same manner karuyag You ask the client to describe himself or signon wry problema. Ky it mental herself. Ex: yana nga nagkasakit ka ano status an gin checheck dinhi.The ability man imo gin aabat? Pano kaman naka of a client to make decisions is part of siring nga der ka gin lilipong nga your cognitive pattern nakasakit ka?. You let them describe. Ask them about their appearance or Objective: body image ​ Mental status assessment Objective: ​ Mental status assessment 8.​ ROLE-RELATIONSHIP PATTERN procedures on the appearance, behavior & mood of the client. Subjective: You write down what you observe here ​ Perception of major roles & for your objective. responsibilities in the 10.​COPING-STRESS TOLERANCE PATTERN 13  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 ​ Physical characteristics (e.g., Subjective: skin color, posture) ​ Perception of stress & problems ​ Body functions (e.g., heart rate, in life respiratory rate) ​ Coping Methods & support ​ Appearance (e.g., dress and systems hygiene) You let them describe again, ano ba it ​ Behavior (e.g., mood, affect) naka stress ira. Ira ba trabaho? Ira ba ​ Measurements (e.g., blood asawa? Ira ba mga anak?. Iton iyo pressure, temperature, height, ipapakiana. weight) ​ Results of laboratory testing Objective: (e.g., platelet count, x-ray ​ Mental status assessment findings) 11.​ VALUE-BELIEF PATTERN III. VALIDATING ASSESSMENT DATA Subjective: -​ A crucial part of assessment that often ​ Values, goals & philosophical occurs along with collection of subjective beliefs and objective data. ​ Religious and spiritual beliefs -​ It serves to ensure that the assessment This is your spiritual beliefs of your process is not ended before all relevant client. Ano ba it importante para haim data have been collected, and helps to patient. How is he or she proceeds prevent documentation of inaccurate data. accomplishments in life? Nakakabulig ba it ira spirituality? You ask them. How do you validate your crucial data or Objective: your subjective data? Is through ​ Observe religious practices documentation. You write it down. Anything ​ Observe client's behavior for that is relevant you write it down. Reliable signs of spiritual distress So for data it aton gin susurat. Your objective and your objective you'll be subjective data is also known for your encountering tools. Assessment “CUES”.they can be your objective or tools for anxiety down to subjective cues. depression, hopelessness, VALIDATING DATA powerlessness. So meada kamo -​ Validation is the act of mga assessment tools that can “double-checking” or verifying data be found in your book. to confirm that it is accurate and factual RELIABLE SOURCE OF DATA II. COLLECTING OBJECTIVE DATA You double check labi na kun nag iinterview. -​ The examiner directly observes objective Ha phases of interview hain dida it pwede data. ka mag vadidate? We have 3 phases, -​ These data include: introductory, working and closing or 14  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 summary. Ha closing phase kamo ma ​ Double-check data that are extremely Validate ky amo na iron iyu pag document. abnormal, Ky ig rerely na niyo tag usa usa an imo na Ayaw gud pag lakat kun dre kam na double collect nga data ha im client or haim check, anything that is abnormal, you classmate. Ha validation never infer, when relay, before you relay you double check. we say infer you interject your own beliefs ha client. If you have doubts you clarify. Example: Client's perception of "feeling hot" need to VALIDATING ASSESSMENT DATA be compared with measurement of the Guidelines body temperature. ​ Compare subjective and objective data to verify the client's statements Client. "I've felt sick on and off for 6 with your observations. weeks." Nurse: Describe what your sickness Kun ano an imo gin surat nga subjective is like. Tell me what you mean by "on and data, dapat amo ghap an imo ginsurat off." Observation: Dry skin and reduced hii objective data. Dre dapat it nag tissue turgor. iimpate. There should be a parallelism of Inference: Dehydration ​ your subjective and objective data. Action: Collect additional data that are needed to make the inference in the ​ Clarify any ambiguous or vague diagnosing phase. statements. E.g. determine fluid intake, amount and Anything nga maka siring kam dre man appearance of urine, and blood pressure ito amo. for example, “maul-ol akon Observation: A resting pulse of 30 beats dughan”, ay pag tapod nag maul-ol la, per minute or a blood pressure of 210/95 ma verify kpa, ano ka ul-ol? Anot mmHg. Action: Repeat the measurement. dekalidad hit kaul-ul- thats how you Use another piece of equipment as needed clarify. Or “Ma’am, sir, if ig rarate naton to confirm abnormalities, or ask someone an kaul-ol han im dughan, form 1 - 10, 10 else to collect the same data. it pinaka maul-ul, 1 it dre hain man dida?” ​ Be sure your data consist of cues and not Validating Assessment Data inferences. you do not document, you do not validate Guidelines the date by writing down dehydration. ​ Determine the presence of factors that What you do is, you write, you determine may interfere with accurate measurement. how many fluid intake, you monitor the ​ Use references (textbooks, journals, intake of the output, pira an gin suka, pira research reports) to explain phenomena. an gin uro, gaano kadamo an gin ihi, amo Do not be contented with all you got, do it iron iyo ig sususrat. Ky iba na it properly and then use your books dehydration ky diagnosis na iton. Nursing diagnosis na iton. Nursing assessment Example specific kita diba? Specific focus problem ​ A crying infant will have an abnormal oriented assessment. Never infer. respiratory rate and will need quieting before accurate assessment can be made. 15  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 ​ A nurse considers tiny purple bluish-black 4.​ Propose possible nursing swollen areas under the tongue of an diagnoses. elderly client to be abnormal until reading Kun ano an imo na identify nga problems. about physical changes of aging. Such Amo it imo hihimoan hin nursing varicosities are common. diagnosis. Defining characteristics and nursing diagnosis karuyag signgon an signs an symptoms based on the IV. DOCUMENTATION OF DATA clustered subjective and objective data, -​ Forms the database for the entire nursing and then you confirm nursing diagnosis. process and provides data for all other 5.​ Check for defining characteristics members of the health care team. of those diagnoses. -​ Vital to ensure that valid conclusions are 6.​ Confirm or rule out nursing made when the data are analyzed in the diagnoses. second step of the nursing process 7.​ Document conclusions. DOCUMENTING DATA FACTORS AFFECTING HEALTH ASSESSMENT -​ Documenting or recording the data completes The client's culture, family, and the the assessment phase. community where the person lives may all -​ Data is recorded in a factual manner and not affect his or her health status. Factors interpreted by the nurse. affecting health assessment, culture, anot -​ To increase accuracy, the nurse records cultura hiton nga patiente ngan an ira subjective data in the client's own words. family, do they live a healthy lifestyle? Ha When you say subjective data, kun anot iya community, do they live in a community gin yakan, asya ghap an imo gin susurat where there is no violence? Do they live in example: “masakit akon ulo” open, close a poverty? in a type of community where quotation. With a quotation ito ha it iyo there is poverty? So tanan ito affects subjective. clients health status. PROCESS OF DATA ANALYSIS CLASSIFY THE FOLLOWING DATA AS -​ Follow these 7 Major steps: SUBJECTIVE OR OBJECTIVE DATA: 1.​ Identify abnormal data and DYSPNEA strengths. WEARS EYE GLASSES You identify and differentiate deviations HOARSENESS OF VOICE from normal to abnormal. WEIGHT GAIN OF 121BS 2.​ Cluster the data. CHEST PAIN LASTING 2 HRS Kikitaon niyo ha iyo data kun hain it ABDOMINAL CRAMPS subjective ngan objective. You make a HEADACHE column that's how you cluster the data PRURITUS 3.​ Draw inferences and identify PULSE RATE OF 312 BPM problems. NAUSEA Inferences coming from the nurse, but VOMITING the problems that you identify should WATERY STOOLS come from the client. TINNITUS VERTIGO 16  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 To identify areas for health promotion and disease prevention HEALTH ASSESSMENT: COLLECTING OBJECTIVE DATA So aside from gaining knowledge, you're AND PHYSICAL EXAMINATION supposed to do. Your motor skills, your psychomotor skills will be applied here because LEARNING OUTCOMES: when you perform or apply objective data, you Discuss the purposes of physical assessment. are to do something. Dri la kutob pag interview Identify the purposes of the physical ngan pag interpret han iyu subjective data. But examination. for your objective data, you are to interact, you Explain the four techniques used in physical are to touch and observe the environment of examination: inspection, palpation, percussion, the patient and auscultation. In short objective data is what you observe Identify the equipment and positions used from the patient, what the patient elicits. What during a physical assessment. is elicited by the patient, the information that List techniques for preparing a patient you get from the patient. And they're also physically and psychologically before and applying examination techniques. And they also during an examination utilize instruments here. Prepare the patient and the environment for a health assessment. What is Physical assessment? How is this Systematically conduct a physical assessment. related or how is this significant to your Document health assessment findings objective/ in obtaining objective data? - It is concisely, descriptively, legally, and the assessment of your body. appropriately. Describe nursing responsibilities before, 3 Types of Physical Assessment during, and after diagnostic procedures. Complete assessment-This involves the client who is admitted in the hospital. OBJECTIVE DATA: Examination of the body systems-It is the THE PHYSICAL HEALTH ASSESSMENT review of your body systems. PURPOSES OF PHYSICAL EXAMINATION Examination of a specific body area- for To obtain baseline data about the client's example of specific body area kun may functional abilities. problema ha lungs, difficulty of breathing? So To supplement, confirm, or refute data amo itun em e examinon, an lungs. obtained in the nursing history. To obtain data to help establish nursing 3 BASIC KNOWLEDGE IN PHYSICAL diagnoses and plans of care. ASSESSMENT: To evaluate the physiological outcomes of health care and, thus, the progress of a client's Types and operation of equipment needed for health problem. the particular examination To make clinical judgments about a client's Preparation of the setting, oneself, and the health status. client for the physical assessment Performance of the four 17  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 techniques:inspection,assessment > Textiles and Laundry palpation,percussion, and auscultation > Safe Injection Practices HEAD-TO-TOE FRAMEWORK For Vital Signs Examination: -​ Sphygmomanometer to menstic diastolic and systolic blood presure -​ Stethoscope to auscultate blood sounds when measuring blood pressure -​ Thermometer (oral, rectal, tympante) to measure holy temperature -​ Watch with second hand to time heart rate, pulse rate -​ Pain rating scale to determine perceived pain level REPARING & CONDUCTING PHYSICAL ASSESSMENT For Nutritional Status Examination: -​ Skinfold caliper to measure skinfold CONSIDERATIONS: thickness of subcutaneous tissue 1. INFECTION CONTROL -​ flexible tape measure to measure 2. EQUIPMENT mid-arm circumference 3. ENVIRONMENT -​ Skin marking pen to mark 4. PHYSICAL PREPARATION OF THE measurement PATIENT For Skin, Hair and Nail Examination: EQUIPMENTS -​ Examination Light Equipment Needed for Physical -​ Metric ruler Examinations: -​ Penlight -​ Magnifying glass to enlarge For All Examinations visibility of vision -​ Gloves -​ Mirror? -​ Gowns -​ Woods light? For Head and Neck Examination : INFECTION CONTROL -​ Stethoscope to auscultate the thyroid STANDARD PRECAUTIONS: -​ Small cup of water to help client > Hand Hygiene swallow during examination of the > Personal Protective Equipment (PPE) thyroid gland > Respiratory Hygiene/Cough Etiquette >Patient Placement For Eye Examination: > Patient Care Equipment and -​ Penlight to test pupillary Instruments/Devices constriction > Care of the Environment 18  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 -​ Snellen E chart to test distant vision -​ Newspaper to test near vision -​ Opaspse? card to test for strabismus -​ Ophthalmoscope to view the red reflex and to examine the retina of the eye PREPARING THE ENVIRONMENT For Ear Examination: POSITIONING OF THE CLIENT -​ Tuning fork to test for bone and air conduction of sound -​ Otoscope to view the ear canal and tympanic membrane For Thoracic and Lung Examination: -​ Stethoscope (diaphragm) to auscultate breath sounds -​ Metric ruler and Skin marking pen to measure diapapaai cucunior? ​ Dorsal recumbent position - client lies down on the examination table For Heart and Neck Vessel Examination: or bed with knees bent, the legs -​ Stethoscope (bell and diaphragm) to separated, and the feet flat on the auscultate heart sounds table or bed. -​ Two metric rulers to measure jugular -​ This position may be more venous pressure comfortable than the supine position for clients with pain in the For Female Genitalia and Rectum back or the abdomen. Examination: -​ The abdominal pain should not be -​ Liquid Pap medium assessed because the abdominal -​ Pill paper muscles are contracted in this -​ Feminine napkins position. 19  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 ​ Supine (horizontal recumbent) position - lying down with the legs together. -​ A small pillow may be placed under the head to promote comfort and if the client has trouble breathing, the head of the bed may need to be raised. -​ This position allows the abdominal ​ Sitting position - the client should muscles to relax and provides easy sit upright on the side of the access to peripheral pulse sites. examination table. -​ This position is good for evaluating the head, neck, lungs, chest, back, breast, axillae, heart, vital signs and upper extremities. ​ Lithotomy position - the client lies ​ Sims position - the client lies on the on the back with the hips at the right or left side with the lower arm edge of the examination table and placed behind the body and the upper the feet supported by the stirrups. arm flexed at the shoulder and the -​ Used to examine the female elbow. genitalia, reproductive tracts, and -​ The lower leg is flexed at the knee, the rectum. while the upper leg is flexed at a -​ An exposed position. sharper angle and pulled forward. -​ This position is useful for assessing the rectal and vaginal areas. ​ Prone position - the client lies down on the abdomen with the head to the side. -​ Used to assess the hip joint 20  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 -​ Clients with cardiac and respiratory Expose only areas of the body to be problems cannot tolerate this position. examined in order to avoid chilling Permit ample time for the client to answer your questions and assume the required positions Be aware of cultural differences. The client may want a family member present during disrobing. Arrange for an interpreter il the client's ​ Knee-chest position- clients kneel on language differs from the examination table with the weight of that of the nurse. the body supported by the chest and the Ask clients how they wish to be knees. addressed, such as "Mrs." or -​ A 90-degree angle should exist between "Miss." the body and the hips. Adapt assessment techniques to any -​ The arms are placed above the head, sensory impairment: for example, make with the head turned to one side. sure eyeglasses or hearing aids aro -​ This position is useful for examining the nearby. rectum. If clients are older or frail, it is wise to conduct the assessment in several DRAPING segments in order to not overtire them. PHYSICAL EXAMINATION TECHNIQUES Objective Assessment Techniques Inspection- involves the use of senses of vision, smell, and hearing to observe and detect any normal or PREPARING ONESELF AND THE PATIENT abnormal findings. This technique is used from the Health Assessment of the Adult moment that you meet the client and Be aware of normal physiological continues throughout the changes that occur with aging (see the examination. Lifespan Considerations later in this Auscultation- type of assessment chapter). technique that requires the use of Be aware of stiffness of muscles and stethoscope to listen for heart joints from aging or history of orthopedic sounds, movement of blood through surgery, The client may need the cardiovascular system, movement modification of the usual positioning of the bowel, and movement of the necessary for examination and air through the respiratory tract assessment. Percussion Palpation 21  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 INSPECTION are used for discriminatory sensation Guidelines to achieve the best results such as texture, vibration, presence during inspection: of fluid, or size and consistency of a 1. Make sure that adequate lighting is mass (Right) The dorsum, or back of available, either direct or tangential. the hand, is used to assess surface 2. Inspect body cavities by using a temperature direct lighting source (e.g., a penlight or lamp). Light palpation 3. Inspect each area for size, shape, color, symmetry, position, and abnormality. 4. Position and expose body parts as needed so all surfaces can be viewed, but privacy can be maintained. 5. When possible, check for side-to-side symmetry by comparing each area with its match on the opposite side of the body. 6. Validate findings with the patient. Bimanual position (Left Palmar surfaces of the examiner's fingertips and finger pads 22  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 Deep palpation PERCUSSION Direct and indirect percussion Characteristics of Masses: Location - site on the body, dorsal/ventral surface Size - length and width in centimeters Shape - oval, round, elongated, irregular Consistency - soft, firm, hard Surface - smooth, nodular Mobility-fixed, mobile Pulsatility - present or absent ASSESSMENT USES OF PERCUSSION: Tenderness - degree of tenderness to 1.​ Eliciting pain palpation 2.​ Determining size, shape, and location 3.​ Determining density CHARACTERISTICS OF MASSES 4.​ Detecting abnormal masses DETERMINED BY PALPATION 5.​ Eliciting reflexes Shape- Round,Ovoid,Tubular,Irregular Size- Measured in centimeters Consistency- Firm,Edematous,Spongy,Cystic Surface- Smooth,Nodular Granular Mobility- Fixed or nonmobile,Mobile Tenderness- Amount of tenderness to touch Pulsatile- Pulsation can or cannot be felt in the mass 23  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 Percussion tones ASSESSMENT GUIDE 3-1 How to Use the Stethoscope The stethoscope is used to listen for (auscultate) body sounds that cannot ordinarily be heard without amplification (e.g., lung sounds, bruits, bowel sounds, and so forth). To use a stethoscope, follow these guidelines: 1.​ Place the earpieces into the outer ear canal They should fit snugly but comfortably to promote effective sound transmission. The earpieces are connected to binaurals (metal tubing), which connect to rubber or plastic tubing. The rubber or plastic Sound tones (elicited by percussion) tubing should be flexible and no more than 12 inches long to prevent the sound from diminishing.​ 2.​ Angle the binaurals down toward your nose This will ensure that sounds are transmitted to your eardrums.​ 3.​ Use the diaphragm of the Auscultation stethoscope to detect high-pitched sounds The diaphragm should be at least 1.5 inches wide for adults and smaller for children. Hold the diaphragm firmly against the body part being auscultated.​ 4.​ Use the bell of the stethoscope to detect low-pitched sounds The bell should be at least 1 inch wide. Hold the bell lightly against the body part being auscultated. Some Do’s and Don’ts ​ Warm the diaphragm or bell of the stethoscope before placing it on the client’s skin. 24  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 ​ Explain what you are listening for Four Characteristics of sound are and answer any questions the client assessed by auscultation: has. This will help to alleviate anxiety. 1.​ Pitch (ranging from high to low) ​ Do not apply too much pressure 2.​ Loudness ( ranging from soft to when using the bell—too much loud) pressure will cause the bell to work 3.​ Quality ( e.g., gurgling or swishing) like the diaphragm. 4.​ Duration ( short, medium, or long) ​ Avoid listening through clothing, which may obscure CLIENT IN CONTEXT: CULTURE, or alter sounds SPIRITUALITY & FAMILY ASSESSMENT ASSESSING CULTURE CONTEXT FOR ASSESSMENT · Culture includes contexts beyond the basic beliefs and behaviors that vary. · Culture also includes family structure and function, spirituality and religion, and community, which serve as context for growth and development, health and illness, and health care delivery. CONCEPTS AND TERMS RELATED TO CULTURE -​ culture defines VALUES (learned beliefs about what is held to be good or bad) and NORMS (learned behaviors that are perceived to be appropriate or Inappropriate -​ ETHNICITY, or a person's ethnic identity, exists when the person Identifies with a "socially, culturally, and politically constructed group of individuals that holds a common set of characteristics not shared by others with whom its members come in contact" (Lipson & Dibble, 2005, P. xiv). -​ MINORITY often refers to a group that has less power or prestige within the society, but actually means a group with smaller population numbers -​ IMMIGRATION 25  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 CULTURAL COMPETENCE · Religion · ASKED mnemonic (awareness, skill, - is defined as the rituals, practices, knowledge, encounters, and desire) and experiences shared within a 1.​ CULTURAL AWARENESS group that involves a 2.​ CULTURAL SKILL search for the sacred (i.e., God, Allah, 3.​ CULTURAL KNOWLEDGE etc.), 4.​ CULTURAL ENCOUNTERS · Spirituality 5.​ CULTURAL DESIRE - is defined as a search for meaning and purpose in life; it seeks to CULTURAL ASSESSMENT understand life's ultimate questions in relation to the sacred. · PURPOSES AND SCOPE OF ASSESSMENT: FOUNDATIONAL KNOWLEDGE FOR - To learn about the client's beliefs SPIRITUAL ASSESSMENT and usual behaviors associated with health and illness, including beliefs RELIGION about disease causes, caregiving, Definition: Rituals, practices, and expected treatments experiences involving a - To compare the client's beliefs and search for the sacred (Le. God, Allah, practices with those of other persons etc.)" that are shared from a similar cultural background (to Characteristics avoid stereotyping). Formal - To assess the client's health relative Organized to diseases prevalent in the specific Group oriented cultural group. Ritualistic Formal or informal Objective, as in easily measurable FACTORS AFFECTING APPROACH TO (e.g, church attendance) PROVIDERS · Ethnicity SPIRITUALITY · Generational status Definition: A search for meaning and · Educational level purpose in life, which · Religion seeks to understand life's ultimate · Previous health care experiences questions in relation to the · Occupation and income level sacred. · Beliefs about time and space Characteristics · Communication needs/preferences Informal Individualistic Self-reflection Experience ASSESSING SPIRITUALITY AND Subjective, as In difficult to RELIGIOUS PRACTICES consistently measure leg, dally spiritual experiences, spiritual TERMS RELATED TO SPIRITUALITY well-being, ete.) 26  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 ​ What role do your beliefs play SPIRITUAL ASSESSMENT in regaining your health? Definition: Active and ongoing conversation that assesses the P—Personal spirituality spiritual needs of the dent. ​ Describe the beliefs and Characteristics practices of your religion that Formal or informal you personally accept. Respecttul ​ Describe those beliefs and Non-biased practices that you do not accept or follow. SPIRITUAL CARE ​ In what ways is your Definition: Addressing the spiritual spirituality/religion important needs of the dient as they unfold to your life? through spiritual assessment. ​ Has your spirituality Characteristics influenced how you handle Individualistic stress? Client oriented ​ Are there certain aspects of Collaborative medical care that your religion discourages or forbids? SPIRITUAL ASSESSMENT I—Integration with a spiritual ​ Approach community ​ Techniques: Nonformal and formal ​ Do you belong to any religious or spiritual groups or communities? ASSESSMENT TOOL 12-1 Taking a ​ How do you participate in this Spiritual History: SPIRIT Acronym group? What is your role? ​ What importance does this S—Spiritual belief system group have for you? ​ Do you have a formal ​ In what ways is this group a religious affiliation? Can you source of support for you? describe it? ​ What types of support and ​ Do you have a spiritual belief help does this group provide that is important to you? for you in dealing with health ​ What is your belief system? issues? ​ What aspects of your spirituality or religion do you find most helpful to you? R—Ritualized practices and ​ Have your beliefs influenced restrictions how you take care of yourself in this illness? 27  NCM 101 HEALTH ASSESSMENT Conceptual Overview of Nursing Health Assessment Lecturer: Vivian Cezar, RN Clinical Group B | 02/27/2025 ​ What specific practices do available either in the hospital you carry out as part of your or at home? religion? (E.g., prayer, ​ Are there religious or spiritual meditation, services, etc.) practices that you wish to ​ What lifestyle activities or plan for at the time of death practices does your religion or following death? encourage, discourage, or ​ How much do you plan on forbid? practicing these traditions ​ What meaning do these with family members? practices and restrictions ​ For what in your life do you have for you? still feel gratitude even ​ To what extent have you through illness? followed these guidelines? ​ When you are ill or in pain, how do you find comfort? I—Implications for medical care ​ As you face the end of life, what in your religion will be ​ Are there specific elements of most important to you? medical care that your religion discourages or forbids? ASSESSING FAMILIES ​ What aspects of your religion/spirituality would you FOCUS OF FAMILY ASSESSMENT like me to keep in mind as I. Focus on the individual as the client care for you? and the family as a context for the ​ What knowledge or client's illness and care understanding would · Determining strengths and problem strengthen our relationship as areas within the family's structure a provider and patient? and function that influence the ​ Are there any barriers to our family's ability to support the client. relationship based on religious or spiritual issues? TERMS RELATED TO FAMILY ​ Would you like to discuss ASSESSMENT religious or spiritual · The family is a social system implications of health care? composed of two or more persons who coexist within the context of T—Terminal events planning