NLE Health Assessment — Health History & Physical Examination TechniquesConcept Map

Concept

Health Assessment Foundation

Sub Concepts

• Subjective Data (Symptoms/Covert)
• Objective Data (Signs/Overt)
• Baseline Establishment
• Problem Identification

Relationship To Central

Core purpose and definition of nursing assessment

Concept

Assessment Types

Sub Concepts

• Initial/Comprehensive Assessment
• Focused/Problem-Oriented Assessment
• Emergency Assessment
• Ongoing/Time-Lapsed Assessment

Relationship To Central

Different approaches based on clinical context

Concept

Health History Interview

Sub Concepts

• Preparatory Phase
• Introductory Phase
• Working Phase
• Closing Phase
• Communication Techniques
• Components of Complete History

Relationship To Central

Structured data collection through therapeutic communication

Concept

General Survey

Sub Concepts

• Physical Appearance
• Body Structure and Nutrition
• Mobility Assessment
• Behavioral Observation

Relationship To Central

Initial overall impression preceding detailed examination

Concept

Vital Signs

Sub Concepts

• Temperature 36.5-37.5°C
• Pulse 60-100 bpm
• Respirations 12-20/min
• Blood Pressure <120/80 mmHg
• SpO2 95-100%
• Pain as Fifth Vital Sign

Relationship To Central

Objective baseline measurements essential to assessment

Concept

Physical Examination Techniques (IPPA)

Sub Concepts

• Inspection
• Palpation
• Percussion
• Auscultation
• Abdominal Examination Order

Relationship To Central

Systematic methods for objective data collection

Concept

Client and Environmental Preparation

Sub Concepts

• Environment Setup
• Client Readiness
• Positioning Techniques
• Equipment Preparation

Relationship To Central

Foundational elements ensuring quality assessment

Concept

Documentation and Legal Standards

Sub Concepts

• Objective Recording
• RA 9173 Compliance
• Code of Ethics Standards
• Confidentiality and Privacy

Relationship To Central

Professional accountability in nursing practice

To

Subjective Data

From

Nursing Health Assessment

Strength

strong

Relationship

Assessment foundation requiring both types of data

To

Objective Data

From

Nursing Health Assessment

Strength

strong

Relationship

Measurable, observable findings that validate subjective reports

To

Subjective Data

From

Health History Interview

Strength

strong

Relationship

Interview is primary source of subjective information

To

Objective Data

From

Physical Examination IPPA

Strength

strong

Relationship

IPPA techniques generate objective observable and measurable findings

To

Objective Data

From

Vital Signs

Strength

strong

Relationship

Vital signs are baseline objective measurements

To

Physical Examination IPPA

From

General Survey

Strength

strong

Relationship

General survey precedes and provides overview for detailed IPPA

To

Communication Techniques

From

Health History Interview

Strength

strong

Relationship

Therapeutic communication enables effective history gathering

To

Cultural Sensitivity

From

Communication Techniques

Strength

moderate

Relationship

Cultural awareness enhances communication effectiveness

To

Light Palpation

From

Palpation

Strength

strong

Relationship

Light palpation precedes deep palpation in proper sequence

To

Deep Palpation

From

Palpation

Strength

strong

Relationship

Deep palpation follows light palpation for complete assessment

To

Inspection

From

Physical Examination IPPA

Strength

strong

Relationship

Inspection is first technique in standard IPPA sequence

To

Auscultation

From

Physical Examination IPPA

Strength

strong

Relationship

Auscultation is final technique except in abdominal exam

To

Percussion Sounds

From

Percussion

Strength

strong

Relationship

Different sounds indicate different tissue densities

To

Stethoscope Use

From

Auscultation

Strength

strong

Relationship

Stethoscope is primary tool for auscultation technique

To

Client Readiness

From

Client and Environmental Preparation

Strength

strong

Relationship

Client readiness is essential component of preparation

To

Positioning Techniques

From

Client and Environmental Preparation

Strength

strong

Relationship

Proper positioning ensures examination access and client comfort

To

RA 9173 Compliance

From

Documentation and Legal Standards

Strength

strong

Relationship

Philippine nursing law governs documentation requirements

To

Code of Ethics Standards

From

Documentation and Legal Standards

Strength

strong

Relationship

Ethical standards guide confidentiality and documentation practices

To

Initial Comprehensive Assessment

From

Assessment Types

Strength

strong

Relationship

Comprehensive assessment includes full health history and IPPA

To

Focused Problem-Oriented Assessment

From

Assessment Types

Strength

moderate

Relationship

Focused assessment targets specific presenting complaint

To

Emergency Assessment

From

Assessment Types

Strength

strong

Relationship

Emergency assessment prioritizes ABC over comprehensive approach

To

Chief Complaint

From

Health History Interview

Strength

strong

Relationship

Chief complaint is starting point of history

To

OLD CARTS

From

History of Present Illness

Strength

strong

Relationship

OLD CARTS framework organizes symptom analysis

To

PQRST

From

Pain Assessment

Strength

strong

Relationship

PQRST is specialized framework for pain analysis

To

BMI Calculation

From

Vital Signs

Strength

moderate

Relationship

BMI calculated from vital sign measurements for nutritional status

To

Auscultation

From

Abdominal Examination Order

Strength

strong

Relationship

Abdominal exam differs: auscultation precedes percussion and palpation

To

Hand Hygiene

From

Standard Precautions

Strength

strong

Relationship

Hand hygiene is cornerstone of infection prevention

To

Glove Use

From

Standard Precautions

Strength

strong

Relationship

Gloves required when contact with body fluids anticipated

To

Positioning Techniques

From

Client Comfort

Strength

moderate

Relationship

Position selection balances examination access with client tolerance

To

Objective Accurate Recording

From

Documentation

Strength

strong

Relationship

Documentation must reflect only observed findings

To

Environment Setup

From

Preparatory Phase

Strength

strong

Relationship

Environment preparation occurs during preparatory phase