JOSE RIZAL UNIVERSITY

COLLEGE OF NURSING HEALTH & SCIENCES

In Partial Fulfilment of the Requirements for the Activity:

Assessment Data: (P)

NUR C102 – 103N – GROUP 2

Submitted by:
Estupa, Melshequeen
Fiestada, Ira Shaine
Florentino, Aira Mae
Hicban, King Aldrin
Lariosa, Jesli Khaine
Ligaya, Je-Anna Francesca
Lopez, George Valerie
Lozada, Charles Nathaniel T.
Lucero, Erich Venice
Lumbo, Alexa Guinevere
Madali, Althea Joyce

Submitted to:
Ma’am Russel Z. Pantaleon
PROFESSOR

May 8, 2024
Describe a patient assessment including its purpose?

Assessing is the systematic and continuous collection, organization, validation, and

documentation of data. Assessing is a continuous process carried out during all phases of
the nursing process. Its purpose is to establish a database about the client's response to
health concerns or illness and the ability to manage healthcare needs.

When and by whom is an assessment carried out?

An assessment is carried out whenever a patient enters a facility, which provides a
service to assist the patient achieve or maintain optimal health and continues while the patient
resides in that facility. Assessments are carried out upon admission, emergence of episodic
health problems, changes in health status or upon the request of paraprofessionals, etc.
Various members of the healthcare team such as nurses, doctors, physiotherapists,
nutritionists, social workers, etc. carry out assessments. Their findings complement each
other. The LPN’s collaborative role in assessment is articulated in the practice expectations
document.

What possible sources of information does the nurse use to complete an assessment?

To complete an assessment, the nurse uses different possible sources of information,

this includes doing a physical examination, interviewing the patient, patients’ health
history/record, also by obtaining information from the patient's family and general observation
made by the nurse.

Differentiate the four basic types of assessment.

The four basic types of nursing assessment are:
● Initial comprehensive assessment involves collection of subjective data about the
client's perception of his or her health of all body parts or systems, past health history,
family history, and lifestyle and health practices (which includes information related to
the client's overall function) as well as objective data gathered during a step- by-step
physical examination.
● Ongoing or Partial Assessment of the client consists of data collection that occurs
after the comprehensive database is established. This consists of a mini overview of
the client's body systems and holistic health patterns as a follow-up on health status.
● Focused or Problem-Oriented Assessment does not replace the comprehensive
health assessment. It is performed when a comprehensive database exists for a client
who comes to the health care agency with a specific health concern.
● Emergency Assessment is a very rapid assessment performed in life-threatening
situations. The data collection is focused on the patient's emergent problem with a
systematic prioritization of need beginning with the ABCs of airway, breathing, and
circulation.
What is the difference between subjective and objective data? Provide three examples
of each.

Subjective data in nursing are collected from sources other than the nurse's
observations. This type of data represents the patient's perceptions, feelings, or concerns as
obtained through the nursing interview. The patient is considered the primary source of
subjective data. Other sources, including the patient's family or caregivers, and other
members of the healthcare team, are called secondary sources.

Any information the patient provides should be included in the subjective nursing
assessment data. Keep in mind that subjective data is information relayed to the nurse as
experienced or felt by the patient. It is vital for nurses to be careful to document everything
the patient says. For example, feelings, concerns, or the patient's perception of his well-being
are each important. In some cases, and as you will observe in a few examples later in this
article, all subjective data should be recorded. Even if the data may seem incorrect in
someone else's view, if the patient feels it, says, or perceives it, it should be documented as
subjective nursing data.

Examples:
● “My abdomen hurts.”
● “It started last night after dinner.”
● “I can feel the discomfort in my abdomen specifically in the lower part.”

While objective data in nursing refers to information that can be measured through
physical examination, observation, or diagnostic testing. Examples of objective data include,
but are not limited to, physical findings or patient behaviours observed by the nurse,
laboratory test results, and vital signs.

Objective nursing data is an essential part of patient assessments. Objective data is

the view of the patient's status through the eyes of the assessing nurse. While a patient may
state, "My stomach hurts," the nurse may observe changes in his vital signs or abnormal lab
results that signal abnormal changes in the patient's body and give practitioners an idea of
where to start the diagnosis process.
Examples:
● Blood Pressure
● Body Temperature
● Complete Blood Count
What are the physical examination techniques used to complete an assessment?
Describe each.

POSITIONING THE CLIENT

Supine position- Used to examine the head, neck, chest, abdomen, and extremities.
Prone position- Posterior head, back buttocks, and extremities.
Dorsal recumbent- External genitalia inspection, vaginal examination, rectal, urinary
catheter insertion.
Lithotomy- Internal pelvic examination, obstetric delivery, bladder examination, rectal
examination.
Sim’s position- Rectal, vaginal, rectal temp, suppository insertion, enema administration.
Knee chest position- Rectal and lower intestinal, prostate gland
Modified standing- prostate gland.
To conduct a systematic head-to-toe assessment, you must first understand the four
basic assessment techniques. These techniques include inspection, palpation, percussion,
and auscultation.
● Inspection involves using the senses of vision, smell, and hearing to observe
and detect any normal or abnormal findings. This technique is used from the
moment that you meet the client and continues throughout the examination.
Inspection precedes palpation, percussion, and auscultation because the latter
techniques can potentially alter the appearance of what is being inspected.
Although most of the inspection involves the use of the senses only, a few body
systems require the use of special equipment (e.g., ophthalmoscope for the
eye inspection, otoscope for the ear inspection).
● Palpation is the process of using parts of the hand to touch and feel for the
following characteristics: texture, temperature, moisture, mobility, consistency,
pulse strength, size, shape, and tenderness. The four types of palpation follow:
Light palpation: There should be very little or no depression (less than 1 cm).
Feel the surface structure using a circular motion. This technique to feel for
pulses, tenderness, surface skin texture, temperature, and moisture. Moderate
palpation: Depress the skin surface 1 to 2 cm (0.5 to 0.75 in) with your dominant
hand, and use a circular motion to feel for easily palpable body organs and
masses. Deep palpation: Place your dominant hand on the skin surface and
your nondominant hand on top of your dominant hand to apply pressure. This
should result in a surface depression between 2.5 and 5 cm (1 and 2 in). This
allows you to feel very deep organs or structures that are covered by thick
muscle. Bimanual palpation: Use two hands, placing one on each side of the
body part (e.g., uterus, breasts, spleen).
● Percussion is the process of tapping body parts to produce sound waves.
These sound waves, or vibrations, allow the examiner to evaluate the
underlying structures. The three types of percussion are direct, blunt, and
indirect. Direct percussion is the direct tapping of a body part with one or two
fingertips to elicit possible tenderness (e.g., tenderness over the sinuses). Blunt
percussion is used to detect tenderness over organs (e.g., kidneys). Indirect or
mediate percussion is the most commonly used method of percussion. The
 tapping done with this type of percussion produces a sound or tone that varies
with the density of underlying structures.
● Auscultation is a type of assessment technique that requires the use of a
stethoscope to listen for heart sounds, movement of blood through the
cardiovascular system, movement of the bowel, and movement of air through
the respiratory tract. A stethoscope is used because these body sounds are not
audible to the human ear. The sounds detected using auscultation are
classified according to the intensity (loud or soft), pitch (high or low), duration
(length), and quality (musical, crackling, raspy) of the sound.

NOTE: Remember to use the COLDSPA mnemonic (Character, Onset, Location, Duration,
Severity, Patterns, and Associated Factors) to investigate and collect information for each
symptom the client shares.

What skills and abilities do the nurse have to carry out an effective assessment?

1. Resourcefulness
Bedside patient care — and the illnesses that put patients in the hospital — is a complex
process, involving both the treatment of the root disease and promotion of wellness. You will
discover through your career how much little adjustments and learned strategies will help you
provide better care.

2. Creative Problem Solving

Whether you’ve learned to fix the printer with a barbecue skewer or tighten a screw in your
desk chair with a dime, you probably already have the kind of creative problem-solving it takes
to be a nurse. Every patient will present a unique challenge to you, and you must be able to
approach each one with your problem-solving and creativity skills ready.

3. Intuition
You know what people are going to say before they say it. You anticipate the needs of others
before they ask. You can keep track of unique patterns and stay ahead of your work. This
kind of professional intuition is what separates life-changing nurses from the rest, and it will
serve you well for the rest of your nursing career.

4. Confidence
To be able to trust your intuition, you must have confidence in yourself and your ability to
make sound decisions. To gain this confidence in your nursing abilities, you must attend a
quality nursing program.

5. Self-Discipline
Our most successful nursing students are highly self-disciplined and make a priority out of
spending regular, focused time on their coursework. This carries over into successful
professional nursing, as our students refuse to cut corners or compromise their patients’ care,
down to the last dressing change five minutes before a shift ends.
6. Good Assessment Abilities
Can you look at a problem, immediately pick it apart, and solve the issue? If the answer is
yes, then you have good assessment skills. Sometimes patients are not able to give you a
detailed description of their problem, and you must figure out what’s causing their distress
with a minimal number of questions. Your attention to detail will help piece together what
could be the cause of the patient’s pain. Good assessment skills separate superior nurses
from the average.

7. Communication
Are you good at getting people to speak to you about personal issues? This is a great skill to
have, especially when it comes to dealing with a patient. You’ll have patients who are more
than able to answer questions if the right ones are asked. Don’t be afraid to rephrase
questions and keep digging until you find the source of the issue that landed them in the
hospital.

8. Compassion
When you turn on the television and see someone’s sad story, you may imagine yourself in
that person’s shoes. This is something you must do often as a nurse. It goes beyond inserting
a proper IV or delivering medicine. You treat patients the way you would want to be treated,
and to do that you have to empathise with them. It’s about more than just an illness or injury;
it’s about helping and healing the whole patient — mind, body, and spirit.

9. Time Management
Nurses juggle multiple patients during a shift. Each patient has different needs, which can
range from treatment to comfort to hygiene. Nurses can’t be late for any of it. Prioritising care
and managing every minute is the only way to ensure proper care.

10. Endurance
While all these personality traits and characteristics make for a good nurse, you will likely
need a certain level of physical endurance to get the job done. Most nurses are on their feet
for the majority of their shifts. Not to mention, lifting patients, helping them while they move
around, and adjusting them throughout the day takes a decent amount of strength.
What factors impact the quality and thoroughness of an assessment?

● Nurse’ knowledge and competency

● Presenting health problems, concurrent health problems and stability of the patient.
● Communication barriers: Inability to communicate with patient due to patient’s
cognitive limitations from past, current or concurrent health challenge, developmental
delays, language preference differences, presence of appliances [Link],
tracheostomy, positional factors.
● Physical limitations related to the environment.
● Growth and development variation.
● Cultural implications.
● Effects of medication or lack thereof such as education from an analgesic, inadequate
analgesia, absence of medications.
● Presence/absence of family/support. · Insufficient time and resources to carry out the
basement.
● Patient discomfort, anxiety, fears.

The nurse is caring for a patient receiving Penicillin. During the assessment, the nurse
noticed a rash on the inner aspect of the forearm. Discuss how the nurse completes a
comprehensive assessment based on the given data.

The nurse makes inferences about the possible relationship of Penicillin and the rash.
Consequently, the nurse is guided to gather more focused data related to this finding. The
nurse gathers further data about the rash i.e. was the rash present prior to the first dose of
Penicillin; has the patient received Penicillin in the past and if so, did the patient have any
reactions; is the rash bilateral and present elsewhere; does the patient have any known
allergies, etc.
REFERENCE:

• Weber & Kelly; Health Assessment in Nursing, Seventh Edition. (Page 3-4)

• Weber & Kelly; Health Assessment in Nursing, Seventh Edition. (Page 34-39)

• PATIENT ASSESSMENT - College of Licensed Practical Nurses of BC Anon & Ellchuk

D. (2005)

• Ctx Admin. (2023b, October 11). 12 essential skills and qualities of a nurse - ABSN@CTX.
Concordia Texas Accelerated bachelor’s in nursing.
[Link]

• “PATIENT ASSESSMENT - College of Licensed Practical Nurses Of.” [Link],

[Link]/doc/8178750/patient-assessment---college-of-licensed-practical-nurses-of.

• Subjective VS. Objective nursing data: What’s the difference? (n.d.).

[Link]

• Toney-Butler, T. J., & Unison-Pace, W. J. (2023, August 28). Nursing admission

assessment and examination. StatPearls - NCBI Bookshelf.
[Link]

• R.N, Marianne Belleza. “Head-To-Toe Assessment: Complete Physical Assessment

Guide.” Nurseslabs, 18 Feb. 2012, [Link]/head-to-toe-assessment-complete-
physical-assessment-guide/#google_vignette.