HEALTH ASSESSMENT IN NURSING STEPS OF HEALTH ASSESSMENT

NURSING PROCESS (ADPIE) 1. Collection of Subjective Data

2. Collection of Objective Data
PURPOSE:
3. Data Validation
- Collect subjective and objective data - Purpose: confirm/verify and ensure SD and OD
are reliable and accurate.
- When to validate: discrepancies or gaps (SD &
OD; inconsistencies in data)
- Methods:
Recheck by repeat assessment
Clarify by asking additional questions
Verify w/ another health care prof.
Compare OD vs SD
4. Data Documentation
- Determine client’s over-all level of functioning
- “what is not written is not done.”
- Holistic assessment
- Validate a diagnosis DOCUMENTATION
- Provide basis for effective nursing care
- Evaluate nursing care - Document legibly/print neatly in non-erasable
ink.
FRAMEWORK FOR NURSING H.A - Use correct grammar and spelling.
- Avoid wordiness that creates redundancy.
1. Health History:
“KISS”
- Present illness
- Use phrases instead of sentences to record
- Past health history
data.
- Family history
- Record data findings, not how they were
- Medications
obtained.
- Lifestyle and Health pattern
- Write entries objectively w/o making premature
2. Physical assessment
judgements or diagnosis.
3. Head to toe (cephalocaudal)
- Avoid recording the world normal for normal
4. Organ system
findings.
TYPES OF ASSESSMENT - Record the client’s understanding and
perception of problems.
1. Initial Comprehensive Assessment
- Record complete info and details for all client
- Subjective
symptoms or experiences.
- Objective
- Include additional assessment content when
2. On-going or Partial Assessment
applicable.
- Follow-up
- After ICA COLLECTING SUBJECTIVE DATA
- Mini-overview of the body system
INTERVIEW
- Determine prognosis
3. Focused or Problem Oriented Assessment - Establishing rapport (comfortability/familiarity)
- Specific health concern and trusting relationship.
- Must have a comprehensive data base - Gather information from client and significant
4. Emergency Assessment others related to the care or condition of the
- Life threatening situations patient.
- E.g. Airway-Breathing-Circulation
PHASES OF INTERVIEW

1. INTRODUCTORY
- introduce
 - explain the purpose What to avoid:
- privacy and confidentiality
- Biased/leading questions
- “trust and rapport”
- Rushing through interview
- Reading the questions
2. WORKING
- History taking REMEMBER SOLER!!
- Listening, observe nonverbal cues, critical
thinking Sit erect
- Nurse-client collaboration Open arms
Listen actively/Lean forward
3. SUMMARY AND CLOSING Eye contact/Empathy
- Summarizes info for clarification and validation Relaxed
- Identifies possible plans to resolve the problem SPECIAL CONSIDERATIONS DURING INTERVIEW
with the client
- Ask: other concerns - Gerontologic (elderly) variations
o Low voice
COMMUNICATION - Cultural variations
NON-VERBAL - Emotional variations.

- Appearance INTERACTING W/ AN ANXIOUS CLIENT

- Demeanor 1. Explain who you are and your role and purpose.
- Facial Expression 2. Provide client w/ simple organized info
- Attitude 3. Ask simple, concise questions
- Silence 4. Avoid becoming anxious like the client
- Listening 5. Do not hurry and decrease any external stimuli
What to avoid: INTERACTING W/ AN ANGRY PATIENT
- Excessive or insufficient eye contact 1. Approach client in a calm, reassuring, in-control
- Distraction and distance manner
- Standing 2. Allow him to ventilate feelings
VERBAL 3. If client is out of control, do not argue/touch
the client
- Open-ended questions 4. Obtain help from other health team members
o pt express themselves freely 5. Avoid arguing and give personal space
- Close-ended questions
o Answerable by yes or no INTERACTING WITH A MANIPULATIVE CLIENT
- Laundry list 1. Provide structure and set limits
o Specific categories for the pt 2. Differentiate manipulation and a reasonable
- Rephrasing request
o For clarification 3. Ask/obtain opinion from other nursing
- Well-placed phrases colleagues
o To indicate that the nurse is still
listening INTERACTION W/ A SEDUCTIVE CLIENT
- Inferring (figure something out through 1. Set firm limits on overt sexual client behavior
reasoning) 2. Avoid responding to subtle seductive behaviors
o Clarifications and follow-up questions 3. Encourage client to use more appropriate
- Providing information methods of coping in relating to others.
o Understandable and type of info in
scope of practice
DISCUSSING SENSITIVE ISSUES LIFESTYLE AND HEALTH PRACTICES

- Be aware of your own thoughts and feelings  Description of a typical day

- Ask simple questions in non-judgmental manner  Nutrition and Hydration
- Allow time for ventilation of feelings  Activity and Exercise
- IF YOU DO NOT FEEL COMFORTABLE OR  Sleep and Rest
COMPETENT DISCUSSING PERSONAL,  Use of medications, and other substance
SENSITIVE TOPICS, YOU MAY TAKE REFERRALS  Self-concept
AS NEEDED.  Self-care responsibilities
COMPLETE HEALTH HISTORY  Social activities
 Relationship
COMPONENTS: BCH-PF-RL  Value belief pattern
1. Biographical data  Past, current, and future plans for education
2. Chief complaint  Type of work, level of job satisfaction, work
3. History of Present Health Concern stressors
4. Past Health History  Finances
5. Family Health History  Stressors in life, coping strategies
6. Review of Body Systems for current problems  Residency and environment
7. Lifestyle and Health Practices Profile and
DEVELOPMENTAL LEVEL
Development Level
 SIGMUND FREUD – Psychosexual development
HISTORY OF PRESENT ILLNESS
 JEAN PIAGET – Cognitive development
Character Severity  ERIK ERIKSON – Psychosocial development
Onset Pattern
Location Associated factors
Duration

PAST HEALTH HISTORY

• Problems at birth
• Childhood illness
• Immunizations
• Adult illnesses (physical, emotional, mental)
• Surgeries
• Accidents
• Prolonged pain or pain patterns
• Allergies

FAMILY HEALTH HISTORY COLLECTION OF OBJECTIVE DATA

•Age of parents (Living? Deceased?) A. PHYSICAL EXAMINATION

•Parent Illnesses  Obtain BASE LINE DATA (foundation/point of
•Grandparents’ Illnesses reference) about client functional disabilities
•Aunts’ and uncles’ illnesses  Supplement, confirm and refute data obtained
•Children’s ages and illnesses or handicaps from the nursing history
REVIEW OF SYSTEMS  Obtain data that will help the nurse establish
nursing diagnoses and plan the client’s care
• Ask the signs and symptoms  Evaluate the physiologic outcomes of health
• Cephalocaudal care thus the progress of a client’s health
• Per system problem
 PREPARATION GUIDELINES
1. Always dress in a clean, professional manner,
identification must be visible
2. Remove all jewels
3. Fingernails must be kept short; hands must be
warm
4. Hair must not fall forward
5. Check necessary equipment
6. Room is well lit, warm and private
7. Introduce self & Identify the pt
8. Explain the procedure
PHYSICAL EDUCTION GUIDELINES
1. A pt who presents to their nurses with a particular
ailment injury/other medical concern will need to
undergo PE in order to assist the physician in making
a diagnosis
2. PE may require the nurses to touch the pt. Some
examinations may require the client to disrobe while
some may result in a level of physical discomfort for
the pt. CONSIDERATION should be given for
potential cultural sensitivities
3. The nurse must OBTAIN CLIENT’S CONSENT to
conduct the examination
CONSENT AND COMMUNICATION
1. Essential prior starting examination (except for
emergency situations)
a. Why the examination is needed? Purpose
b. What parts will be examined? Disrobing
must be explained
c. What the examination entails. Hanggang
saan
d. Who will be present in the room when the
examination is being undertaken?
2. Allow the client to ask questions
3. Document the client’s consent including all persons
present in the examination (family members,
chaperones, other medical team members, student
interns, etc.)
4. Communicate in a professional manner with the
client during the examination
5. Nurses should NOT CONDUCT the examination if the
client DOES NOT CONSENT
6. AUTONOMY: IF the examination is in progress and
the client WITHDRAWS CONSENT, nurses SHOULD
CEASE THE EXAMINATION IMMEDIATELY.
7. CHECK GENERAL WELL BEING: Nurses MUST BE
ALERT to a client experiencing UNDUE DISTRESS
during the examination
8. CLIENT WHO LACKS DECISION MAKING CAPACITY,
REQUIRE (PHYSICIAN) SURROGATE DECISION
MAKER CONSENT
a. PATERNALISM – physician who is entitled to
decide for a patient.
PHYSICAL EXAMINATION
I. PRIVACY
 Nurses SHOULD NOT assist a client to
dress/undress UNLESS THE CLIENT NEEDS
ASSISTANCE
 Avoid making inappropriate verbal/non-verbal
expressions during the examination
 Examination must be uninterrupted
 After every assessment, the findings must be
communicated to the client
 Gloves must be worn when conducting
intimate/internal examination
CHAPERONE
 Should be an IMPARTIAL OBSERVER to the
examination
 Chaperone IS DIFFERENT FROM A SUPPORT
PERSON (relative/friend)
 The client must consent to having a chaperone
 If the chaperone is not available, or If a client is
not comfortable with the choice of chaperone,
the nurses should offer to postpone the
examination until an appropriate chaperone is
available (if this does not affect the client’s health
care)
CHAPERONE MUST BE:
o Qualified
o Be of gender approved by the
client/supporter
 o Must respect the privacy and dignity of Hollow
the client HYPERRESONANT Very loud, STOMACH
 The nurse should be careful not to reveal lower pitched
confidential client information in front of the TYMPANIC Loud, high- Air collection,
chaperone. pitched, large
 The nurse SHOULD RECORD the chaperone’s moderate pneumothorax,
length, stomach filled
name, and qualifications in the client’s medical
musical drum- of gas.
record
like
 If the nurse has concerns about a particular client
and would like to have a chaperone present, but
the client does not consent, the nurse DOES NOT D. AUSCULTATION
HAVE TO PERFOM THE EXAMINATION. The
 Listening to sounds
nurse may ask to defer the examination/refer
 Direct and indirect
the client to other nurses.
POSITIONING THE CLIENT
4 TECHINIQUES OF PHYSICAL ASSESSMENT
A. SITTING POSTION
A. INSPECTION
 High-fowler’s position
 Observe
 To assess: head, neck, lungs, chest, breast,
 Vision
axillae and heart
 Smell
 Hearing B. STANDING POSITION

B. PALPATION  To assess: posture, balance, gait (walking), and

male genitalia
 Touch
 Light Palpation – surface < 1 cm C. SUPINE POSITION
 Moderate Palpation – 1 – 2 cm/ ½ - ¾ inches, for
 To assess: head, neck, lungs, chest, breast,
lesions, degree of tenderness, pain, masses etc.
axillae, heart, extremities and abdomen
 Deep Palpation – 1 – 2 inches/ 2.54 cm up, for
internal organs D. DORSAL RECUMBENT
C. PERCUSSION  To assess: head neck, lungs, chest, breast,
axillae, heart, extremities
 Tapping fingers and hands
 Produce different sounds
 Direct and Indirect

SOUND DESCRIPTION PART

E. LITHOTOMY POSITION
FLAT Short, Soft, Solid; bones
High pitched,  Lying supine, with feel and lower extremities
Extremely dull supported by stirrups
as found over  To asses: female genitalia, reproductive tract,
thigh
rectum
DULL Medium in Organ: liver
intensity, Pitch
moderate
length
Thud-like
RESONANT Long Lungs (normal)
Loud
Low pitched
F. SIM’S POSITION o Penlight
o Snellen’s chart
 lie on the side with lower arm behind the body
o Rosenbaum’s chart
and upper arm flexed at shoulder and elbow,
 EAR AND NOSE
 lower leg is flexed at sharper angle and pulled
o Otoscope
forward
o Tuning fork
o Nasal speculum
 MUSCULOSKELETAL
o Goniometer
 FEMALE GENITALIA
o Vaginal speculum
o Sterile cotton tipped
G. PRONE POSTION o Glass slide
 OTHER EQUIPMENT
 To assess: hip joint, back o Reflex hammer
 NOT FOR CLIENTS WITH CARDIO &
RESPIRATORY PROBLEMS STEPS OF HEALTH ASSESSMENT

H. KNEE-CHEST POSTION 1. COLLECTION OF SUBJECTIVE DATA

 Client kneels on the examination table 2. COLLECTION OF OBJECTIVE DATA

 90 degree angle between body and hips 3. DATA VALIDATION
 Arms placed above the head, the head turned to
the side 4. DATA DOCUMENTATION
 To assess: the rectum ASSESSMENT FORMS USED FOR DOCUMENTATION

A. INITIAL ASSESSMENT FORM

- Nursing admission/admission database

 OPEN-ENDED/TRADITIONAL
o History of present illness and chief
complaint
o Narrative
o gives “total picture” specific complaints
in client’s own words
PHYSICAL EXAMINATION EQUIPMENT
o provides lines for comments
 VITAL SIGNS o time consuming
o Stethoscope o individualized information
o Wristwatch  CUED/CHECKLIST
o Digital thermometer o findings
o Sphygmomanometer o Standardized
 ANTHROPOMETRIC MEASUREMENT o Category for symptoms
o Skin-fold calipher o Prevent missed questions
o Platform scale o Easy and rapid documentation
o Tape measure  INTEGRATED CUED CHECKLIST
 SKIN o WITH NURSING DIAGNOSIS
o Centimetre rule o Combines assessment data with
o Wood’s light (germ light) identified nursing diagnosis
 EYE EXAMINATION o Cluster data
o Ophthalmoscope o Interprofessional communication
  NURSING MINIMUM DATA SET
o CUED AND TRADITIONAL
o Long term facility
o Cued format for specific criteria

OTHER ASSESSMENT FORM:

B. FREQUENT/ON-GOING ASSESSMENT FORM

 Monitoring
 Flow charts (VS and assessment flow sheet)
 Progress notes

C. FOCUSED/SPECIALTY AREA ASSESSMENT FORM

 Focused on one problem

 Cardio/neuro assessment forms