INTRODUCTION

TO HEALTH
ASSESSMENT:
THE NURSING PROCESS
Lecturer: Jonnafe G. Gayatin, RMT, RN, MAN

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THE NURSING PROCESS
A systematic, rational method -Cyclical, follows a logical sequence
of planning and providing -Enables the nurse to respond to the
individualized nursing care. changing status of the client

-Identify client’s health status – actual or

potential health problems or needs
Purposes: -Establish plans to meet the identified needs
-Deliver specific nursing interventions to
meet those needs

-An individual
-Family
The client may be:
-Community
-Group
 CYCLIC AND DYNAMIC
• Data from each phase provide input to the next
phase

CLIENT CENTERED
• Plan of care is according to client’s
CHARACTERISTICS problems/needs
OF THE NURSING
FOCUS ON PROBLEM SOLVING AND
PROCESS DECISION MAKING
• Identifying possible solutions and choosing the
best one to implement
• Approaches include trial and error, intuition
and research
• Directed towards client’s responses to real or
potential disease/illness.
 INTERPERSONAL AND
COLLABORATIVE
• Communicating with clients, significant others
and support groups
• Collaborating with the health care team

UNIVERSAL APPLICABILITY
CHARACTERISTICS
OF THE NURSING • Nursing process is used as a framework for
PROCESS nursing care for all types of settings with clients
from all age groups

USE OF CRITICAL THINKING AND

CLINICAL REASONING
• Making clinical judgements based on
knowledge base in nursing and clinical
experience
 ATTITUDES THAT FOSTER CRITICAL THINKING
INTELLECTUAL
INSIGHT INTO INTELLECTUAL COURAGE TO
INDEPENDENCE FAIR-MINDEDNESS
EGOCENTRICITY HUMILITY CHALLENGE STATUS
QUO AND RITUALS
• Thinking for • Assessing all • Examining • Awareness of • Courage to
yourself and viewpoints one’s own the limits of recognize
making your and avoiding biases or one’s own that beliefs
own biases or customs; Self- knowledge are sometime
judgements prejudice awareness false or
misleading.
Courage to be
open to new
thinking.
ATTITUDES THAT FOSTER CRITICAL THINKING
INTEGRITY PERSEVERANCE CONFIDENCE CURIOSITY

• Being able to • Lifelong • Confidence in • Examining

readily admit determination the reasoning traditions and
and evaluate in finding process and exploring new
inconsistencies effective examining options
with and solutions to emotion laden-
between one’s client and arguments.
belief and nursing Anchored on
those of problems the belief that
another well-reasoned
thinking will
lead to
trustworthy
conclusions
 SETTING PRIORITIES

• Determining which is most relevant and most

important

DEVELOPING RATIONALES
COMPONENTS • Explanations of priority setting and nursing
OF CLINICAL interventions
• Acts as a check for potential errors, justifies
REASONING nursing actions and contributes to client safety

LEARNING HOW TO ACT

• Understanding relevant medical and nursing

information and translate knowledge into plan of
care
 CLINICAL REASONING IN TRANSITION

• Ability to recognize changes in client’s condition

over time

RESPONDING TO CHANGES IN THE

CLIENT’S CONDITION
COMPONENTS • Ability to detect changes, identify change in
OF CLINICAL priorities, adjust nursing care and alert primary
care provider when appropriate
REASONING
REFLECTION

• Identifying factors that improved client care and

those thar required changing or elimination
• Thinking back / Reviewing interventions
implemented and whether they were effective
OVERVIEW
OF THE
NURSING
PROCESS

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 COLLECTING, ORGANIZING, VALIDATING AND
DOCUMENTING CLIENT DATA

PURPOSE:
• To establish a database about the client’s response to
health concerns or illnesses and the ability to manage
healthcare needs

ACTIVITIES:

ASSESSING / • Establish a database

• Obtain nursing health history
ASSESSMENT • Conduct physical assessment
• Review client records
• Review nursing literature
• Consult support persons
• Consult health professionals
• Update data as needed
• Organize data
• Validate data
• Document / Communicate data
DIAGNOSING / DIAGNOSIS
• Purposes:
• To identify client’s strengths and health
Analyzing problems that can be prevented or resolved
by collaborative and independent nursing
and interventions
• To develop a list of nursing and
synthesizing collaborative problems
• Activities:
data • Interpret and analyze data
• Determine client’s strengths, risks and
problems
 Determining how to prevent, reduce or resolve the identified priority
client problems; how to support client strengths; and how to implement
nursing interventions in an organized, individualized and goal-directed
manner

PLANNING Purpose: To develop an individualized care plan that specifies client

goals/desired outcomes and related nursing interventions

Set priorities and ACTIVITIES: Communicate

goals/outcomes care plan to
in collaboration Select nursing Consult other Formulate a relevant heath
with the client strategies / health nursing care care providers
interventions professionals plan
 Carrying out (or Purpose: To assist Activities:
delegating) and the client to meet
-Reassess the client to
documenting the desired
update the database
planned nursing goals/outcomes;
-Determine the nurse’s
interventions promote wellness; need for assistance
IMPLEMENTING / prevent -Perform planned
illness/disease;
IMPLEMENTATION restore health;
nursing interventions
-Communicate nursing
facilitate coping actions implemented:
with altered Document care and
client response to care;
functioning
Give verbal reports as
necessary
 EVALUATING / EVALUATION

Measuring the degree to which Purpose: To determine whether

goals/outcomes have been achieved
Activities:
to continue, modify or terminate
and identifying factors that Collaborate with client and collect data related
plan of care to desired outcomes
positively or negatively influence
Judge whether goals/outcomes have been
goal achievement achieved
Relate nursing actions to client goals/outcomes
Make decision about problem status
Review and modify the care plan as indicated
or terminate nursing care
Document achievement of outcomes and
modification of the care plan
 In Review: PHASES OF THE NURSING PROCESS
PHASE DESCRIPTION PURPOSE
• To establish a database about the client’s response to
• Collecting, organizing, validating and
ASSESSING health concerns or illnesses and the ability to manage
documenting client data
healthcare needs
• To identify client’s strengths and health problems that
can be prevented or resolved by collaborative and
DIAGNOSING • Analyzing and synthesizing data
independent nursing interventions
• To develop a list of nursing and collaborative problems
• Determining how to prevent, reduce or
resolve the identified priority client
• To develop an individualized care plan that specifies
problems; how to support client strengths;
PLANNING client goals/desired outcomes and related nursing
and how to implement nursing interventions
interventions
in an organized, individualized and goal-
directed manner
• Carrying out (or delegating) and • To assist the client to meet desired goals/outcomes;
IMPLEMENTING documenting the planned nursing promote wellness; prevent illness/disease; restore
interventions health; facilitate coping with altered functioning
• Measuring the degree to which
goals/outcomes have been achieved and • To determine whether to continue, modify or
EVALUATING
identifying factors that positively or terminate plan of care
negatively influence goal achievement
 Initial Assessment

TYPES OF Problem Focused Assessment

ASSESSMENT Emergency Assessment

Time Lapsed Assessment

TYPES OF ASSESSMENT

INITIAL PROBLEM-FOCUSED
ASSESSMENT ASSESSMENT
Performed within a specified time Ongoing process integrated with
after admission to a health care nursing care
agency Purpose: to determine the status
Purpose: to establish a complete of a specific problem identified in
database problem identification, an earlier assessment
reference and future comparison
TYPES OF ASSESSMENT

EMERGENCY TIME-LAPSED
ASSESSMENT ASSESSMENT
Done during any physiological or Done several months after
psychological crisis of the client initial assessment
Purpose: To identify life- Purpose: To compare the
threatening problems / To client’s current status to
identify new or overlooked baseline data previously
problems obtained
 Nurse’s Role in Health
Assessment
• obtaining the patient’s health history
• performing a physical assessment
• Nursing assessment focuses not only on
physiological and psychological responses to
The goal of medical
practice is to diagnose and
actual or potential health problems but also on
treat disease. The goal of
the psychosocial, cultural, developmental and
nursing is to diagnose and spiritual dimensions.
treat human responses to • Compliment medical assessments to ensure
actual or potential health best possible care for patients
problems.
 COLLECTING DATA

Database – contains all the

information about a client.

Includes nursing health history,

Data collection is the physical assessment, primary care Client data should include
process of gathering provider’s history and physical past history as well as
examination, results of laboratory
information about a client’s and diagnostic tests and materials
current problems
health status contributed by other health
personnel
Types of Data
*Symptoms or covert data
*Can be described or verified only by that person
Subjective Data *E.g. sensations, feelings, values, beliefs, attitudes,
perceptions of personal health status and life
situation

*Signs or overt data

*Detectable by an observer or can be measured
Objective Data or tested against an accepted standard
*Obtained by observation or physical
examination
 CLIENT
• Best source of data
• Consideration: privacy and confidentiality
SUPPORT PEOPLE
• Family, friends, caregivers
• Consideration(e.g. in abuse): client wishes to remain anonymous. Client
authorizes gathering of data from support people / significant others

CLIENT RECORDS
Sources • Demographic profile
• Medical records

of Data • Laboratory records

• Records of therapies
HEALTH CARE PROFESSIONALS
• Nurses, social workers, primary care providers, physiotherapists
LITERATURE
• Provides additional and useful information regarding standards / norms;
cultural and social health practices; spiritual beliefs; assessment data for
specific client conditions; nursing interventions and evaluation criteria;
information on medical diagnosis, treatment and prognoses; current
methodologies and research findings
 Occurs whenever
the nurse is in
OBSERVING contact with the
client or support
persons

DATA Used mainly

COLLECTION INTERVIEWING when taking the
nursing health
history
METHODS
Major method
EXAMINING used in physical
assessment
 OBSERVING

To gather data using Two aspects:

the senses:
Patient / client (most important) Noticing the data
Environment Selecting, organizing, and
interpreting the data
 INTERVIEWING

Interview – a planned communication ; a conversation with a

purpose

Focused interview – the nurse This allows the nurse to collect

asks the client specific questions information that may have
previously been missed and yields
to collect information related to more in-depth information
the client’s problem. (D’Amico & Barbarito, 2013)
 DIRECTIVE INTERVIEW

• Highly structured and elicits specific information

• The nurse establishes the purpose of the
interview and controls the interview
• Client may have limited opportunity to ask
questions or discuss concerns
INTERVIEWING • Usually used when time is limited (e.g.
emergency situation)
APPROACHES
NON-DIRECTIVE INTERVIEW

• Also known as rapport-building interview

• Allows the client to control the purpose, subject
matter and pacing
• Rapport – an understanding between two or
more people
 TYPES OF INTERVIEW QUESTIONS:
Closed vs. Open-Ended Questions

CLOSED QUESTIONS OPEN-ENDED QUESTIONS

• Used in directive interview • Associated with non-directive

• Restrictive and generally require “yes” interview
or “no” or short factual answers that • Invite clients to discover, explore,
provide specific information elaborate, clarify or illustrate their
• What, When, Where, Who, Do, Did, thoughts and feelings; invites answers
Does, Is, Are, Was, Were questions longer than 1 or 2 words
• Often used when information is • What and How questions
needed quickly (e.g. emergency) or • Gives clients freedom to divulge only
when interviewing a highly stressed the information they are ready to
person disclose
TYPES OF INTERVIEW QUESTIONS:
Neutral vs. Leading Question

NEUTRAL QUESTION LEADING QUESTION

Questions that client can answer Usually closed
without direction or pressure from Directs client’s answer
the nurse
Give client less opportunity to decide
Open-ended and used in non- whether the answer is true or not
directive interviews
May create problems if the client
gives inaccurate answers just to
please te nurse = inaccurate data
 • Avoid asking “Why” questions
• Can be perceived as interrogation by
the client (Kneisl and Trigoboff, 2013)
• Can put the client on the “defensive”
Point to
Remember… • Exception: In an emergency situation
the use of probing and direct
questioning may be appropriate to
gain a greater volume of data in a
shorter period of time (Kneisl and Trigoboff,
2013)
 Time
PLANNING
Place
THE
INTERVIEW Seating Arrangement
AND Distance / Proxemics
SETTING
Language
 OPENING
• Establish rapport
• Orientation: purpose and nature of the interview

BODY
STAGES OF • Client communicates what he/she thinks, feels, knows

AN and perceives in response to questions from the nurse

CLOSING
INTERVIEW • Offer to answer questions
• Conclude
• Provide a summary to verify accuracy and agreement
• Thank the client
• Express concern for the person’s welfare and future
• Plan for the next meeting
 EXAMINING
Physical Examination or Physical Assessment

Systematic data collection that uses observation (senses) to detect health

problems

INSPECTION
Techniques used to conduct the AUSCULTATION
examination: PALPATION
PERCUSSION
INTRODUCTION TO
HEALTH ASSESSMENT
(PART 2)
Jonnafe G. Gayatin, RMT, RN, MAN
ORGANIZING DATA
Also referred to as nursing health history, nursing assessment
or database form
ASSESSMENT FORMATS
Gordon’s Functional Health Patterns
Conceptual Models or Orem’s Self-Care Model
Frameworks Roy’s Adaptation Model

Includes factors and attitudes that

Wellness Models influence levels of wellness

Body Systems Model

Non-Nursing Models Maslow’s Hierarchy of Needs
Developmental Theories
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 Roy’s
Adaptation
Model

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Developmental Theories
VALIDATING DATA

The act of “double-checking” or verifying

data to confirm that it is complete,
factual and accurate.
 VALIDATING DATA

Ensure that Ensure that Obtain Differentiate Avoid jumping

assessment subjective and additional between cues into
information is objective data information and inferences conclusions and
complete agree that may have focusing in the
been Cues – subjective or wrong direction
objective data that can
overlooked be directly observed by
to identify
the nurse problems
Inferences – nurse’s
interpretation or
conclusions made
based on the cues
 The nurse validates data
when there are
Not all data requires
discrepancies between
validation. (e.g. height,
VALIDATING weight, lab studies)
data obtained in the
interview and physical
DATA assessment.

Nurses need to be aware

To build an accurate
Points to of their own biases,
values and beliefs and to
database, nurses must
validate assumptions
Remember… separate fact from
inference, interpretation
regarding client’s physical
or emotional behavior.
and assumptions.
 Compare subjective and objective data to verify the
client’s statements with your observations

Clarify any ambiguous or vague statements

GUIDELINES
IN Be sure your data consist of cues not inferences

VALIDATING
Double check data that are extremely abnormal
ASSESSMENT
DATA Determine the presence of factors that may interfere with
accurate measurement

Use references to explain phenomena

DOCUMENTING DATA Recording of client data
Documentation
Report – oral, written or computer-based communication intended to
convey information to others

Record – also called chart or client record; a formal legal document that
provides evidence of client’s care; can be written or computer based

The process of making an entry on a client record is called recording,

charting or documenting.

Nurse is accountable and should document according to organization

policies and universal standards
 Accurate documentation is essential
and should include all data collected
about the client’s health status.

Data are recorded in a factual manner

and not interpreted by the nurse.
Points to Avoid restating or paraphrasing client’s
subjective data (It should be
remember… documented verbatim in quotation
marks).

Avoid judgements or conclusions (e.g.

normal appetite)
 General Guidelines for Recording

Accepted
Date and Time Timing Legibility Permanence
terminology

Correct
Signature Accuracy Sequence Appropriateness
Spelling

Completeness Conciseness Legal prudence

 DATE AND TIME
• Document date and time for each recording.
• Time may be recorded in the conventional manner (12 hour; AM /
PM) or according to 24-hour (military) clock

TIMING
• Documenting should be done as soon as possible after an
DOCUMENTATION assessment or intervention. (Do not document before assessment
or intervention is done)
GUIDELINES LEGIBILITY (FOR WRITTEN DOCUMENTATION)
• Must be legible or easy to read. Hand-printing or easily understood
handwriting is permissible. (avoid script or shorthand)

PERMANENCE
• Written in “dark ink or permanent pen”
• For Electronic Records, changes are made in accordance with
software guidelines
 DOCUMENTATION
GUIDELINES
ACCEPTED TERMINOLOGY
• Use only commonly accepted
abbreviations, symbols and terms. Refer
to approved list given by the institution.
CORRECT SPELLING
• Incorrect spelling gives a negative
impression to the reader and decreases
the credibility of the nurse
SIGNATURE
• Includes name and title of the nurse
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 DOCUMENTATION GUIDELINES
• ACCURACY
• Client’s name and identifying information should be stamped or written on each page of the
clinical record. Do not identify charts by room number. Special care is needed when caring for
clients with the same last name.
• Accurate notations consist of fact or observations not opinions or interpretations.
• Avoid general words (e.g. large, good, normal). Chart specific data (e.g. exact measurement)
• Write on every line, never between lines.
• If there is a blank space, draw a line through the blank space so that no additional information
can be recorded at any other time or by any other person. Then sign the notation
• When recording a mistake – draw a single line, indicate your name or initials above or near the
line (depending on agency policy). Avoid writing the word “error” when recording a mistake (it
may be interpreted as a “red flag” and lead to an assumption that a clinical error has caused
client injury). DO NOT ERASE, BLOT OR USE CORRECTION FLUID. Original entry must remain
visible. For computerized entry, follow agency protocol.
 SEQUENCE
• Document events in the order in which they occur.
DOCUMENTATION APPROPRIATENESS
• Record only information that pertains to client’s health problems and care.
Recording irrelevant information may be considered invasion of client’s
privacy and/or libelous.
COMPLETENESS
GUIDELINES

• Not all data that a nurse obtains about a client can be recorded. However,
the information that is recorded needs to be complete and helpful to the
client and the health care team.
• Record all assessments, dependent and independent nursing
interventions, client problems, client comments and responses to
interventions and tests, progress toward goals and communication with
other members of the health care team.
• Care that is omitted because of the client’s condition or refusal of
treatment must also be recorded. Document what was omitted, why it
was omitted and who was notified. (Remember, what is not documented is
NOT DONE.)
 CONCISENESS

• Recordings need to be brief as well as complete.

• Client’s name and the word “client” are omitted.
• End each thought with a period.

LEGAL PRUDENCE

DOCUMENTATION • Accurate and complete documentation should give legal

protection to the nurse, the health care team and the
GUIDELINES institution.
• Admissible in court as a legal document, the clinical
record provides proof of the quality of care given to the
client.
• Documentation is usually viewed as the best evidence of
what really happened to the client.
• Adhere to professional standards of nursing care but also
follow agency policies and procedures for intervention
and documentations in all situations.
ENSURING
CONFIDENTIALITY
AND SECURITY OF
COMPUTER
RECORDS
 • A personal password is required to enter and sign off
computer files. Do not share this password with
anyone, including other health team members.
• After logging on, never leave the terminal
unattended.
• Do not leave client information displayed on the
Tips and monitor where others may see it.
Suggestions: • Shred all unneeded computer-generated work sheets.
• Know the facility’s policy and procedure for correcting
an entry error.
• Follow agency procedures for documenting sensitive
material, such as diagnosis of AIDS.
• Information Technology (IT) personnel must install
firewall to protect server from unauthorized access.
Video #1
Data Collection (Basic Theory: Health History)

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

Data base
-are information that are found about the patient and the history of the patient.
- contains all the information about a client includes:
• nursing health history
• physical assessment
• primary care provider’s history and physical examination
• result of laboratory and diagnostic tests
• material contributed by other health personnel

Kinds of Data
Constant Data – is the information that does not change over time. Ex. Race, blood type
Variable Data- can change quickly, frequently or rarely over time. Ex. us, age, level of pain.

Types of Data
Subjective – symptoms, covert data, only known to client, sensations, feelings, values, beliefs, attitudes
and perceptions.
Objective- signs, overt data (visible/can be seen or detected) detectable by observer or the nurse or can
be measured or tested, obtained by observation or physical examination. Include lab values (can be
seen, measured or tested and are not felt).

Sources of Data
Primary – client, best source of data
Secondary – all other (family, friends, other HCU and/or records)
The Client- can provide subjective data that no one else can offer
Support People – family members, friends and care givers
Client Records- include information documented by various healthcare professionals, include medical
records, records of therapies and laboratory records and must be taken in consideration of current
situation.
Health Care Professionals- verbal reports from other health care professionals serve as other potential
sources of information, promotes continuity of care
Literature- standards or norms against which to compare findings, cultural and social health practices,
spiritual beliefs, and assessment data needed for specific client conditions, nursing interventions and
evaluation criterial relevant to a client’s health problems.
CHADVASC – evaluation criteria for the use of anticoagulant, part of your assessment depending upon
the needs of the patients, information about medical diagnoses, treatment, prognoses, current
methodologies and research finding.

Data Collection Methods

Observing- to gather data using the senses
Two aspects:
 • Noticing the data
• Selecting, organizing and interpreting the data
Organizing observation:
• Signs of distress
• Threats to safety ( real or anticipated)
• Presence and functioning of equipment
• Immediate surrounding, including people
In order: life threatening>safety>equipment>surroundings
Interviewing- planned communication or a conversation with a purpose
Two approaches:
Direct Interview- structured, elicit specific information, nurse controlled and time constrained
Non-direct interview- rapport (building interview), client controlled

Types of Interview Questions

Closed questions- used in directive, usually yes/no questions, what, when, where and who
Open minded questions- used in nondirective interview, allows discovery, exploration, elaboration,
clarification and illustration, provides long answer, may start with what or how.
Neutral questions- closed, used in a directive interview, and directs the client’s answer
Leading questions- closed, used in a directive directs the client’s answer and avoid asking why

Planning the Interview and Settling

Time- client is physically comfortable and free of pain
-minimal interruptions by friends, family and other health professionals
Place - well- lit, well ventilated room, private
-relatively free of noise, movements and distractions
Seating arrangement- client in bed, nurse sit at a 45 degree angle to bed
Distance – proxemics is the study of use of space, 2-3 ft apart
Language- failure to communicate in language the client can’t understand is a form of discrimination
-use lay terms, use live interpreter when available.
Stages of an Interview
The Opening- established rapport (and orient the interviewer)
- Orientation
- The nurse will explain the purpose and nature of the interview ex. What information is needed,
how long the interview will take and what is expected of the client.
The Body – the client will communicate of what she/he thinks, feels, knows, perceives and response to
questions from the nurse.
- Includes questions that will elicit information that is needed for the assessment
The Closing- termination, techniques, summarize
• Offer to answer questions: “do you have any questions?”
• Conclude by saying “well that’s all I need to know for now”
• Thank the client
• Express concern for the client’s welfare and future: “I hope all goes well for you”.
• Plan for the next meeting
Summarize
- help terminate the interview
- reassure the client that the nurse has listed
- check the accuracy of the nurse’s perceptions of the things that were answered by the client
- clears the way for new ideas
- helps the client to note progress as well as a forward direction
Examining
- physical examination/ assessment
>is a systemic data collection method that uses observation
>uses hearing, smelling, sight, feeling to conduct the examination the nurse will use:
• Inspection, percussion, palpation, auscultation
• Head to toe or by body system

Video #2

Data Collection (Making a Comprehensive Health History)

Components of a Comprehensive Health History

• Date and time of history
• Identifying data aka biographic data
• Informant and reliability
• Chief complaint
• History of present illness
• Past history
• Family history
• Personal and social history
• Development level
• Psychological history

Date and Time of History- always important

- be sure to always document the time when you evaluate the patient, especially in cases of
urgent or hospital setting
- allows your assessment to be used by future providers
Biographic data- the identifying data
- includes client’s name address, age, sex, race marital status, occupation, religious, preference,
healthcare financing, and usual source of medical care
- usually closed questions that require specific answers because they are truth/facts.
Informant and Reliability
- source: patient, a family member or a friend, an officer, a consultant or the clinical record
- helps you to assess the quality of the referral information, questions you may need to address in
your assessment and written response
- reliability may not be precise in order to allow their healthcare workers to read your assessment
to understand that the information is not reliable.
Chief complaint – the reason that the client came to the hospital or to the clinic
- make every attempt to quote the patient’s own words
 - answer the question: “Describe the reason you came to the hospital or clinic today”
History of present times- complete, clear and chronological description of the problems prompting the
patient’s visit
- each symptoms will have its own paragraph
- attributes of a symptoms: OLDCARTS
• onset
• location
• duration
• character/quality
• associated symptoms
• aggravating factors
• relieving factors
• timing
• treatments
• setting
If the patient has 2 problems that are not related with each other, you have to have a different
paragraph for the second problem.
HISTORY OF PRESENT ILLNESS: OLDCARTS
Onset- when did it start, sudden or insidious
Location- specific location in the body, ex. RUQ, LUQ. LLQ, diffuse, generalized, left or right, etc.
Duration – how long a symptom is present ex. 5 min seizure, 5 min chest pain
- always important in diagnosis and determine the urgency of management and the kind of
management
Character/ quality- describes the type of the severity of the symptoms
For example:
Dyspnea- with moderate exertion at rest or minimal exertion
Abdominal pain- bloated, sharp, dull, gnawing, burning, pain as well as intermittent or continuous.
Pain also has an additional description which is the pain score ( identify how sever the pain is 1-10)
Associated symptom- what other symptoms are noted associated with the main problem ex. Abdominal
pain that is associated with vomiting and LBM or chest pain associated with dyspnea, headaches
associated with visual aura prior.
-are connected to each other

Aggravating factors- any situation or action that will worsen the symptoms ex. Headache that is
worse with bearing down or with bending down, dyspnea that is worse when a pt is in a
particular place (work)
Relieving factors- any situation or action that will make the symptom better
>opposite of the aggravating factors ex. Abdominal pain of appendicitis is better in a fetal
position or leg pain in PAD that is better when the leg is dangled.
Timing- when the symptoms occur
>associated with a specific event, time of the week, time of the day.
>doesn’t have to be a specific time ex. Some fevers only occur in the late afternoon or night as
in IB or some that only occurs after every meal in some types of ulcers.
Treatments- include any medication or herbal drugs or home remedies that were taken for the
problem whether received or not.
Setting- in what situations dues the symptoms occur.
 >happens only in certain situation

Constructing the History of Present Illness

Start with time- how long since you saw the patient did the symptoms start ex. 10 days prior to
consult admission
HPI- history of present illness
Sample:
Informant: Client
Reliability: 90%
Problem: DOB
- 3 days prior to admission, patient had sudden onset episodic DOB associated
with runny nose, not affecting ADLS worsened when walking through nearby
flower fields. No associated cough, fever, malaise vomiting, dizziness,
palpitations or tremors. Took salbutamol 1 tab TID and salmeterol+ fluticasone
propionate 250 mg 2 puffs with transient relief. Patient also had recent history
of URTI the preceding day. No consult done. Condition tolerated.
- 2 days prior to admission, symptoms worsened. DOB now associated with
wheezing, still not affecting ADL, nebulization with salbutamol 1 nebul done and
took 1 tab TID plus salmeterol + fluticasone propionate 250 puffs with transient
relief. No consult done. Condition tolerated.
- One hour prior to admission, patient was awakened by an episode of now
nebulization which prompted admission.

Video #3
Data Collection (Making a Comprehensive Health History)

Past history
Childhood Illness – include disease such as measles, rubella, mumps, whooping cough, chicken fox,
rheumatic fever, scarlet fever and polio
-Also includes all immunizations received tetanus, pertussis, diphtheria, polio, measles, rubella, mumps,
influenza, varicella, hepatitis B virus (HBV) human papilloma virus (HPV), memingococcal disease,
haemophilus in influenza type b, pneumoccocci and herpes zoster.

Adult Illness
Medical
Comorbids: diabetes, hypertension, hepatitis, asthma and HIV, allergies, other chronic illness
• Hospitalization
Ex. Date Institution Reason 10x Duration of the day
May 2020 Riverside Cholecystitis 5 days
Medication currently being taken
Ex. Generic Dose Tabs Timing
Apixaban 5 mg ½ tab BID
Surgical – all surgical procedures including dates what procedure and for what reason
Ex. Date Institution Procedure Reason
May 2020 Riverside Hemicolectomy Colon Cancer
Psychiatric – includes all psychiatric illness and time frame, diagnoses, hospitalizations and treatment.
OB/GYN: MIDAS CPCS, LMP, GP (TPAL)
• Menarche: age> of when the first menstruation occurred
 • Interval of Menstruation: regular or irregular or number of cycle days if regular
• Duration of menstruation
• Amount of bleeding during menstruation
• Symptoms associated

OB/GYN: MIDAS CPCS, LMP, GP (TPAL)

• Coitarche > is the age where the patient first had sexual intercourse
• Partners
• Contraceptive use (IUD) (condoms) (pills)
• Smear (PAP smear) > the date when the patient last had PAP smear
• LMP (last menstrual period) > the first day of the last menstrual period

OB/GYN: MIDAS CPCS, LMP, GP (TPAL)

• Gravida – number times become pregnant (even if miscarried)
• Para- number of times pt gave birth
• Term- number of pregnancies that lead to the birth of a full term baby
• Preterm- number of pregnancies that lead to the birth of a preterm baby
• Abortion- number of pregnancies that lead to an abortion/ miscarriage
• Live- number of living children
Answer: G6 P3 (T2 P1 A2 L3)

Family history – to ascertain risk factors for certain diseases, the ages of siblings, parent, and
grandparents and their current state of health or if they are deceased, the cause of death are
obtained.
- hypertension , coronary artery disease, elevated cholesterol level, stroke,
diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease,
headache, seizure disorder, mental illness, suicide, substance abuse, and
allergies, cancers as well as symptoms reported by patient.
Personal and social history – lifestyle and psychological history
- includes occupation; sources of stress, both recent and long-term, leisure
activities; religious affiliation and spiritual beliefs.
Baseline level of function
• Activities of daily living and instrumental activities of daily living
Activities of Daily Living (ADLs)
Bathing
Dressing
Toileting
Transferring
Continence
Feeding

• Instrumental activities of daily living (IADLs)

Using the telephone
Shopping
Preparing food
Housekeeping
Laundry
Transportation
Taking medicine
Managing money

Development level- usually best used in pediatric patients with regards to their developmental level

Video #4
Data Collection (Physical Assessment)
Types of Physical Examination
Comprehensive- complete
Focused- body system/ area
Functional- abilities

Comprehensive- an initial assessment that the patient has been admitted

-a total and complete assessment of all body systems which are normal and which of them has
significant changes.
Focused- usually used in cases when we need to examine a particular area based on the symptom or the
complaint of the patient.
Functional- examine one or more aspect of a client’s ability such as: ADLs> to determine the functional
ability of the client.

Physical Health Assessment

• to obtain baseline data about the client’s functional abilities
• to supplement, confirm, or refute data obtained in the nursing
• to obtain data that will help establish nursing diagnoses and plans of care
• to evaluate the physiologic outcomes of healthcare and thus the progress of a client’s health
problem.
• to make clinical judgements about a client’s health status
• to identify areas for health promotion and disease prevention
2 Aspects of Assessing the Client’s Health
1. The nursing health history
2. Physical assessment

HEAD – TO – TOE FRAMEWORK > most clinically used

Health assessment- conducted in a systematic and efficient manner that will result in the fewest
position change for the patient.

• General survey
• Vital signs
• Head
-hair, scalp, face
-eyes and vision
- nose
 - mouth and oropharynx
• Neck
-muscles
-lymph nodes
-trachea
-thyroid gland
-carotid arteries
-neck veins
• Upper extremities
-skin and nails
- muscle strength and tone
- joint range of motion
- brachial and radial pulses
-sensation
• Cheek and back
-skin
-thorax
-lungs
-heart
-spinal column
-breast and axillae
• Abdomen
-skin
-abdominal sounds
-femoral pulses
• External genitals
• Anus
• Lower extremities
-skin and toenails
-gait and balance
-joint range of motion
-popliteal, posterior tibial, and dorsalis pedis pulses
Shift assessment- in order to use as a baseline in order to compare the later data focused on the
immediate needs and problems
Observe
• level of consciousness
• skin color
• respiratory effort
• nutritional status
• body position
• speech
• hygiene and grooming
• Check vital signs including pain
• Auscultate lungs and apical pulse Can point to a life- threatening condition
• Check capillary refill and peripheral edema
• Auscultate bowel sounds
• Observe skin turgor and surfaces for lesions
• Observe mobility
• Examine drains, catheters, wound dressings, or tubes: location, patency, and description of
drainage, if any.

PREPARING THE CLIENT

• Explain the procedure
- What, when, where, why
• Reassure confidentiality
• Determine in advance any positions that are contraindicated
• Empty bladder
• Proper draping
• Children: least invasive to more invasive
• Adult: the head and neck, heart and lungs, and range of motion- ears, mouth, abdomen, and
genitals

PREPARING THE ENVIRONMENT

• Convenient time
• Well lighted
• Organized equipment
• Warm room for the patient to be comfortable
• Private
 PROPER POSITIONING

CLIENT POSITIONS AND BODY AREAS ASSESSED

POSITION DESCRIPTION AREAS ASSESSED CAUTIONS

Sitting A seated position, back Head, neck, and Other adults and weak
unsupported and legs posterior and anterior clients may require
hanging freely. thorax, lungs, breast, support.
axillae, heart, vital
signs, upper and lower
extremities, reflexes
Supine (horizontal Back-lying position Head, neck, axillae, Tolerated poorly by
recumbent) with legs extended; anterior thorax, lungs, clients with
with or without pillow breasts, heart, vital cardiovascular and
under the head. signs, abdomen, respiratory problems.
extremities, peripheral
pulses.
Semi- Fowler’s (30-45 Back lying with head of Jugular vein distension May be uncomfortable
degrees) the bed elevated unless the foot or knee
approximately 30-45 is elevated slightly.
degrees.
Sims’ Side lying position with Rectum, vagina Difficult for older
low ermost arm behind adults and people with
the body, uppermost limited joint
leg flex at hip and movement.
knee, upper arm flexed
at shoulder and elbow.
Dorsal recumbent Back lying position with Female genitals, May be
knees flexed and hips rectum and female contraindicated for
externally rotated; reproductive tract. clients with cardio
small pillow under the pulmonary problems.
head; soles of feet on
the surface.
 EQUIPMENT AND SUPPLES

EQUIPMNENT AND SUPPLIES USED FOR A HEALTH EXAMINATION

SUPPLIES PURPOSE
Flashlight or penlight To assist viewing of the pharynx or to determine
the reactions of the pupils of the eye.
Opthalmoscope anyway A lighted instrument to visualize the interior of
the eye.
Otoscope A lighted instrument to visualize the eardrum and
external auditory canal. (a nasal speculum may
be attached to the otoscope to inspect the nasal
cavities)
Percussion (reflex) hammer An instrument with a rubber head to test
reflexes.
Tuning Fork A two-pronged metal instrument used to test
hearing acuity and vibratory sense.
Gloves To protect the nurse.
Tongue blades (depressors) To depress the tongue during assessment of the
mouth and pharynx.

METHODS OF EXAMINING

• Inspection
• Palpation
• Percussion
• Auscultation

1. Inspection
- Through a visual examination which uses assessment using light, sense of light or eyes.
- Celiberate, purposeful and systematic.
- Moisture, color, and texture of body surfaces as well as shape position size, color and
symmetry.
- Sufficient lighting (natural or artificial lighting)
- Can be combined with other assessment techniques in order to perform the assessment
simultaneously in an efficient amount of time.
2. Palpation
- Examination of the body using the sense of touch.
- Texture, temperature, vibration, position, size, consistency and mobility of organs or
masses, distention, pulsation, tenderness or pain.
TWO TYPES:
Light
Deep
PALPATION: LIGHT

- Always precede deep palpation.

- The nurse will extend the dominant hands/ fingers parallel to the skin surface and gently
press while moving in a circular motion.
- Light Palpation, light depression of the skin.

PALPATION: DEEP

- Not done during routine examination and will require a significant skilled practitioner.
- Requires significant practitioner skill.
- Extreme caution: can cause damage.
- Not indicated in clients: can cause damage
- Not indicated in clients who have acute abdominal pain or pain that is not yet diagnosed
- Is done with 2 hands or can be one hand.

PALPATION: TEMPERATURE AND VIBRATION

TEMPERATURE: Use the dorsum (back) of the hand and fingers

VIBRATION: Palmer surface of the hand.

TACTILE FREMITUS VIBRATION OF

CHEST WALL ASSESSMENT

- vibration coming from the lungs Examiner feels for changes in

when the patient is vocalizing. intensity of Fremitus by palpating
chest wall.
- result of sound transmitting through
lung tissue.

CAUSES OF FREMITUS CAUSES OF FREMITUS

-excess air in lungs *LUNG CONSOLIDATION

-thickness of chestwall - air in healthy lung replace

something else (inflammatory
exudate, blood, pus, cells)

PALPATION: GENERAL GUIDELINES

* The nurse’s hands should be clean and warm and the fingernails short.

* Areas of tenderness should be palpated last

* Deep palpation should be done after superficial palpation

PALPATION

Assist a client to relax by:

1. Gowning and draping the client appropriately.

2. Positioning the client comfortably.
3. Ensuring that their own hands are warm before beginning.

3. PERCUSSION
- Act of striking the body surface to elicit sounds that can be heard or felt.
- Determine the size and shape of internal organs by establishing their borders
- Indicates: fluid filled, air filled, or solid
TYPES
- Direct
- Indirect

PERCUSSION: DIRECT

- Strikes the area with the pads of two, three, or four fingers or with the pad of the middle
finger.
- Movement is from the wrist.

PERCUSSION: INDIRECT

- Striking of an object held against the body area to be examined.

- PLEXIMETER- finger being hit
- PLEXOR- finger striking
- Strike distal interphalangeal joint.
- the angle should be 90 degrees
- the blows must be firm, rapid, and short to obtain a clear sound.

PERCUSSION: SOUNDS

-Describe according to its intensity, pitch, duration, and quality

PERCUSSION SOUNDS AND TONES
Sound intensity pitch duration quality example of
location
Flatness Soft High Short Extremely Muscle, bone
dull
Dullness Medium Medium Moderate Thud like Liver, heart
Resonance Loud Low Long Hollow Normal lung
Hyperresonance Very Very low Very long Booming Emphysematous
loud lung
Tympany Loud High Moderate Musical Stomach filles
(distinguished with gas air
mainly by
 musical
timber)

4. AUSCULTATION
- Process of listening the sounds produced within the body.
- describe according to their pitch, intensity, duration and quality
PITCH- frequency of the vibrations
INTENSITY (amplitude)- loudness or softness of a sound
DURATION OF A SOUND- length (long or short)
QUALITY OF SOUND- subjective description of a sound, for example, whistling, gurgling, or
snapping.

DIRECT AUSCULTATION

- using the unaided ear

- not using any materials for the hearing

INDIRECT AUSCULTATION

- using a stethoscope, which transmits sounds to the nurse’s ears.

- Using stethoscope

DATA COLLECTION
• OTHER SOURCES
• DIAGNOSTICS
• MEDICAL CHARTS

Diagnostics and Procedures- will yield important data for the diagnosis and management of the patient.

Intraop Record- can get a lot of information it could have a bearing with the care plan.

• Vital signs
• Blood or fluid loss
• Devices
• Procedure
• Final diagnosis

Intraop Technique

• What was done

• Intraoperative findings- can show that there were pus, absess, and infections once they open
the abdomen.
• Surgeon
• Nurses involved
• Final diagnosis
 MEDICAL CHARTS

COMPONENTS OF THE SOURCE-ORIENTED RECORD

FORM INFORMATION
Admission (Face) Sheet legal name, birth date, age, gender, Social
Security number, address, marital status, closest
relatives or individual to notify in case of
emergency.
Date, time, and admitting diagnosis
Food or drug allergies
Name of admitting (attending primary care
provider)
Insurance information
Any assigned diagnosis related group (DRG)

Initial nursing assessment Findings from the initial nursing history and
physical assessment.
Graphic record body temperature, pulse rate, respiratory rate,
blood pressure, daily weight, and special
measurements such as fluid intake and output
and oxygen saturation
Daily Care Record Activity, diet, bathing, and elimination records
Special Flow Sheets Examples: fluid balance record, skin assessment
Medication record Name, dosage, route, time, date or regularly
administered medications
Name or initials of individuals administering the
medication.
Nurse’s notes Pertinent assessment of client
Specific nursing care including teaching and
client’s responses.
Client’s complaints and how the client is coping.
Medical history and Physical Examination Past and family medical history, present medical
problems. Differential of current diagnoses,
findings of physical examination by the primary
care provider.
Physician’s order form Medical orders for medication, treatments, and
so on.
Physician’s Progress Notes Medical observations, treatments, client progress
and so on.
Consultation records Reports by medical and clinical specialists.
Diagnostic reports Examples: laboratory reports, x-ray reports, CT
Scan reports.
Consultation reports Physical therapy, respiratory therapy
Client discharge plan and referral summary Started on admission and completed on
discharge: includes nursing problems, general
information, and referral data.
That's what we do with the data we have So what this organizing data it's also referred to as of course
processing of data in an organized fashion or in a systematic fashion OK so it's place already in a way
that they are clustered no according to a certain criteria so assessment formats a very from institution
to institution and we could make use of certain models or frameworks to organize the data that we have
collected the first model not our framework examples of this are your good dogs functional health
pattern yourself care model by Dorothy Oregon now and calista Roy's adaptation model are you still
familiar with this honestly

they are saying clear risks right so unsexual models or frameworks would help us get close to the top
that are related to each other OK so we can make use of this conceptual models or frameworks to
organize gate to cluster the data that are related to each other and will later on guide us to have a
clinical picture not of a certain aspect of our patient another assessment format is your Wellness model
it includes factors that influence levels of Wellness further examples of the Wellness models for example
one example of a Wellness model is the lifestyle OK what are the lifestyle collectivistic Sabha certain
patient press source a health risks another example would be the nutritional characteristics of the
patient so these fat words influence the Wellness of our patient along the continuum of health OK so we
can make use of these models full cluster and lifestyle practices what are the what is the common dying
of your patient what are the common stresses or health risks that your patient is presented do so these
are different factors and attitudes that influence the level of Wellness of our patient debug stress buying
lifestyle beliefs and practices not like for example they believe in organic king among a food or they
believe in nonmedical therapies Gaelic for example a few fresh or acupuncture so those are certain
models that we can use now to determine not the Wellness of our patient and of course last but not the
least are your non nursing models so not nursing models examples of these are but these systems model
your maslow's hierarchy of needs and the different developmental theories have you learned already
the developmental theories in your 100 yes or no

guys I'm not yet so I think you'll be learning it in your phone and of course part of your pediatric nursing
in your second year you will learn these different humans are developmental theories or theories of
development so again not as a summary so we make use of assessment for months such as conceptual
models or frameworks Wellness models and non nursing models to organize or cluster not related
information from the assessment that we have made not by collecting your subjective and objective
views so here is an example of organizing data affording to Gordon's functional health patterns OK so
the first column indicates the functional health pattern OK so let's take for example health perception
and management So what are now the different patterns now of health and well being and how is
health managed by the lion examples of the data that you put in here are compliance to medication red
chimneys is the client is the client what is Shane shoes thinking his or her maintenance medication is the
fly as does the fly and abide by the die yet or the exercise pattern or regular check up perception health
management so next is your nutritional and metabolic pattern so here we cluster no pattern of food and
fluid consumption related to the clients consumption so in relation to that so we check aside from the
diet patient we also check the condition of the steam thief here nails because my brains as well as the
height and weight so quickly pointed at my enclosed I mean if I was not BMI now of the patients end
nutritional metabolic our height and weight is a reflection of our nutrition
when it comes to physical activity guess activities of daily living because the activity and exercise of our
patient affects not our cardiovascular and respiratory status from The Walking Dead by these are Arabic
exercises that of course keep our heart and loves healthy so those are examples or another example is
the role relationship pattern of your patient and yellow mulation ships with a significant others and your
major roles and responsibilities as a mother as a father as students not as children OK so mega affect
applenet condition some patient remember the patient is not just a fishel logic being my psycho
emotional my spiritual my cultural my social aspect activation so we organize this data according to the
garden so mccluster similarly have another example Royce adaptation model so the roys adaptation
model our partner aspect now the fish ological functions the self concept the role function and the
interdependence of all these functions to each other low students

sorry we had a glitch so I had the glitch here with my Internet connection can you already hear me this
means OK thank you so let's proceed

Feedback exercise for example you took the blood pressure of your patient to which aspect
physiologique self concept role function or interdependence new chelis section app did you say become
blood pressure are very good so that's an example a self concept unbold should be for example like I am
a I am a mother of two kids visual logics of concept role function are interdependent I really function so
those are examples not of clustering data not according to this model let's proceed with your human by
the organ system so this this is an example already of your non nursing model see so let's take for
example the WBC count of your patient the initial look back among the different human body systems
there presented WBC count circulatory ZWB circulatory so then WBC is is responsible for what pretty
good immunity lymphatic system how about blood sugar not really very good in the crane system OK
exercise and activity pattern muscular means they're very good muscular let's give them an abnormal
body weakness you can give me actually two systems for body weakness they include well very good
nervous system and muscular system how about heart treat very good circulatory system how about
diarrhea diarrhea patient very good they just give system up skeem furger so very good menstrual cycle
email very good your female reproductive system chest X ray result of your patient very good yard
respiratory system actually played it line some heart so mobile and when I search as X ray couldn't
enlarged our heart so uh there and then additional national later on but basically just X ray would reflect
the condition of the lungs of your patient respiratory system OK so just a little tip from this woman
budget problems of your patient OK now meet the meet born no model not for organizing your data is
the body organ systems model we shall logic problem sufficiently how about can psychologic or psycho
emotional usually we make use of the Gordon's functional health patterns OK so I'm not sure guys
importance of organizing your data OK so let's proceed

this is another example of your non nursing models that different developmental series you will learn
more about this not as you go along and these for me have this is one of the very interesting topics not
when you are already in your SIM because you begin to understand no why you are thinking that way
why well your relationship with other people the ideology Sigmund Freud for psychosocial development
Erik erikson for psychosocial development Jean piaget for cognitive development and Lawrence
kohlberg for moral reasoning OK so now maybe check my Skype did you know many mention behind or
this is how you will cluster your data especially if you are assessing no the stages of growth and
development of your patient OK so for example your patient is a priest school child OK so I know
normally gay I initiative versus guilt OK so preschool age are afraid to be scolded no they are afraid of
punishment not so I'm not sure and of course for the phallic stage they are now becoming interested no
of there being male or female huh somebody sting wished I I'm a girl well I'm a boy OK how about
adolescence to adulthood or so so cognitive development changing this is how you will approach or you
will approach the lessons and adults for most thinking that so they could already explain things they can
already give rationale for their actions now so those are the different developmental theories that will
guide us on what are the normal OK behaviors of our patients as a search at a certain age so during
assessment normally I'm young last psychosocial development as psychosocial is normal OK so those are
the developmental series models that you can use to cluster data I normally and young thinking normal
reasoning OK or we keep development open in front or this is how they move this is how they interact
with equal gay so Nicola I don't trust versus mistrust not on backpack in the shop some other person I'm
gonna get there so yeah Bruce so I'm gonna get my trust there is still mistrust so I'm not sure adapter
mean that when we are assessing our patients with regards to what is normal and what is abnormal
following the different developmental OK so this is this model will help us organize not data that are
related to each other and these data will reflect a certain aspect of the client OK he didn't wanna class
my determann later on I'm normal abnormal during your analysis and sentences in the diagnostic page
or the nursing diagnosis face so that is why assessment is very very important as the first phase of the
nursing process OK so after you gather you organize your data OK because organizing your data will
make it easier for you to go on to the next phase which is diagnose now after organizing the data we
need to validate it what is the purpose of validation to verify data or to confirm data if it is complete if it
is factual and if it is accurate we don't just list right away because there are certain data subjective and
objective data that are fun flick Ting not malicious she feels warm she feels hot clear temperature
normal so I need to validate the feeling of the patient can develop on mug menopause I'm patient OK so
when you when the patient tells you I feel hot I feel warm it doesn't me right away that the patient has
fever OK that's because of the effect of the hormones gonna give time information OK so after
organizing your data you validate the data you double check you very fight to make sure that what we
the data that we have collected or gathered is complete factual and accurate OK So what are our
guidelines number one ensure that the assessment information is complete this is very very simple just
make sure that your history taking information sheet as well as your physical assessment data sheet is
complete OK my template number two we need to ensure that the subjective and objective data agree
with each other what do we mean by this inside OK for example patient tells you not gingka lot injury is
but upon your assessment you notice that it's not an insect bite it is a cigarette burn if we did and then
you could ask to verify now when did the when the when did the insect bite you OK then better mean if
the patient is really telling the truth by uh reviewing no this stages of the inflammatory process but we
need to ensure that the subjective and the objective data go inside another is full for example manner of
the fracture or manner of the dislocation does not go inside with the way the patient is you can find
notion who gay or not gay for example but yes so that pallab Bruce why is it not no so there are certain
things that we need to verify so we have further questions not like the manner of the injury next is we
need to obtain additional information that may have been overlooked so as we as you go along now as
studying the different assessment of our patient from head to toe now to be discussed in your midterms
and your finals you will be able to learn further no information that needs to be gathered for each part
of the body or for each system of the body OK next is we need to differentiate between cues and
inferences OK subjective or objective data that can be directly observed is known as your cues and
infrared is the interpretation of the nurse or conclusion based on the cues for example the patient has
LVM queue patient has sunken eyeballs that's a cute patient has sunken one panels that's a cute what is
an inference the patient may be dehydrated that's an inference because that's already the nurses in
interpretation or conclusion based on documents OK so that's the difference between a Q and an
infrared OK I know there example the patient is walking through and fro OK that's a cute the patient is
walking to and fro what's an inference the patient is agitated Speech OK that's an inference already so
we need to differentiate now our own interpretation from what is factual what is happening with
suppression OK and last minute they least avoid jumping into conclusion and focusing in the wrong
direction to identify problems I will not shop now we always look at the patient objectively and all
subjectively throughs are taken as is OK patient right so remember it now I'm critical thinking and bias
OK so that's part of critical thinking when you are gonna be playing so points to remember not all data
requires validation OK like laboratory studies OK when I'm with the result celebratory see that's what is
the reflection based on the machines not the termination of the for example the CBC the blood levels of
your patient I'm like wait maybe sharing tools and that height and weight is standardized already so
quote 555 no need to validate again I will tell you what type then what we have they're nice instruments
OK so just make sure that it is well calibrated and at weighing scale for the week OK next is the nurse
validates data when there are discrepancies between the data obtained in the interview and the
physical assessment similar to the example I said earlier I'm just need I got called West gay I was like the
temperature it's normal OK I feel feverish don't feel good are normal that's what I felt last week yes yes
last week booster feeling you need to validate now if there are discrepancies next is you need to be
aware of your own biases values and beliefs and separate facts from inference interpretation and
assumption gay So what we always make sure is what we are documenting and what we are stating in
the database of our patients are facts interpretation we do not say their patient is agitated no patient is
walking to and fro so move you are making inferences already if you are diagnosing you are patient but
not yet in assessment gay you don't put there in your assessment patient is anemic no what we put
there is RBC count I'm moving my 12 patient is fail there is fire there is sweetness we don't put their
patient is anemic that way they don't make inference or interpretation OK patient is paralyzed patient
and able to move extremities patient is paralyzed because it's already interpretation McGee who I'm
able to move right arm unable to move left leg so I'm looking at Next is to build an accurate database we
must validate our assumptions regarding clients cycle and emotional behavior OK must difficult to
validate can psycho emotional because it is body to given to you is subjective no no it's quite difficult to
validate it it is subjective data because subjective data is the clients own opinion of a certain condition
of himself or herself yeah so we take it patient we write it verbatim Lauer clear email check the
feedback temperature 36.9 degrees Celsius eight delete oil you will make use of this data to analyze and
this synthesize when you're already buying the client feels warm they don't normally when I meet young
temperature so you analyze one and yes unmixed face that's why I cannot learn accurate unpacked
document assessment feedback So what are the different guidelines that we need to follow and validity
OK first is to compare subjective and objective data not to verify client statements with observation
client feels warm check them clarify any ambiguous or vague statements for example client tells you I
feel sick I feel sick general OK so you need to clarify what are you feeling is there any pain do you have
any business comforts did you have any injury no Superman put on motion to clarify who are sick I know
probably take shot I feel sick some bolka I feel sick simply vicious psychologically sick or physically sick
be sure that your data consists of cues not inferences yeah it's working all and fro why can't yes Sir
patient is agitated because it's already an inference a patient is walking to and fro center not keep still
that's cute OK so that's how you takedown your notes huh assessment findings next double check the
data that are extremely abnormal example patient is sitting down very calm pillow on blood pressure
200 / 120 asking how are they laugh they check or request another nurse check you want abnormal
needed another example are great yeah pretty long what's the normal heart rate it's 60 to 130 heart
rate so when extremely abnormal very high or very low data OK so they didn't sign up the five owners
no would would exercise now how many extremely abnormal just to make sure I did laugh dating is
double checking extremely abnormal with it next is better in presence of factors that may interfere with
accurate measurement for example bug hi leans they have full health hey Helen I never spirit for you
read yeah of course if the factor that the patient has just arrived the patient walked no or ran on to say
we affect of course the accuracy of the respiratory care taking from your patient another would be
blood fresh word so of course 130 vital signs taking now but prior to taking the blood pressure patient
should be rested correct do you agree with me students guys are you still there can you give me some
some reactions there

signs not discussion they knew anything 101 our skills lab enter back in your vital signs I someone that
shut well so another example is italianissimo movies great well now it's a CG OK when taking the ECG
stop will appoint no Julie remove so gonna remove that cell phones or metals like coins and jewelry
from the patient because taking the ECG took my metal somebody will have an erratic result because of
the static cost by metals and magnetic magnetic media vices gay kiss on patient and come with update
I'm underside real some bad method no remove the heart attack the patient the interference accurate
measurement so that means proper positioning of the patient now and taking a CG as well as proper
placement of the program or of course removal of metals in the body OK so these are this is just an
example Thursday meeting for fear with after eight measurements OK and of course last look at the
least use references to explain phenomena go back to the books that is normal what is subnormal what
are the updated information that may help explain the condition of our patient examples I'm I'm go back
now to references so these are some of the guidelines that will help us validate our assessment the OK
check and compare check OK before you document your assessment data so we organize then we
validate our assessment feedback after organizing and validating we document documenting is the
recording taking down notes of all the assessment findings that we have gathered through interview
huh physical examination and of course our assessment So what is a report not a report is an oral
written or computer based communication intended to convey information to others so our report we
do it through our endorsement underreport is to an endorsement so we convey information to the next
 shipment runners we convey information to the physician when we are documenting all when we are
making reports right doctor patient has not eaten the whole morning since Aretha that's an oral report
also the chart or clients records is a formal legal document that provides evidence of client care it can be
written or for people take note here that they have underline formal document and I placed aye aye aye
made the evidence no word read one yes I want that the chart or the client report is a formal legal
document that's why we ask ourselves should be very careful and we should follow guidelines and
policies when documenting data even just for assessment they will just formal especially in assessment
and of course all client care activities the whole of the patients chart is considered as a legal document
and when legalities matter it can serve as evidence in court and that I needed next I see you reach
second year after your capping you will be already hopefully not having your exposure in the hospital
beside McGrath balance and temperature some patient OK it should be accurate it should be
documented correctly and accurately in the patient chart in chapter word 8 inch in temperature wipe it
high temperature low my shop temperature is very very important than the woman to support
unfamiliar it can serve as evidence so very very carefully when document so the process of making an
entry is but of course recording charting or documenting so Mama let's start with that and here please
take note the nurses accountable and should document according to organizational policies and
universal standards so the main basis for documentation organizational policies and universal standards
so even just know what our student nurse final, you're already part of the health care team if you are
there having your RLE exposures in the hospital so left align I also intake and output accurate take one
100CC again in Rome with that 1000CC where did the 900CC come from or be it will matter later on
especially if it will be used as evidence in court no someone left here next word with make short supply
ads hey it's remember accurate documentation is essential and should include all data collected about
the client's health status and still the same data are reported in a factual manner not based on the
interpretation of the nurse also avoid restating or fire freezing clients subjective feedback it should be
documented in verbatim in quotation marks with lab you are thought was a subjective data quotation
mark I feel sick I feel sick I feel like I'm going to harm it I feel like I'm going to vomit when patient is not
cheated interpretation but I feel no shame no I feel like I'm going to vomit not the interpretation that no
patient is no sheated analysis later on but what you will need to document is the patient said I feel like
I'm going to vomit OK because saying no patient saying I feel like I'm going to vomit doesn't necessarily
mean nanosheet patient expression or for example yeah interpretation so it should be documented in
pay fine Pena has many other interpretations aside from being machine that's why when we record top
one but end we don't have money patient subjective data listed the best chance not avoid judgment or
conclusions example normal appetite what is normal for you may not be normal for the patient how do
you document it properly ate half of the rice consume one glass of milk and one apple and one whole
egg OK so one apple half cup of rice one glass of milk you don't put their normal appetite so that's an
example now document what is factual what really happened what the patient is we don't document
the normal appetite heavy I'm gonna no you document what has been functional huh so clear that that's
how we document no when we are assessing our patients game able to walk four steps without
assistance nothing about I did not get any patient has is paralyzed or patient has a para pleasure a
patient has muscle pain before steps gay so I think it back make judgments or conclusions OK so that's
how we document the fact accurate and batch OK so there are 13 main guidelines for recording patients
data OK we'll discuss them one by one let's start with your date inside OK when you're documenting
 make sure that you have stated the date and time for each recording hey I'm the arrest Michigan
interview I know my date so not last charts on patient not name of the patient my baby not that time so
time can be documented in 12 hours now clock AM PM or it could be a 24 hour military flag on 24 hours
not signing OK so timing documenting should be done as soon as possible after an assessment or doctor
intervention do not document before you have done the assessment or intervention and the after hey
this way when you are in the clinical area you are required to have a small multiple alright you know
why some vital signs my notebook they pause are both substation igrafx patients chart you don't bring
and graft beside the patient so the last small notebook so last small notebook vital signs station
graphing hey so do not draft before assessment is done next legibility for written documentation so for
written documentation your penmanship should be legible and easy to read hand printing or easily
understood handwriting is permissible so use always now we avoid script or shorthand we might seem
what's not shorthand now so we don't make use of that one one word short long abbreviation gay boy
I'm because because we are very right now huh we are very adjusted that with text messaging my short
and I need uh online Bible way BTW I know but not usually now we avoid those things damn pause no
I'm big like an awkward messy so legibility should be very important now class we are different from
physicians OK so the documentation legible and he knows this notes Or success meant sheet so I can
match question next for recent documentation it should be written in ink or permanent pin one last
time add it's short boil pin not sentence now invent mega blocks stop Ben and usually client records in
the chart are double sided so bullpen no sign for electronic records changes are made in accordance
with software guidelines OK got under that device within some program that you cannot change the
information OK when you type something to change that are red shirt so you will learn more of those in
your nursing informatics such OK so again I'm finding a firmer right after and we do not document on
the next day OK so that part well once again access to the moment document do not have that habit
tomorrow so let me know right after that assessment so legibility practitioner proper handwriting for
those now maybe fakulty when it comes to 10 month ship it I'm gonna say remanent next would be
accepted terminology we make use of commonly accepted abbreviations symbols and curves you will be
fought with regards to the symbols and terms let me give you an example in the comments among us a
symbols I'm with Nathan is C with a bar on top and without ass with a bar on top so call 1 with those
without so uh those are just examples that I am sharing with you that why not you will be taught in your
fundamentals in nursing of the common abbreviations symbols and things you can also refer to the bold
examples of hey correct spelling please take notes in spelling gives a negative impression to the reader
and decreases the credibility of the nerves so make sure that when you are writing you are writing with
correct spelling signature it should include the mean and the title of the nurse so call me OK for example
when word art in yeah I still did 1S N CS that means student nurse got from CSD so for electronic records
of course you will have your own code or password not word my school my number or some boy for the
nurse that is unique to you for electronic records right so here based on the joint permission this is
established worldwide a here are the do not use list of symbols and units huh do not use you for unit
because it can be mistaken for zero or #4 or Sissy my balangir so word name where I used it can be
misinterpreted as intravenous or #10 the printer so right give international you me QD QD qod every
other day right get daily or every other day gay are you that but my zero open my zero or leaving 0
decimal point is mixed well who are Latin zero bye bye 10 milligrams study by 100 milligrams so one
whole number numb and long in the .0 gay solid 0 Norman leading zero popping decimal so when
decimal 0.25 ML beat song give after 70.25 ML bye see Abby Mila 25 MLK in Mesquite so when my when
does emotional fraction 0.25 and end so 0.25 one whole number misinterpret it is open yo hey
magnesium sulfate morphine sulfate magnesium sulfate it can be confused for one another so right my
long I'm more painful feet with magnesium sulfate OK so please take note of this multi very cool and
may the misinterpretation may affect not your care for your patience so please take note he shall not
lose my list OK so basically right now I've been talking to clamp row it could matter no.25 zero point
25ML it's way smaller than 25 10ML big difference man 110. Soldner document that accurately
especially on numbers terminology correct spelling and of course proper signature that's move on to the
next one you receive now we gonna see a curacy first reminder the clients name end identifying
information should be stamped or written on each beach of the client record every pitch so cut the
document my so let them mean supplier number date today time today special gear is needed when
clients have the same last name twins baby eight baby patient will BB8 baby be like the world is my you
wanna see you silly apellido Ruiz baby baby be similar OK my junior and senior in one syllable father and
son lucila my junior amazing you're my junior my daughter did forgive so special theory is needed
specially if not so clear we carefully must recheck give up you're holding the correct chart no not now it
could happen huh next would be I create locations consists of facts or above our observations not
opinions or interpretations again avoid your own interpretation I have given examples that earlier I
don't need elaborate on that now avoid general words like large board normal not because what is large
for you may not be large for others what is good for you may not be good for others like appetite
normal appetite normal weight measurement OK so short the clients ossific data the exact measure
when it comes to appetite when it comes to weight when it comes to height wrong when it comes to
size measure get 20 by 30 by 70 centimeters large it's not measurement shooting placement right on
every light never between lights so some idling yeah that's in between lines blocker no one and three for
each line on the chart again one and P for each line on the chart I know to building increases one entry
or one sentence well well we always remember that if there is a blank space draw a line through the
blank space so that no additional information can be recorded at any other time or by any other person
and then sign the notation what do I mean by this right remove make it 9 I swear so this is sample this is
one night my end vehicle blue for example of your writing I'm entry here Internet edge open end 39.
Hey so team So what do I do by Mary mean a blank space they didn't mention that yeah and then you
sign at the end I partner in Vietnam so and treat that is your protection asked the nurse now again
Wednesday night my line then they blank space add or draw a line on the blank space and then sign up
the end the game clear the bat so I the up went and tree I will put a line to complete that total to
complete the blank space and then I will sign and that is what is meant by this diagram that that will be
legally implicating on you good luck to you someone protection our entry in there is so next when we
draw a single line in the paper name and initials above or near the line depending on agency policy in
Chandler because it may be interpreted as a red flag not not follow my errors appear some patient no so
do not put the word error so the original entry must be visible so crash out one line laugh but I'm
intrigued playing the original entry should be visible for computerized entry follow the agency profile so
it depends you will learn it for your during your nursing informatics here I have also placed in all caps do
not erase do not block or do not news for action fluid for correction in our patients sharp mortal sin my
blood or my gamut correction loaded while lap hey goodnight again but highlight so here like increase
maybe for example so let me get intrigued what do I do please align insert that shot I will put my initials
here and then of course enter the entry I am sorry with the correct entity after how many inches my red
line and then my signature going up that means get delete for not sure I am the one in the Panama
shopper momo I am the one who deleted it and this is my correct entry and then in playing again delete
gay in in sign language not OK so that's how we make corrections if we have entered a mistake not are
my errors but as much as possible yeah writing and erroneous data on the patient chart I know love
much quote brass much as possible in Hawaii and madelung before check see patient is with me I can't
get my patience I'm gonna give me alright I'm gonna give me a call along about Ben sleeping my blow
my black and my red and she's depending on your ship mice scratch so let me check my email when
insert for now right Lena or Romeo notebook correctly section so I'm gonna eat that remove also left so
scratch rewrite rewrite miss transferring sharp or my hand hey so that is what happens OK OK so that's
clear accuracy can I have a thumbs up if clear on accuracy

OK very good connection manager Wi-Fi man OK so we're done with accuracy OK so very important give
me accurate and of course please take note that we should know how to properly correct the data that
we have encoded and we always make sure that what we have encoded in our patients chart is correct
A and accurate 5th minutes right deafness when your document and how animal dilone relax make sure
that you are confident that you are doing it correctly winning short scratch on my back on 3rd check
things before entering the bases once in break on what you are doing You mean that give me classmate
some more then I got charging then I got graphing students with my mother graphing charting

Yeah and each word time you said they serve Goodman in I'm miss or I serve as Sir 100 10/5 I'm missing
OK indeed make erase a indeed yeah but then that first year is action and they have a thumbs up on that
yeah in the there is always the proper way to correct on this OK and don't be afraid to say your CI Sir but
then long OK people all the more again it is it is move that game let him in jail indeed how we will be
there to guide you and supervise you on how to do it and upgrade again mine and what you are hey
when you're already in bed I know my job if you're doing it correctly and the confidence that UCI is there
guiding you and do it properly it can be smooth on your own have that motivation I will do this properly
I will concentrate I will write OK so I'm gonna show they are coming that to guide you and that to school
you has to dance I'm gonna have I need that make you help you learn how to do it properly so in human
in human responsibility is to do it correctly and confidence hey no OK let's move on to sequence the
document the events in order in the order in which they Porsche because when we document it should
be in 859 no pick a weird man listen to Asha this one gives the soil gain gain miss if I did look really long
but I know trouble look so weird OK so that part according to the timeline in which sequence so my
documentary mobile charting hey according to the events as they work and according to the
interventions as you did in oral care unbold remove minutes next is appropriateness record only
information that pertains to client health problems and air recording of irrelevant information may be
considered as invasion of clients privacy or you will be accused of libel libel hey it's a boy I'm glad that
patient hey so you are recording now or you are assessing now the local discharges of your patient I'm
up at the and and fuller I got serious steaks or your mom with my things abdomen because you're
accessing expression and war city diner you don't need to document it cannot expression G because
that's relevant information to your client care and lab charges they're giving birth OK later on from the
list emotional I'm sorry please now subjektive Don or sing diagnosis listening or I'm ciety chart because if
he can be considered a flight now or it is already an invasion express that so appropriate client
physiological response after giving birth hypogastric theme local discharges so that's just an example
that the nurse should also consider the appropriateness of the information that he or she is
documenting in the chart OK want to give me information but we also consider appropriateness when
we are document especially patient know sometimes they're psycho emotional normal I know you
expressed that's good one next is complete not only fast but the nurse some things about the client can
be recorded whoever they information that is recorded needs to be complete and helpful to the client
and the help So what we need as I've given the example earlier complete this charges amount
defendants and independent nursing interventions client problems client comments and responses to
interventions and tests progress towards voice and communication with other members of the health
care team condition or what does this mean for example the client refused super thanks yeah used to be
intubated so document what was on mitted why it was omitted and he was not ified so for example
client refused integration Paris informed hey refusal form refusal form or be an art form sign in sign
sufficiently I'm using cell form they may receive cell form so that's why the client has the right to self
determination client has the right to open refuse in our client here yes document it so have the client
side I'm I'm sorry or that do not receive one so Please remember what is not documented is not bad
play document refusal if you're the best scared beginner document when it comes to port remember
next is so they should be lion's why is playing simply refuse intubation so no need client refused
intubation refused intubation if you sounds form sign that means inside my client and end each spot
with a period so very concise but so this is where your training in grammar and English comes in maybe
English because it will be applied in your documentation my my appreciate you amigo making 6 it is
applied in our you don't need to be alive document but basic English and proper so now it's not easy
sweet we need to make it the horse left but not the least is legal prudence since the chart is a formal
legal document that serves as evidence in case of legal problems how are you guys so after it incomplete
documentation we'll give perfection to the nurse the health care team and the institution so when you
are properly documenting you are not just protecting yourself you're protecting the holy healthcare
theme and of course the institution it is admissible in court as a legal document so the clinical record
provides proof of the quality of care given to the patient so proof that some quality some gear and no
completeness and care what are the management's given to the patient completing the chart I'm not
leaving avoid taking on any shores and we properly correct our mistakes or errors in the documentation
next documentation is usually viewed as the best evidence of what really happened to the client upon a
time line complete correct huh and reminder I'd hear the professional standards of nursing care and
follow agency policies and procedures for intervention and documentation in all situation so when
you're working now I center see you are oriented why you are being given orientation on what did you
and of course it is your responsibility to study the patients chart thing in the book and in ending the
colors unbold pan right now with the advancement of technology we already make use of electronic
records so I know your generation is attacking generation you are what do you call this digital natives
come here come here digital immigrants from paper to elect to digital generation generation from
Electro or from paper to digital so not migrate immigrant when you were born I saw OK someone got
Jack funny things not more generation so it's easier for you to uh but the adapt to the electronic world
but legally again now we follow always agency protocol when documenting care for our patients when
documenting assessment findings no to follow that one OK especially now legal food dance is a similar
cases make sure that you do not own legal prudence especially in cases of abuse I assessment wise very
important not in cases of abuse so this is just an example unconscious patients forget that is very very
important so let's now proceed ensuring confidentiality and security of computer records since now we
are in a generation or we are in a time where in digital records is very common and usually used in the
hospital we have several tips and such as sessions to ensure protection insecurity of both the nurse as
well as the record itself the client record so number one remember that a personal password is required
to enter & off computer files so what's the main tip never share your password gay with anyone
including other health team members last protection when I email password when you had that mobus
word southwood mold entries gay or Miley patch on my leg number or in my password need to send in I
will let you out email password I'm sure password more with my sword Nelly password move into your
password in multiple data signatures fear in your data Next up sister veena or not some fashion thing in
that in outlook in password so that could happen in the So what is this do not share your password with
anyone can imagine this you know by sometimes uncontrollable circumstances that could lead to an
error and that error maybe that hey the number 2 hey attended hey I do not know the soap opera
others may see it I'm gonna shop and I bring the money for his face strategically in the station gay they
may he says or my instances sometimes nothing more than some significant others or some other
people know that they are the different example of my information birthdate and everything or
commitment in imposing patient possibly so simple birthday now leepa careful that is why versus you
thought you named it you don't get that now area hey Shred all I needed computer generated
worksheets yes we print something we print a we print we have print outs OK so all I needed is red now
is shredded I was thinking to her boy you've seen it in movies you've seen it in soap operas that Sam not
information in the used later on so we shred it huh hey Quinn next no the facilities policies and
procedures for correcting an entry error so you will be oriented on the agency's policy file no the agent
policy went correcting and entry error hey follow agency procedures for documenting sensitive
materials such as diagnosis of aids sample it's a very sensitive topic you may invade privacy and
confidentiality of information if you do not follow agency protocol OK so if I log it so policies and
procedures can also be termed as as not a lot first hey I thi personnel must is called a firewall to protect
server from unauthorized course not shop sports no protect the data especially if it is already digital
information and we not know very advantageous month if you are taking at the same time you are also
a nurse OK is sending a single class area to hospital management information system or ID office let me
add it that numbers OK so context cervical at the same time you're also good nurse you are you can also
be employed as part of the I team or the information technology team like when I T language class and
ID language information in the beginning includes new season so one month create forms and
documents no a nurse is needed because the nurse understands how things are how things go about in
the clinical area OK so we begin class in duty as stuff nurse did I see office forms to go even get checked
some some entries no so another quality control in three someday 80 office cerner's is the fermentation
it got to the check on complete an entry some data some assessment form now I think digitally encoded
not hopefully not yeah yeah I'm gonna career OK so with advancement technology additional jobs and
expertise can also be a career path for the nurse OK so now we know you're a nurse also an IP expert
clear I'm not mine carrier flash meant to act as if you are dead so organizing validating and documenting
client data is an important part of assessment so after gathering information collecting data no we of
course a organize the data using the different models we validate the data by double checking and
verifying information and we document data properly so that concludes the first phase of the nursing
process you proceed with the diagnosis and that concludes my topic with you word assessment not
introductory fool assessment
Which of the following methods of data collection

-all of the choices are correct*******

Which of the following is consider variable data

-ECG tracing

-birthday

-blood pressure

-age#

A kind of data does not changes over time

-variable data

-overt data

-neutral data

-constant data#

Contains all of the information about a client

-database #

-medical chart

-biographical data

-physical assessment

It is a planned communication or a conversation with a purpose

-all of the above#

-observe

-interview

-examine

This is to gather data by using the senses

-examine

-observe#

-All of the above

- interview

What is the best source of data

-roommates

-clients#

-family who lives with the pt.

-mother

Which of the following is the best categorized as a sign

-dyspnea

-Pain

-Cyanosis#

-bloating

Which of the following statements is best categorized as overt data

-bp 110/80#

- nurse in charge endorses pt. had bm

- doctor tells you pl. rales on pe

-records shows history of appendectomy

Blood pressure is what kind of data

-constant

-variable#

-covert

-neutral

Repetition of questions can breed mistrust and cause annoyance for the patient

-it may or may not be true depending on the patients

-false

-true#

It is highly structured interview and elicits specific information

-neutral

-directive#

-nondirective

-open-ended

Which of the following questions should be avoided

-how did you go to the park?

-where in the park did you go?

-why did you go to the park?#

-what happened to the park?

The following are the type of interview questions except

-neutral

-all the choices are correct#

-closed

-leading

Which of the following is a constant data

-age

-sex#

-height

-weight

It is a highly structured interview and elicits specific information

-directive#

-neutral

-nondirective

-open-ended

POST TEST 2

PATIENTS AGE IS CATEGORIZED INTO WHICH COMPONENT OF THE HEALTH ASSESSMENT

-history of present illness

-chief complaint

-past history

-biographic data#

WHICH OF THE FOLLOWING ARE ATTRIBUTE OF A SYMPTOM.

- All of the choices are correct******

ALSO KNOWN AS IDENTIFYING DATA

-biographic data
-date and time

-past history#

-chief complaints

THESE DESCRIBE ANY SITUATION OR ACTION THAT WILL MAKE THE SYMPTOM

-location

-timing

-setting

-relieving#

WHICH OF THE FOLLOWING CAN BE SOURCE OF DATA

-fellow nurses

-friend

-clinical record

-all of the choices are correct#

INCLUDED CLIENTS NAME,ADDRESS ,AGE,SEX,RACE, MARITAL STATUS,OCCUPATION,RELIGIOUS

PREFERENCE,HEALTHCARE FINANCING ,AND USUAL SOURCE OF MEDICAL CARE.

-present illness

-past history

-biographic data#

-chief complaints

ONE DAY PTA ,PATIENT EXPERIENCED SUDDEN ONSET, INTERMITTENT,STABBING EPIGASTRIC PAIN
RADIATING TO THE RLQ AND LLQ LASTING FOR 15MINS,PS 10/10,PARTIALLY RELIEVED BY KNEE CHEST
POSITION, WORSENED BY FOOD INTAKE ,WITH UNDOCUMENTED FEVER ,CHILL AND NAUSEA AND
VOMITING OF 5 TIMES ,APPROX.240ML PER EPISODE OF PREVIOUSLY TAKEN FOOD THAT IS PROJECTILE
AND COFFE COLORED. IN THIS HPI WHAT WERE THE ASSOCIATED SYMPTOM?

-all of the choices are correct#

-fever

-vomiting

-nausea

INCLUDE ALL MEDICATIONS, HERBAL DRUGS, HOME REMEDIES AND EVEN TOPICS THAT WERE TAKEN
FOR THE PROBLEM

-setting
-relieving

-onset

-treatments#

SPEAKS OF WHAT OTHER SYMPTOMS ARE NOTED ASSOCIATED WITH THE MAIN PROBLEM

-location

-setting

-associated symptoms#

-character

SPEAK ON HOW LONG A SYMPTOM IS PRESENT

-setting

-timing

-location

-duration#

WHICH OF THE FOLLOWING ARE ATTRIBUTES OF A SYMPTOM

-alleviating

-all of the choices are correct#

-setting

-aggravating

THIS IS THE REASON THE PATIENT CAME TO THE HOSPITAL

-history of present illness

-past illness

-chief complaint#

-biographic data

THIS ATTRIBUTE OF A SYMPTOM ANSWERS THE QUESTION CAN YOU POINT OUT WHERE IT HURTS?

-timing

-duration

-location#

-setting

ALSO KNOWN AS IDENTIFYING DATA

-past history

-biographic data#

-date and time

-chief complaints

POST TEST 3

Which of the following information is best categorized under OB/gyn history

- I have a 28 day cycle**********

THIS THE AGE OF FIRST MENSTRUATION

-menarche#

-coitarche

-lmp

-puberty

HOW DO YOU DEFINE LMP?

-when the last menstrual period ended

-day pt. conceived a baby

-first day of the menstrual period#

-when pt. last had sexual intercourse

SPEAKS OF THE NUMBER TIMES PT.`S PREGNANCY LEAD TO PRETERM BIRTH

-para

-preterm#

-live

-gravida

WHAT DATA MUST BE ELICITED OF REGARDING HISTORY OF HOSPITALIZATION

-all of the choices are correct#

-institution admitted

-reason of admission

-date of admission

THIS THE LAST AGE OF FORST SEXUAL INTERCOURSE

-menarche
-lmp

-puberty

-coitarche#

WHAT TYPE OF LEVEL OF FUNCTIONING IS BATHING

-none of the choices are correct

-instrumental activities of daily living

-activities of daily living#

- both adl and iadl

THIS IS ALSO KNOWN AS THE PERSONAL AND SOCIAHISTORY

-lifestyle history#

-past history

-functional history

-medical history

WHICH OF THE FOLLOWING STATEMENTS ARE CORRECT EXCEPT?

-none of the choices are correct

-it is the responsibility of the nurse to organize the patients story

-the patient story often unfolds in a similar sequence as the health history#

-it is the responsibility of the nurse to arrange patients information to fit the different components of
the health assessment

WHICH OF THE FOLLOWING INFORMATION IS THE BEST CATEGORIZED UNDER MEDICAL HISTORY

-I drink 1 bottle of beer everyday

-I walk 3miles a everyday

-I take amlodipine 5mg every morning#

-my mom has diabetes

WHAT IMPORTANT INFORMATION MUST BE WRITTEN DOWN IN THE HISTORY WITH REGARD TO
MEDICATIONS EXCEPT

-dose

-brand names#

-all of the choices are correct

-timing

SPEAKS OF THE NUMBER TIMES PT.S PREGNANCY LEAD TO PRETERM BIRTH

-preterm#

-grativa

-para

-live

WHEN ELICITING HISTORY OF CONTRACEPTIVE USE WHICH OF THE FOLLOWING QUESTIONS ARE
IMPORTANT TO ASK,EXCEPT?

-when was your IUD inserted?

-when did you have your intradermal implants inserted?

-how long have you been taking pills?

-do you carry condoms?#

THIS IS THE AGE OF FIRST SEXUAL INTERCOURSE

-coitarche#

-pubertt

-menarche

-LMP

LONG QUIZZ DOC HILLADO

These are usually closed questions with short specific answer. This allows identification of the owner
of the information

- Present illness
- Past history
- Biographic data*****
- Chief complaints

Which of the following statements is best categorized as primary data

- HR of 110bpm
- Crackles says he is sad all the time
- Report her son to be sad all the time
- Patient says he is sad all the time ******

Factors that may influence how comfortable the client will be and what special arrangements might
be needed.

- All of the choices are correct******

 - Gender
- Culture
- Age

Which of the following statements is best categorized as covert data

- Crackles noted on auscultation

- Patient grimace noted
- HR of 110bpm
- Patient says he is sad all the time*****

Which of the following chronic diseases are important to note in the past medical history

- Pneumonia ********** SALA

- UTI
- Hyperlipidemia
- Cellulitis*******

Describes in what situations does the symptom occur

- Timing
- Treatment
- Setting*******
- Onset

This sound is booming in quality

- Dullness
- Flatness
- Tympany
- Hyperresonance********

This is a type of auscultation used when assessing the heart

- Indirect*********
- Direct
- Light
- Deep

This sound is booming in quality

- Tympany*****SALA
- Flatness
- Dullness
- hyperresonance

What important information must be written down in the history with regard to surgical procedures,
except

- Institution admitted
- Date of admission
 - Reason for procedure
- All of the choices are correct******

In this HPI what the quality of the symptom? One day PTA, patient experienced sudden onset,
intermitted, stabbing epigastric pain radiating to the RLQ and LLQ lasting for 15mins, PS 10/10,
partially relieved by knee chest position, worsened by food intake, with undocumented fever, chills
and nausea and vomiting of 5 times, approx.. 240ml per and coffee colored.

- Stabbing ********
- Insidious
- Epigastric
- Sudden

The best framework for PE in all situations is the head-to-toe framework

- True
- False*******

Which of the following is an PE finding of palpation

- Circular rash
- Tympanitic
- Hyperactive bowel sounds
- Soft abdomen, non tender*****

Which of the following diseases are important in an interview fir family history, except

- Hypertension
- All of the choices are correct******
- Tb
- Thyroid disease

Which of the following is true of the purpose of taking a physical assessment

- Establishing nursing diagnosis

- All of the choices are correct ******
- For baseline data
- Evaluating outcomes

Give 1 vial Diazepam IV now which are of the medical chart does this belong to?

- Daily care record*******SALA

- Physicians order form *****
- Medical history ******** sala
- Nurses notes*** sala

Wala ang 16

The best position in performing digital rectal exam

- Sitting
 - Supine
- Sims ******
- Semi-fowlers

Source of the data will help determine which of the following, except

- Quality
- All of the choices are correct******
- Reliability
- Correctness

I feel hot and sweaty every afternoon is a sentence that speaks to which attribute of a symptom?

- Timing *******
- Setting
- Relieving
- Onset

My mom gave me Vicks vapor rub when I had a stuffy nose is a sentence that speaks to which
attribute of a symptom?

- Timing
- Setting
- Onset
- Treatment******

Which of the following is true of the time in an interview, except

- Should be when there are minimal interruption

- Must be decided but the nurse *******
- When pt. is free of pain
- When pt. is free of discomfort

Which of the following is an PE finding of inspection

- Cyanosis*****
- Nodular
- Fremitus
- Dullness

When preparing a client for PE this is an important way to maintain a client’s dignity and privacy

- Draping*****
- Isolation
- Confidentiality
- Single nurse

Which of the following are component of a comprehensive health exam, except

- Chief complaint
- All of the choices are correct*****
 - Biographic data
- Data and time

What type of level of functioning is showering

- None of the choices are correct

- Both ADL and IADL
- Instrumental activities of daily living
- Activities of daily living*************

Which of the following objective data validate a subjective data of dyspnea

- Wheezing of auscultation
- Increased JVP
- All of the choices are correct****
- Increased RR

This component of comprehensive health assessment is always important and allows your assessment
to be used by future providers

- Past history**** SALA

- Biographic data********SALA
- Date and time**********
- Chief complaints

On eliciting smoking history of a 60yo pt. states, I used to smoke 10yrs ago. I usually smokes half a
pack a day since I was 18 what would be his pack yrs?

- 25 *********
- 21******ARIII
- 30
- 16

Important things to prepare in the environment before PE, except

- Should be in a private room

- Make sure the room is warm enough for pt. to be comfortable
- Organize equipment prior to starting
- Use well lighted environment using natural light at all times*****

Nurse come assess lungs and heart of patient complaining of dyspnea. This describes which type of PE

- Functional
- Specific
- comprehensive
- focused******

In this HPI what was the character of the symptom? One day PTA, patient experienced sudden onset,
intermittent, stabbing epigastric pain radiating to the RLQ and LLQ lasting for 15mins, PS 10/10,
partially relieved by knee chest position, worsened by food intake, with undocumented fever, chills
and nausea and vomiting of 5 times, approx.,240ml per episode of previously taken food that is
projectile and coffee colored.

- Epigastric pain
- PS 10/10*********
- Gnawing
- Radiating

This component of a comprehensive health assessment is always important and allows your
assessment to be used by future providers

- Date and time*******

On eliciting smoking history of a 50yo pt. states I stated smoking when I 10yo, my uncle taught me
how. I could finish 30 sticks a day what would be his pack yrs.?

- 60*********

This sound is heard best when percussing the normal lung

- Tympany
- Dullness
- Flatness
- Resonance*****

When eliciting history of contraceptive use which of the following questions are important to ask?

- What type of pills are you taking?*****

- Do you keep your condoms in your wallet?
- Have you had a pap smear?
- Is your IUD still in place?

29yo female patient came into the ER due to dizziness and pallor. As the nurse in the ER you are
taking the health history. Which of the following components of the OB/GYN history may point to the
source of the problem

- Interval
- Menarche
- Symptom
- Amount ******

A distance that the most people are comfortable with during interview is

- 2-3m
- 2-4ft
- 2-4m
- 2-3ft*******

I noticed that I am having runny nose every morning is a sentence that speaks to which attribute of a
symptom?
 - Timing**********
- Setting
- Relieving
- Onset

The review of nursing and related literature can provide additional information for the database.
Which part of literature review is involved when you research for alternatives for blood transfusion?

- Cultural and social health practices

- Information about media diagnones, treatment, and prognoses######
- Standard or norms against which to compare findings*******
- Assessment data needed for specific client condition********** ari

During the initial interview the client makes this statement I don’t understand why I have to have
surgery I’m really not that sick or in pain right now what is the nurses best response?

- What kind of questions do you have about your surgery*******

- I think these are things you should be asking your doctor
- It’s ok to be worried. Surgery is a big step
- Have you had surgery before ******SALA

A patient came in to the ER and OB history revealed my first baby was born at 28wks and had to stay
in an incubator for long time …………..

- G2P1(1011)****** CORREK NI SA KAY KEITH PRO SA KAY YVON WRONG IDK

- G2P1(0111)******

Which of the following is true of treatments

- May show any drug interactions that may occur with medications given in the hospital
- All of the choices are correct ***********
- May show possible organ injury to watch out for
- Mat show possible increased risk of bleeding

Which of the following circumstances where open-ended questions would be best suited

- When there is an abundance of time*********

- Taking the past medical history****SALA
- All of the choices are correct******SALA
- Emergent situation

Describe the type of and the severity of the symptom

- Character*******

Speaks of any situation or action that will worsen the symptom

- Aggravating******
- Location
- Associated symptoms
- Character
Which of the following information is best categorized under past history

- All of the choices are correct*****

- I have a measles before
- I completed 6 months of TB treatment
- I got vaccinated for hepatitis B

Which element is best categorized as secondary subjective data?

- Client states severe pain when walking up stairs

- The nurse measures a weight loss of 10 pounds since the last clinic visit
- Spouse states the client has lost all appetite******
- The nurse palpates edema in lower extremities

Speaks of when the symptom occurs

- Relieving
- Location
- Setting
- Timing*******

This component of health assessment answers the question. Describe the reason you came to the
hospital or clinic today.

- Chief complaint *******

- Past illness
- History of present illness
- Biographic data

Which of the following information is best categorized under surgical history

- My father brought me for a check up for a swollen nodule when I was a child
- I had a cyst removed last year****
- None of the choices are correct
- I had leukemia when I was 10yo

A kind of data that change over time

- Variable data*****
- Constant data
- Neutral data
- Overt data

The finger that strikes the nondominat hand in contact with the body surface in order to produce a
sound

- Direct
- Indirect
- Pleximeter
- Plexor *******
Most important in determining data that can be taken from an intraoperative technique that speaks
of what was seen while doing the procedure

- Blood loss
- Devices intraoperative findings****
- Vital sign

Which statement would be true regarding use of observing method of data collection?

- When observing the nurse uses only the visual sense

- Observing is done only when no other nursing interventions ae being performed at the same
time
- Data should be gathered as they occur, rather than in any particular order
- Observed data should be interpreted in relation to other sources of collected data*******

On history taking pt. says the last day of her last menstrual period was on jan 10 and lasted only 5
days. What is her LMP?

- 6-jan*****
- 11-jan
- 10-jan
- 15-jan

I have vomiting and abdominal pain is a sentence that speaks to which attribute of a symptom?

- Associated symptoms********
- Setting
- Character
- Location

This sound is heard when percussing an emphysematous lung

- Dullness
- Tympany
- Flatness
- Hyperresonance*****

Which of the following is best categorized as a symptom

- Peripheral edema
- HR 76
- O2sat 98%
- Pain*******

Which of the following is the best categorized as a sign

- Bloating
- Dyspnea
- Cyanosis*******
- pain
A patient come in to the ER complaining of abdominal pain, upon pregnancy test it was positive. Upon
OB history patient is adamant that she has never has sexual partner prior to her boyfriend whom she
met 3months before. What would be her OB history?

- G1P1(0000)
- G1P1(0010)
- G1P0(0000)*****
- G0P0(0000)

Which of the following information would be best categorized in the past illness

- All of the choices are correct

- my father has cancer
- I used to have crippling sadness and was given medications for it********
- I smoke 2packs per day

My stomach hurts and feel awful is a sentence that speaks to which component of the health
assessment?

- Chief complaint *******

- Past illness
- History of present illness
- Biographic data

This best sound heard when percussing the liver

- Dullness *****
- Tympany
- Flatness
- Hyperresonance

In this HPI what was the duration of the symptom? One day PTA experienced sudden onset,
intermittent, stabbing epigastric pain radiating to the RLQ and LLQ lasting for 15mins, PS 10/10,
partially relieved by knee chest position, worsened by food intake, with undocumented fever, chills
and nausea and vomiting of 5 times, aprrox 240ml per episode of previously taken food that is
projectile and coffee colored.

- Intermittent
- 15mins*****
- 5x
- None of the choices

Which of the following is considered a variable data, except

- Birthday******8

On history taking pt. says the last day of her menstrual period was on jan 3 and lasted only 3 days.
What is her LMP?

- 6-JAN
 - 1-jan********
- 3-jan
- 4-jan

When eliciting alcohol history which of the following information is important

- How pt. drinks

- How often pt. drinks*****
- Where pt. drinks
- All of the choices are correct

A conscious, deliberate skill that is developed through effort and with an organized approach

- Examining
- All of the choices are correct
- Observing*********
- Interviewing

Which of the following is the part of the history involving literature review for information about
medical diagnoses, treatment and prognoses

- Refusal of chemotherapy*******SAL
- Female circumcision ****SALA
- Refusal of blood transfusion and other blood product******
- Cardiac aneurysmal rupture for Kawasaki patient

Which of the following is true when choosing a place for interview

- Must be will lit*******

- Should be in a closed curtained area
- In clear view of the door
- Should be in a closed space

What type of level of functioning is taking tablets

- Both ADL and IADL******SALA

- Activities of daily living**********
- None of the choices are correct*****SALA
- Instrumental activities of daily living******SALA

Speaks of the number times pt pregnancy lead to birth

- Live
- Gravida
- Term
- Para********

What happened this question can best be categorized as

- Leading
- Open-ended******
 - Closed
- None of the choices are correct

The following are contents of the past medical history

- Immunization history*******
- Father dies of cancer
- Use of illicit drugs
- All of the choices are correct

The patient is vague when describing symptoms, and the details are confusing is a sentence that
speaks to which component of the health assessment?

- Reliability ********8
- Client
- Source
- Questions

Examination of the body using the sense of touch

- Inspection
- Auscultation
- Palpation********
- Percussion

My pain starts in the back and goes to the front is a sentence that speaks to which component of the
health assessment?

- Chief complaint
- Biographic data
- History of present illness******
- Past history

This attribute of a symptom is always important in diagnosis and therefore in determine urgency of
management and kind of management

- Duration******
- Timing
- Location
- Setting

Important things to prepare in the environment before PE, except

- Make sure the room is warm enough for pt. to be comfortable

- Nurse should set time that is convenient for the nurse ********
- Should be in private room
- Organize equipment prior to starting

Which of the following is the main reason for receiving verbal reports from other healthcare
professionals
 - Accurate medical records
- Sharing of information
- Completeness of record
- Continuity of care********

Each interview is influence by which of the following

- Time
- Language
- All of the choices are correct******
- Seating

Which of the following is true of history present illness

- All of the choices are correct******

- Complete
- Clear
- Chronologic

It is a complete, clear and chronologic description of the problems prompting the patients visit

- Biographic data
- Past history
- Chief complaint
- History of present illness******

What type of level of functioning is calling the doctor

- Both ADL and IADL

- None of the choices are correct
- Instrumental activities of daily living******
- Activities of daily living

Which of the following is the correct sequence of organizing observation

- Signs of distress> equipment> safety> surroundings

- Signs of distress> safety> surroundings> equipment
- Signs of distress> safety> equipment> surrounding******
- Safety> signs of distress> equipment> surroundings

Which of the following are sources of secondary data except

- Mother
- Chart
- All of the choices are correct*****
- Other healthcare workers

This is instrument is used in examining the external ear canal

- Tuning fork
- Percussion hammer
 - Otoscope******
- Ophthalmoscope

Which of the following information is important to record in the family history

- All of the choices are correct****

- Age at which family members die
- Cause of deaths
- Presence of chronic disease

Speaks of the number times pt pregnancy lead to full-term birth

- Live
- Para
- Term****
- Gravida

Post Test Topic 4 Data Collection Physical Assessment

1. 3 types of physical examination, except

-specific
2. parts of the medical PPE
-all of the choices are correct
3. a type of percussion best suited for examining adult sinuses
- direct
4. this is instrument is used in examining parts of the retina
-ophthalmoscope
5. a type of PE the examines a body system or a body area
- focused
6. a type of PE where all body system is assessed
-comprehensive
7. this sound is heard best when percussing the stomach
-tympany
8.. the two major components of nursing care
- health history and PE
9. what are the two type soft percussion
-direct and indirect
10. assessing by using the sense of sight
-inspection
11. this sound drum like in quality
-tympany
12. a type of PE that examines one or more aspects of the clients abilities
- functional
13. the following are the methods of examining
- all of the choices are correct