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Health Assessment

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12 views3 pages

Health Assessment

Uploaded by

4lona.school
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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HEALTH ASSESSMENT Lec 1

* Nursing Process (ADOPIE)


1. Assessment
-> collecting detail
2. Diagnosis
-> functional-related diagnosis
3. Outcome/s identification
4. Planning
5. Implementation
6. Evaluation

* D-I-K-W
- the more we enrich our data with meaning and context, the more knowledge and insights we
get out of it. At the top of the pyramid, we have turned the knowledge and insights into a
learning experience that guides our actions.

1. Data (raw data) - is a collection of facts in a raw or unorganized form such as numbers
or characters
2. Information - This is data that has been “cleaned” of errors and further processed in a
way that makes it easier to measure, visualize and analyze for a specific purpose. By
asking relevant questions about ‘who’, ‘what’, ‘when’, ‘where’, etc., we can derive
valuable information from the data and make it more useful for us.
3. Knowledge - “How” is the information, derived from the collected data, relevant to our
goals? “How” are the pieces of this information connected to other pieces to add more
meaning and value? And, maybe most importantly, “how” can we apply the information
to achieve our goal? When we don’t just view information as a description of collected
facts, but also understand how to apply it to achieve our goals, we turn it into knowledge.
4. Wisdom - In other words, wisdom is knowledge applied in action.

I. Nursing Assessment

A. Client's profile / Patient's profile / Demographic data


* purpose of getting client's profile: to identify health related risk factors

1. name
2. age
3. birthdate / place of birth
4. gender (biological gender)
why? because there are certain disease that are only present in male only or female
5. nationality / ethnicity
nationality -> can't be changed
6. citizenship
-> can be changed
7. religion
8. civil status
9. address
- current address
- residential address
- permanent address
- occupational address
10. educational attainment
*why? to know kung paano mo iexplain sa kanila yung gagawin or situation according to their
level of education
11. Next of Kin (NOK) / Significant Other (SO)
12. Contact information
- phone number
- email
13. admission date / admission time
14. admitting / attending M.D. (doctor of medicine / physician)
I I
resident consultant

B. Chief Complaint/s / Reason/s for Seeking Health Care


purpose: to provide information about the current health problem
ex.
chest pain (masakit ang dibdib ko)
difficulty of breathing / dyspnea (nahihirapan ako huminga)

C. Health History / Client History


Purpose: is to gather subjective data from the patient and/or the patient's family to create a plan
that will promote their health and to address the health related risk factors

1. history of present illness (HPI) / history of present complaint (HPC)


* describe how the chief complaint transpired
*OLDCARTAM
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Treatment/s taken (if any)
Associated signs / symptoms
signs vs. symptoms
- objective - subjective
ex. ex. pain
Meaning of complaint / Impact of complaint

2. past medical history


3. heredofamilia history / family history
4. socio-environmental / socio-occupational history

* Assignment
1. COLDSPA
Character - describe the sign or symptom (how does it feel, look, sound, smell, etc.)
Onset - when did it begin?
Location - where is it? does it radiate?
Duration - how long did / does it last?
Severity - rate pain from 1-5, how bad is it?
Pattern - what makes it better or worse?
Associated factors - other symptoms that occur with it?

Additional information:
* medulla oblongata - thirst center

* Why do diabetics have polyphagia?


- Without enough insulin, glucose builds up in your blood, causing hyperglycemia (high blood
sugar). Glucose (sugar) is the main form of energy your body uses from the food you eat.
Without enough insulin, your body can't use glucose for energy. This lack of energy usage
causes an increase in hunger.

* Why do diabetics have polyuria?


- If the level of glucose in the blood becomes too high, excess glucose is removed from the
blood by the kidneys and excreted via the urine (glycosuria). This results in greater urine
production and causes the patient to urinate frequently.

* Why do diabetics have polydipsia?


- When blood glucose levels get high, your kidneys produce more urine in an effort to remove
the extra glucose from your body. Meanwhile, because your body is losing fluids, your brain tells
you to drink more in order to replace them.

* progesterone
- hormone of pregnancy
* estrogen
- hormone that gives the features of females like big hips, boobs, etc.

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