UNIT 6

IN THIS UNIT
General Assessment
Use expression for collecting demographic data
Use questions to collect current and past health-illness data

1 General Assessment
Direction:
A comprehensive admission assessment, also referred to as an initial database,
nursing history, or nursing assessment is completed when the client is admitted to the
nursing unit.
These forms can be organized according to body systems, functional abilities, health
problems and risks, nursing model, or type of health care setting.
Complete the nursing assessment form which include vital signs, height, weight,
allergies, drug, health history, a list of his belongings and those sent home, the result
of your physical assessment and a record of specimens collected for laboratory tests.
The basic components of the complete health history (other than biographical
information) include:
Chief complaint
Present health status
Past health history
Current lifestyle
Psychosocial status
Family history
Physical assessment (review of system/head to toe)
Common Terminology

Provocative : What makes the symptom(s) better or worse? What have you done to get relief?
Quality : Describe the symptom(s). When did it begin? How long does it last?
Region : Where is it? Does it radiate? Does it spread?
Severity : How bad is it? On a scale of 1-10, (10 being the worst)
Timing : What other symptoms occur with it? Does it occur in association with something else?
When did the symptom begin? How long does it last? How often does it occur?
Is it sudden or gradual?

Vocabulary :
1. Surname : ..
2. Next of kin : ..
3. Assest : ..
4. Assessment :
2 Use expression for collecting demographic data
1. Implementation step
Study these expression to initiate communication.
Explaining what you are going to to immediately.
It is time for me to
I just want to .
I would like to ..
I am going to .
I reed to .
2. Question to collect demographic data elements
Study and practice these useful expressions
Questions to ask
Name What is your name ?
What is your complete name ?
What is your sure name ?
Age How old are you ?
Address What is your address ?
Where do you live ?
Phone Your phone number, please ?
What is your phone number ?
Do you have a mobile phone number ?
Marital status Are you married ?
Health insurance Do you have any health insurance ?
Occupation & tittle What is your occupation ?
Do you have any academic tittle ?
What is your title ?
What do you do ?
Next of kin Who is your next of kin ?
Reason for contact *) What brings you in this hospital ?
Who sends you to this hospital ?
What makes you come to this hospital ?

*it is reason that make you come to the hospital, it can be a chief complain, medical check up.

3 Use questions to collect current and past health-illness data

CURRENT HEALTH STATUS
What do you think about your health ?
Would you tell me about your health condition recently ?
Sample of patients response : I am usually healthy, have usual cold and have to
take medicine for high blood pressure
ELIMINATION PATTERN
Would you tell me about your ....... ?
Do you have any problem with your ....... ? (bowel movement, waterworks)
Is the stool formed or loosed ?
 Assessment Step : Asking Common Communicable Disease
Have you ever had + a kind of disease ....... ?
Response : Yes, I have / no, I havent
How old are you when you got it ?
Response : I was about ..... years old
Are you allergic to ....... (a certain food/medication)
Example : Are you allergic to antibiotic/penicillin
Kinds of disease : measles, mumps, chicken pox, rubella, rheumatic, fever,
diphtheria, scarlet fever, polio, tuberculosis
Have you ever been immunized againts + (a kind of disease) ?
Have you ever got ....... + (a kind of disease) ....... immunizations ?
Example : Have you ever got polio immunizations ?

4 Patient Assessment
Subjective data : what the patient tells the nurse, it is the patients perception.
(i.e. description of pain, perceptions, feelings or experiences).
Objective data : the nurses observations that are measurable and verifiable.
observations such as vital signs, odours, redness of a wound,
hostile behaviour, and laboratory and medical imaging findings
Correlation of subjective and objective data: e.g. is shortness of breath supported by
decreased breath sounds on auscultation or dullness to percussion?

Subjective Objective

I feel dizzy BP 90/60 mmHg, pulse 100

My bladder never seems empty Voids 100-150mls/void q 1-2 h.

I am too fat 14 yr. old 150 cm (52) 36 Kg (80 lbs)

1. Inspection
When you are using inspection, you are looking for things you can observe with your eyes,
ears or nose. Examples of things you may inspect are skin color, location of lesions, bruises
or rash, symmetry, size of body parts and abnormal findings, sounds, and odors.
2. Palpation
Involve the use of the sense of touch. Giving gentle pressure or deep pressure using your
hand is the main activity of palpation. Palpation allows you to assess for texture,
tenderness, temperature, moisture, pulsations, masses and internal organs.
3. Percussion
Involve tapping the body with fingertips to evaluate the size, borders and consistency of
body organs and discover fluids in body cavities.
4. Auscultation
Listening to sounds produced by the body
Mention what activity do you for each case listed below
No Activity Technique
1 Press the distal part of the middle finger of your non-dominant hand
firmly on the body part

2 Asking patient to stand up to find wheter there is scoliosis or not

3 Testing deep tendon reflexes using hammer

4 Enlargement may indicate a mass

5 Preparing a good lighting, then he observe the body parts

6 Systemic colour changes

7 To know over the aortic, pulmonic, mitral, and tricuspid valves and
over Erbs point

8 Lightly then deeply noting any muscle guarding, rigidity, masses or

tenderness
9 Examining patients respiratory

10 Looking for the condition of mouth and throat

11 Pressing her middle finger of non-dominant hand firmly against the
patients back. With palm and fingers remaining off the skin, the tip of
the middle finger of the dominant hand strikes the other, using quick,
sharp stroke

12 Observing the color of the eye

13 Observing the movement of air through the lungs

14 Checking the tender areas with her hand

15 Pressing abdomen deeply to check the condition of underlying organ

What kind of examination technique ?

..

.
5 Patient Record
PATIENT RECORD
Surname : Grady First name : Jim
DOB : 2.3.50 Gender :M
Occupation : Retired
Marital Stastus : Widowed
Place of birth : Miami
Next of kin : Son
Contact no. : 07765 432178
Smoking intake : n/a
Alcohol intake : 30 units per week
Reason for admission : Snake bite
Medical hsitory : High blood pressure
Allergies : None
GP : Dr. Parkinson, Central Surgery

Find words and abbreviations in the patient record with these meanings.
1. Job occupation
2. Bad reaction, for example to certain medications _______________
3. Family doctor _______________
4. Closest relative _______________
5. The amount of something you eat, drink, etc. regularly _______________
6. Date of birth _______________
7. Male/female _______________
8. Past illnesses and injuries _______________
9. Married/single/divorced/widowed _______________
10. Not applicable (not question for this patient) _______________
11. In each (day, week, etc.) _______________

Activity 1
1. Student A and B work together in pairs. You are going to play the role of a patient
assessment. Invent the following details.

Full name Smoking and alcohol intake

Allergies Marital status
Occupation Reason for admission
Next of kin Medical history
Family history Present health status
Date and place of birth Past health history
2. Student A youre the nurse. Ask student B, the patient, question to complete the
patient record below.
3. Now change roles
PATIENT RECORD

Surname : ............................ First name : ...........................

DOB : ............................ Gender : M / F

Place of birth : ............................

Occupation : ............................

Marital Stastus : ............................

Next of kin : ............................

Contact no : ............................

Smoking intake : ............................

Alcohol intake : ............................

Reason for admission : ............................

Medical hsitory : ............................

Family history : ............................

Present health status : .

Past health history : .

.
.
.
.
.
.

Activity 2
Complete the table that follows based on Mr. Smiths case situation . Identify patient
problems/limitations supported by the assessment data.

Mr. Smith is a 56-year-old widower under your care. He is admitted due to an acute episode of
dyspnea. He states that he awakened suddenly with severe shortness of breath that did not
respond to his inhalers. In fact his condition seemed to worsen. Mr. Smith said with a panicked,
desperate expression, Its so hard to breathecant catch my breath. He reports he smoked
one to two packs a day for 40 years but stopped three months ago after his sister died of lung
cancer. His sister was also a smoker. Currently, Mr. Smiths diagnosis is emphysema with
possible heart failure. Examination and assessment revealed the following: nonproductive cough,
decreased mental acuity; extreme shortness of breath with activity; fatigues easily; nonverbal
expression of anxiety/fear, such as moderate sweating, trembling, irritability, and restlessness;
extremities mildly cyanotic and cool to the touch; capillary refill sluggish ( 4 seconds); greatly
concerned that what happened to his sisters might happen to him; worried about losing his job of
30 years due to too many sick days; and lives with a 19 years old granddaughter; unable to
complete usual household activities without periods of rest; concerned re limited coverage of
health care. Vital signs: BP 178/96, weak pulse of 110, respirations 36/min (labored, irregular
o

rhythm), O Sats 87% and temperature 38 C.

2
 Patient Problems Assessment Data

Ineffective breathing

Dyspnea, decreased mental acuity, O Sats of 87%

2

Impaired tissue perfusion

Increased stress, apprehension, distress, jittery, tremors, fear

of consequences

Fear

Awakening suddenly short of breath, restlessness

Activity intolerance

States need for rest periods with normal activities, normal

routine not maintained, irritable, decreased performance
(work related)

Altered health maintenance

Condition worsened, poor response to inhaler self-

administration

At risk for infection

Temperature 38 C, increased respiratory rate (36), increased

pulse rate (110)