TSU-DEPARTMENT OF NURSING BATTERY EXAMINATION (JULY 2019)

Reviewer in Health Assessment (Lecture)

Health Assessment – is an evaluation of the health status of an individual performing a physical examination
after obtaining a health history.
➢ The techniques used in health assessment include:
INSPECTION – uses the senses of sight and smell, done by observation.
PALPATION – deep and light, uses the hands to determine swelling, masses, areas of
pain.
PERCUSSION – direct and indirect, tapping your fingers to elicit sounds.
AUSCULTATION – involves listening using stethoscope.
TYPES OF HEALTH ASSESSMENT
1. Initial Assessment – also known as triage, helps determine the nature of the problem.
*SUBJECTIVE DATA – symptoms; client’s point of view (S for SINABI NG PASYENTE)
*OBJECTIVE DATA – signs; measurable data like vital signs and etc. (O for na-OBSERVE MO SA
PASYENTE)

Try to answer:
Write S for subjective, otherwise write O for objective.
1. 120/80 mmHg –
2. “nahihilo po ako” –
3. “masakit po tiyan ko”
4. CBC, Hepatitis B Tests -
5. “nasusuka po ako”

2. Focused or Problem Oriented Assessment – The focused assessment is the stage in which the problem is
exposed and treated. Due to the importance of vital signs and their ever-changing nature, they are continuously
monitored during all parts of the assessment.
3. Time-lapsed Assessment - During the time-lapsed assessment, the current status of the patient is compared
to the previous baseline during and prior to treatment.
4. Emergency Assessment - During emergency procedures, a nurse is focused on rapidly identifying the root
causes of concern for the patient and assessing the airway, breathing and circulation (ABCs) of the patient.

FOUR MAIN GOALS OF NURSING

1. To promote health (state of optimum functioning or well-being with physical, social, spiritual, and mental
components)
2. To prevent illness (primary, secondary, and tertiary)
3. To treat human responses to health or illness
4. To advocate for individuals, families, communities and populations.

PHYSICAL EXAMINATION
- Is a routine where the primary care provider performs to check the overall health of the patient.
- Physical Examination is performed to SICK and HEALTHY individuals.

MATERIALS USED IN PHYSICAL EXAMINATION

Consent form (legal person/s)
Quiet, room with privacy
Inquisitive and sensitive mind
Mastery of the Techniques (O, P, P, A)
Tools required

POSITIONING
Proper positioning of patients protects them from complications such as nerve damage and accident such as
falls.

Different positions
1. Fowler’s - is a bed position wherein the head and trunk are raised 40 to 90 degrees.
2. Orthopneic or Tripod - Orthopneic or tripod position places the patients in a sitting position or on the side
of the bed with an overbed table in front to lean on and several pillows on the table to rest on.
3. Dorsal Recumbent Position - A position in which the patient lies on the back with the lower extremities
moderately flexed and rotated outward.

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4. Supine - lying on the back or with the face upward
5. Prone - lying flat, especially face downward.
6. Lithotomy - a supine position of the body with the legs separated, flexed, and supported in raised stirrups,
originally used for lithotomy and later also for childbirth.
7. Sim’s position - is usually used for rectal examination, treatments, and enemas. It is performed by having a
patient lie on their left side, left hip and lower extremity straight, and right hip and knee bent. It is also called
lateral recumbent position.
8. Knee-chest - a prone position in which the individual rests on the knees and upper part of the chest, assumed
for gynecologic or rectal examination.
9. Standing - the parallel stance is a subordinate position where the legs are straight and the feet are placed
closely together.

DIAGNOSTIC/LABORATORY PROCEDURES
- A medical test/procedure performed to detect, diagnose, or monitor diseases, disease processes,
susceptibility or to determine a course of treatment.
Different tests:
➢ Blood examination
▪ Blood sugar, blood chemistry, blood typing, arterial blood gas level, presence of infection
in the blood
*OCCULT BLOOD TEST - the fecal occult blood test (FOBT) is a lab test used to
check stool samples for hidden (occult) blood.
➢ URINE ANALYSIS
▪ Components of urine, acidity
➢ FECAL/STOOL ANALYSIS
▪ Presence of parasites (worms, ascaris)
➢ CULTURE AND SENSITIVITY
▪ Determining the treatment of a certain disease
➢ TISSUE SAMPLE TEST
▪ Biopsy (benign (B for BAIT. Mabait si Benign) and malignant (cancerous))
➢ SCAN/RADIOLOGICAL EXAMINATION
▪ X-ray, MRI, CT (computed tomography) scan, Mammography, Bone Scan

PATIENT CHART
- Also known as MEDICAL CHART
- It comprises of demographics, diagnosis, medications, treatment plans, progress notes.
- It also includes of surgical history, family history, social history

NURSING DOCUMENTATION
- Record of nursing care that is planned and delivered.
- Uses as a communication to other health care providers
- It follows the Nursing Process (ADPIE)

PURPOSES:
1. A form of communication with other professionals.
2. Credentialing
3. Legal Purposes
*SUBPOENA DUCES TECUM – a command by the court to witness to produce documents.
4. Regulation and Legislation
5. Research

FORMATS:
1. Written
2. Electronics Health Records (EHRS)

GUIDELINES:
In addition to ensuring clear, concise and accurate documentation, there are some fundamental rules of
documentation.
• Use permanent ink and ensure your writing is legible – this may require you to print. This is an issue of patient
safety as illegible writing can be misinterpreted and may not bring value to client care.
• Never leave blank lines as it may allow someone to add incorrect information to empty spaces.
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 • Events should be recorded chronologically (or sequentially and logically).
• Document in a timely manner, meaning as close to real time as possible in order to ensure accuracy of details
and timely communication to the team.
• Do not chart in advance of the event or care provided. Pre-charted information is not credible or accountable.
• Include your signature and designation on each entry in both hand written and electronic formats.
• Use professional language and terminology.
• Avoid using abbreviations. Abbreviations may not be understood or may be misinterpreted.
• Only include notes of the care you provided. An exception to this rule may occur in the role of designated
recorder during emergency event. Please check your organizational policy.
• Do not include bias (document only conclusions that can be supported by data)

WHAT IS NOT DOCUMENTED/WRITTEN IS CONSIDERED UNDONE!

HOLISTIC NURSING ASSESSMENT

Holistic - is characterized by comprehension of the parts of something as intimately interconnected and

explicable only by reference to the whole.

Holistic Health Assessment – it goes beyond focusing solely on physical health. It also addresses emotional,
mental, and spiritual health.

ASPECTS OF HOLISTIC HEALTH ASSESSMENT

1. Physiological – physical
✓ VITAL SIGNS also known as CARDINAL SIGNS
▪ Temperature
o 37°C - normal (accdg. To the Academy of Family of Physicians)
o Rectal is more accurate!
o Hypothalamus – the temperature center!
o Celsius to Fahrenheit - °F = (Temp in °C) x 1.8 + 32
o Fahrenheit to Celsius - °C = (Temp in °F) – 32 / 1.8
▪ Pulse rate
o 60-100 beats per minute – normal
▪ Respiratory Rate
o 12-20 breaths
o per minute – normal
▪ Blood Pressure
o 120/80 mmHg
o 120 is the systolic where the heart contracts; 80 is the diastolic where the
heart is at rest.
▪ Pain
o Considered as the Fifth vital sign
Pain Assessment
• Numerical Pain Scale – 0-10;
0 – no pain
1-3 – mild
4-6 – moderate
7-10 - severe
• Wong-Baker Faces Pain Scale – for children
• FLACC Scale
F- face
L- leg
A – activity
C- cry
C – consolability
• Color Analog Scale – with color
Blue – no pain
Red - pain
2. Psychological – potential stressors
3. Sociological – patterns of social relationship and social interaction
4. Developmental – cognitive development

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5. Spiritual – religious and spiritual practices
6. Cultural – special diet, values or culture-specific requests
7. Nutritional Status – respects influence by diet and levels of nutrient in the body.

PATIENTS BILL OF RIGHTS

*no need to memorize, just understand what are the rights of your patients. 😊

DATA PRIVACY ACT

- Republic Act No. 10173 series of 2012

CARING, INTEGRITY, DIVERSITY & EXCELLENCE – four main goals of Nursing (don’t be confused sa
nauna kanina na four main goals. Be familiar with this!)

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Author’s Note:
- Written here are just my lecture notes from my HA Lec class last semester, you can also add some
references if you want to! Happy Reviewing! 😊

IF YOUR HEART BEATS FOR NURSING, CHASE IT

EVEN MORE! I KNOW YOU CAN MAKE IT!
Go, TSUian Nightingale! PAYTTTTT! 😊

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