Lesson-4-11.docx - Health Assessment(NCM 201 l S.Y...

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Health Assessment (NCM 201) l S.Y. 2020-2021 BACHELOR OF SCIENCE IN NURSING – SAN PEDRO COLLEGE Lecturer/s: Terro Nikko Montana Baluyut, RN, CRN, MD Reference/s: PPT Lecture 1: Season 1/ Episode 4 Introduction to the Nursing Process Objectives: At the end of the 5-hour lecture, the students are expected to be able to: - Define health assessment - Describe the evolution of nurse roles in health assessment - Discuss significance of health assessment in nursing What is Health Assessment? Health Assessment - Plan of care that identifies specific needs of clients - How these needs will be addressed by the health care organization, or skilled nursing facility Examples of Nursing Assessments: Client 1: Complains of Abdominal Pain Nurse does what type of assessment? - Inspect, percuss, palpate, and auscultate the abdomen - Take and monitor vital signs Client 2: Admitted due to Head Injury Nurse does what type of assessment? - Take and monitor the vital signs Client 3: Prescribed a cardiotonic drug Nurse does what type of assessment? - Assess the apical pulse and compare with baseline data Client 4: Cast applied on lower leg Nurse does what type of assessment? - Assess peripheral perfusion of toes - Do capillary blanch test - Bipedal pulse (if applicable) - Take and monitor vital signs Client 5: Has minimal fluid intake Nurse does what type of assessment? - Assess tissue/skin turgor - Monitor intake and output - Take and monitor vital signs Evolution of the Nurse’s Role in Health Assessment The Nurse in the Late 1800s to Early 1900s
Weber and Kelly Dillon Nurses relied on natural senses. Observed for changes: color, temperature, muscle strength, use of limbs, body output, nutrition, and hydration status. - HEALTH ASSESSMENT 2020 2
Palpation used to measure pulse rate and quality, plus locate fundus of the puerperal woman. - Independent nursing practices (inspection, palpation (GI), auscultation, testing CN VIII, and examination of school children in school systems) - The Nurse in the 1930s The Nurse in the 1970s The Nurse in the 1950s The Nurse in the 1900s – Present HEALTH ASSESSMENT 2020 3 Weber and Kelly Dillon Routine client and home inspection by public health nurses. Observation notes only. Role is a skilled observer. Case finding, prevention of communicable diseases, routine assessment skills in poor inner-city areas (Frontier Nursing Service, and Red Cross) “Patient admitted to ward in a wheelchair. Stated that he is unable to walk due to pinched nerves of right foot. Patient is crying, says he is homesick. Condition of skin good. Made as comfortable as possible.” Weber and Kelly Dillon Primary health services and conducting health histories with physical and psychological assessments. Records intravenous and blood therapy. Includes observations & information on past illness and diet.

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