Course Name : HEALTH ASSESSMENT

Course Code : NCM 101

Course : The course deals with concepts, principles & techniques of history
Description taking using various tools, physical examination (head to toe),
psychosocial assessment and interpretation of laboratory findings to
arrive at a nursing diagnosis on the client across the lifespan in
community and hospital settings.
Course Credit : 2units lecture, 1unit RLE
Contact Hours/ : 36 lecture hours, 51 RLE hours
Sem
Pre-requisite : Theoretical Foundations in Nursing, General Psychology, Anatomy
and Physiology, Chemistry 2 & Fundamentals of Nursing Practice
Placement : 1st Year, 2nd Semester
Course : At the end of the course and given simulated and actual conditions/
Objectives situations, the student will be able to:
1. differentiate normal from abnormal assessment findings;
2. utilize concepts, principles, techniques and appropriate assessment
tools in the assessment of individual client with varying age group
and development; and,
3. observe bioethical concepts/ principles and core values and nursing
standards in the care of clients.
Course Outline : I. Review of the Nursing Process
II. Health History Guidelines
A. Interview
1. Purpose
2. Structure
3. Guidelines of an effective interview
III. Health History
A. Personal profile
1. Chief complaint of present illness
2. Past health history
3. Current medications
4. Personal habits & patterns of living
5. Psychosocial History
a. Mental Status Assessment
􀂃 Children and Adolescent
􀂃 Adults
B. Functional Assessment
1. Adults
2. Physical activities of daily living (PADC)
3. Instrumental activities of daily living (IADL)
C. Functional Assessment Tests
1. Newborns – Apgar scoring system
2. Infants & children – MMDST
3. Adults
a. Katz Index of Independence in ADL
b. Barthel index
D. Review of Systems (Symptoms)
E. Assessment in pregnancy (e.g. LMP, EDC)
F. Pediatric Additions to Health History (e.g. head circumference,
 weight, height, immunization)
G. Geriatric Additions to the Health History (e.g. immunization,
current prescription medications, over the counter medications,
ADL, social support, etc.)
III. Physical Examination
A. Preparation guidelines
B. PE guidelines
C. Techniques in Physical assessment
1. Inspection
2. Auscultation
3. Percussion
4. Palpation
D. Continuing Assessment
1. Pain
2. Fever
E. Pediatric Adaptation
1. General guidelines
2. Specific age groups
F. Geriatric adaptations
1. General guidelines
2. Modifications
G. Cultural considerations
1. Sequence of PE (adult/pedia/geriatric adaptations)
a. Overview
b. Integument
c. Head
d. Neck
e. Back
f. Anterior Truck
g. Abdomen
h. Musculoskeletal system
i. Neurologic system
j. Genitourinary system
H. Clinical alert
I. Documentation of findings
J. Patient & Family Education & Home Health Teaching
IV. Diagnostic Tests (routine laboratory exams)
V. Appropriate Nursing Diagnosis
Laboratory : Assessment forms Ruler & tape
Supplies and Patient’s chart Vaginal speculum and equipment
Equipment Ophthalmoscope for cytological
Watch with second hand Thermometer bacteriological
Otoscope study
Sphygmomanometer Tuning fork
Flashlight or penlight Reflex hammer
Stethoscope Safety pins
Tongue depressor Paper & pen and pencil
Gloves and lubricant Cotton