Health Assessment (Lecture)

STUDENT ACTIVITY SHEET BS NURSING / FIRST YEAR

Session # 1

Materials:
LESSON TITLE: Introduction to Health Assessment Book, pen and notebook, index card/class list
LEARNING OUTCOMES:
Upon completion of this lesson, the nursing student can:

1. Learn the definition of health and health assessment and

how it is practiced in the field of nursing; References: Bates’ Nursing Guide to Physical
2. Identify the five steps of the nursing process and how they Examination and History Taking (Second Edition)
are applied in all aspects of nursing; by Beth Hogan-Quigley, Mary Louise Palm, and
3. Enumerate and describe the types of health assessment Lynn Bickley.
and to differentiate them from one another.

SUBJECT ORIENTATION (10 minutes)

Your classroom instructor for this subject, Health Assessment (Lecture) ____________________________.
Listed below are the additional information vital in orientation:

1. The calendar of activities for major examinations must be relayed.

2. Classroom rules and regulations will be informed per the instructor’s discretions.
3. Computation of grades specific for this subject must be thoroughly explained to students.
4. The essence and significance in grade computation of these modules must be introduced.
5. If this is the first subject of the class, the instructor must initiate an election for block officers.
6. Any other information that will be deemed necessary by the instructor must be properly coordinated to the class.

MAIN LESSON (50 minutes)

The students will study and read Chapter 1 of their book about this lesson:

Definition of Health
• Health is a relative state in which a person is able to live to his or her potential and includes the “7 facets”:
• Physical health – how the body works and adapts
• Emotional health – positive outlook and emotions channelled in a healthy manner
• Social well-being – supportive relationships with family and friends
• Cultural influences – favorable connections to promote health
• Spiritual influences – living peacefully, morally, and ethically
• Environmental influences – favorable conditions to promote health
• Developmental level – how one thinks, solves problems, and makes decisions
• Health is a sum of these facets and is not solely defined as the absence of disease or eating right, but rather by
the contribution of all dimensions.

Health Assessment
• The nursing health assessment entails both a comprehensive health history and a complete physical examination,
which are used to evaluate the health and status of a person.
• The nursing health assessment involves a systematic data collection that provides information to facilitate a plan
to deliver the best care for the patient.
• The first part of health assessment is the health history, which also incorporates the “7 facets”.
• The nurse asks pertinent questions to gather data from the patient and/or family. Past medical records may also
be used to collect additional information.
• Learning about the patient’s physical and psychological issues, social and cultural associations, environment,
developmental level, and spiritual beliefs contribute to the history.
• The second component of the health assessment is the physical examination.
• The nurse uses a structured head-to-toe examination to identify changes in the patient’s body systems.

1 of 4
 • An unusual or abnormal finding may support the history data or trigger additional questions.
• The purpose of the nursing health assessment is to determine the patient’s health status, risk factors, and need
for education as a basis for developing a nursing plan of care.
• The NURSING PROCESS is the ability of the nurse to extrapolate the findings, prioritize them, and finally
formulate and implement the plan of care is the overall goal.
• The information obtained throughout the health assessment should be documented in a clear, concise manner.
This information is collated in the patient’s medical records.

NURSING PROCESS
• The nurse uses the NURSING PROCESS (a problem-solving process) to identify patient problems; set a goal and
develop an action plan; implement the plan; and evaluate the outcome.

• The NURSING PROCESS steps are:

• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation

• Assessment – it is the first step of the nursing process. It is the subjective and objective data gathered during the
initial health history and physical examination and collected on each patient encounter.
• Diagnosis has a nursing focus and is based on real or potential health problems or human responses to health
problems. The nurse uses clinical reasoning to formulate diagnoses based on the assessment data and the
patient’s problem list.
• Planning is devising the best course of action to address the patient’s diagnoses. During planning, the nurse and
patient select goals for each diagnosis in order to alleviate, decrease, or prevent the problems addressed in the
nursing diagnosis.
• Implementation of the interventions can be completed by the patient, the family, or members of the health care
team. The interventions should clearly relate to the nursing diagnosis and the planned goals.
• Evaluation is a continuing process to determine if the goals have been attained. The nursing care plan is revised
based on the patient’s condition and whether the goals are realistic or appropriate for the patient.
.

Types of Health Assessment:

• The admission of a new patient to a clinic, hospital, long-term care facility, or visiting nurse agency usually
requires a comprehensive health assessment.
a. A focused or problem-oriented assessment is where the nurse focuses on gathering information about the
patient’s problem.

• A follow-up history is a form of a focused assessment.

• An emergency history is the data collection which focused on the patient’s emergent problem with a systematic
prioritization of need beginning with the ABCs of airway, breathing, and circulation.

CHECK FOR UNDERSTANDING (10 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:

Multiple Choice

1. The phase of the nursing process where the nurse establishes both the short-term and the long-term goals for the
patient
a. Assessment
b. Diagnosis
c. Planning
d. Diagnosis

RATIONALE:

2 of 4
 2. This is the ability of the nurse to extrapolate the findings, prioritize them, and finally formulate and implement the
plan of care is the overall goal
a. Health history
b. Health assessment
c. Physical examination
d. Nursing process

RATIONALE:

3. Which of the following facets of health is demonstrated if the patient feels very much optimistic about the results
of her pregnancy?
a. Spiritual influences
b. Physical health
c. Cultural influences
d. Emotional health

RATIONALE:

4. When the patient is communicative with her friends with regard to his marital problems which facet of health is
being applied here?
a. Spiritual influences
b. Environmental influences
c. Cultural influences
d. Social well-being

RATIONALE:
5. When the patient is identifying a solution to financial problems in order to be rid of her financial stresses the
patient is demonstrating which of the following facets of health?
a. Emotional health
b. Developmental level
c. Physical health
d. Social well-being

RATIONALE:

6. Which of the following is NOT true about the assessment phase of the nursing process?
a. Subjective and objective data are gathered
b. It ends when doing the nursing diagnosis
c. It is the first step of the nursing process
d. It continues throughout the entire patient encounter

RATIONALE:

7. Which of the following is NOT true about the nursing diagnosis?

a. It has a nursing focus
b. It is based on real or potential health problems
c. It determines the medical diagnosis of the patient
d. It sets the stage for the remainder of the care plan

RATIONALE:

8. Which of the following best describes problem-oriented assessment?

a. The nurse focuses on gathering information about the patient’s problem.
b. This allows the nurse to obtain a full picture of the patient’s health status and current problems.
c. The nurse here gathers data to evaluate the outcomes of the plan of care
d. The data collection is focused on the patient’s emergent problem

3 of 4
RATIONALE:

9. Which of the following best describes follow-up history?

a. The nurse focuses on gathering information about the patient’s problem.
b. This allows the nurse to obtain a full picture of the patient’s health status and current problems.
c. The nurse here gathers data to evaluate the outcomes of the plan of care
d. The data collection is focused on the patient’s emergent problem

RATIONALE:

10. This is the phase of the nursing process where the nurse determines whether the goals made for the patient have
been attained
a. Nursing diagnosis
b. Planning
c. Implementation
d. Evaluation

RATIONALE:

LESSON WRAP-UP (10 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: Turn and talk

(Students turn to talk partner/s to – find out, summarize, clarify, share ideas, point of view or opinions)

(For next session, read on the chapter about the steps on health assessment)

4 of 4