HEALTHASSESSMENTREVPT.1

• Things to avoid during an interview

  • Biasing yourself
  • Letting family members answer for patient
  • Asking more than one question at a time
  • Not allowing enough response time
  • Using medical jargon
  • Assuming rather than clarifying and validating
  • Offering false reassurance
• Phases of interview

  1. Pre-Introductory Phase

  2. Introductory Phase

  3. Working Phase

  4. Summary and Closing Phase
• Collection of subjective data through interview and health history
• Collection of subjective data through interview and health history

  1. Biographical Data

  2. Reasons for Seeking Health Care

  3. History of Present Illness

  4. Past Health History

  5. Family History

  6. Current Medications

  7. Lifestyle and Health Practices Profile
• Collection of subjective data through interview and health history

  1. Activity and Exercise Patterns

  2. Sleep and Rest Patterns

  3. Substance Use

  4. Self-Care Activities

  5. Social and Community Activities

  6. Values and Belief System
• Sources of data

  • Client
  • Support People/Significant Other
  • Client Records
  • Health Care Professionals
  • Literature
• Levels of Consciousness

  • Alert
  • Lethargy
  • Obtunded
  • Stupor
  • Coma
• Types of data

  • Subjective Data
  • Objective Data
• Factors to consider during interview

  • Time
  • Place
  • Seating Arrangement
  • Distance
  • Language
  • Activities of Daily Living (ADL)
• Data collection methods

  1. Observing

  2. Interview
• Processes involved in the Nursing Process include critical-thinking, problem-solving, and decision-making
• Types of Nursing Diagnosis

  • Actual
  • Risk
  • Wellness
  • Possible
  • Syndrome
• The Nursing Process

  1. The Nursing Care Plan

  2. Assessment

  3. Diagnosis

  4. Planning

  5. Implementation

  6. Evaluation
• The Nursing Process refers to a series of phases describing the practice of nursing
• The Nursing Process is a systematic, chronological, step-by-step procedure of ADPIE (Assessment, Diagnosis, Planning, Implementation, Evaluation)
• Domains of NANDA

  • Health Promotion
  • Nutrition
  • Elimination and Exchange
  • Activity/Rest
  • Perception/Cognition
  • Self-Perception
• Components of Nursing Health History

  • Biographic data
  • Chief of complaint
  • History of the present illness
  • Past history
  • Family history of illness
  • Lifestyle
  • Social data
• The Nursing Process is an organized framework to guide practice, a problem-solving method, systematic, goal-oriented, dynamic, utilizes critical thinking processes, universally applicable, client-centered, and interpersonal and collaborative
• Assessment

  1. To establish data base

  2. Collection, organization, validation, and documentation of data

  3. Begins during the first meeting of the nurse and the client

  4. Four types of assessment: Initial assessment, Problem-focused assessment, Time-lapsed assessment, Emergency assessment
• The Nursing Process is a systematic, rational, dynamic, and cyclic process for planning and providing care for the client
• The Nursing Process aims "to diagnose and treat human responses to actual or potential health problems"
• Advantages of the Nursing Process include providing individualized care, promoting continuity of care, effective communication among healthcare professionals, developing a clear plan of care, personal satisfaction, and professional growth
• Process involved in heat loss

  1. Radiation

  2. Conduction

  3. Convection

  4. Evaporation
• Guidelines for measuring vital signs
• Pulse rate

  1. Age

  2. Pulse

  3. Average range
• Types of pulse

  • Central
  • Peripheral
• Vital Signs


  Is a common, non-invasive physical assessment procedure and the measurement of the body’s most basic functions that are routinely monitored by medical professionals & healthcare providers
• Types of thermometer

  • Glass thermometers
  • Strip thermometer
  • Digital thermometer
• Common types of fever

  • Intermittent fever
  • Remittent fever
  • Relapsing/Recurrent fever
  • Constant/Continuous fever
• Factors affecting the pulse rate

  • Age
  • Gender
  • Exercise and fever
  • Medication
  • Hemorrhage
  • Stress
  • Position changes
• Characteristics of pulse rate/frequency

  • Refers to the number of pulsation per minute
  • Adult: 60 – 100 per minute
  • Infant: 100 – 160 beats per minute
• Sites for temperature measurement

  1. Oral

  2. Rectal

  3. Axillary

  4. Tympanic

  5. Temporal
• Vital Signs

  • Temperature or T
  • Pulse Rate or PR
  • Respiratory Rate or RR
  • Blood Pressure or BP
  • Pain
  • Oxygen Saturation
• Temperature

  1. Balance between the heat produced by the body and the heat lost from the body

  2. Measured by centigrade or Celsius

  3. Normal body temperature is 36.7°C - 37°C or 98.6°F

  4. The Hypothalamus is thermoregulatory center of the body
• Factors that influence body temperature

  • Age
  • Diurnal variations
  • Exercise
  • Hormones
  • Stress
  • Illness
  • Environment
  • Ovulation
• Purpose of taking vital signs
• Terminologies in body temperature

  • Hyperpyrexia
  • Febrile/Pyrexia or Hyperthermia
  • Hypothermia
  • Afebrile
• Pulse points

  • Temporal
  • Brachial
  • Carotid
  • Radial
  • Femoral
  • Dorsalis Pedis
  • Popliteal
  • Posterior Tibialis
• Rhythm


  Refers to the regularity
• Pulse


  1. Pulse rate or Heart rate

  2. Wave of blood created by contraction of the left ventricle of the heart