NCM 101 Health Assessment

 Nursing assessment is the gathering of information about a patient's physiological, psychological,

sociological, and spiritual status by a licensed Registered Nurse.
 Nursing assessment is the first step in the nursing process, the first and most critical phase of the
nursing process.
 If data collection is inadequate or inaccurate, incorrect nursing judgment maybe made that
adversely affect the remaining phases of the process: Diagnosis, planning, implementation
and evaluation.
 Although the assessment phase of the nursing process precedes the other phases in the
formal nursing process, be aware that assessments on going and continuous throughout all
phases of the nursing process.
 Health assessment is more than just gathering information about the health status of the client.
 It is analyzing and may perform the entire physical examination.
 In the home setting the nurse is usually responsible for performing most of the physical
examination.
 Frequency of comprehensive assessments depends on the client’s health promotion practices and
lifestyle.

Medical Health Assessment and Nursing Health Assessment

 The physical assessment techniques used by physicians and nurses are essentially the
same, but some critical differences do exist.
 These differences are defined by the focus and scope of nursing and medical practice.
While the techniques are similar, the underlying rationale differs. 
 Physicians diagnose and treat illness.
 Nurses diagnose and treat the patient's response to a health problem in an effort to
promote his or her health and well-being.

The Importance of Anatomy and Physiology in Health Assessment

 Nurses need “anatomy and physiology” to comprehend how to take good care of their
clients.
 It helps in understanding the health status of the patient.
 It helps in assessing, evaluating, diagnosing and tracking a patient’s health.
 Anatomy and physiology is the study of the body’s system and structures and how they
interact.
 Anatomy is the study of the physical structure of the body. Focuses on the physical
arrangement of parts in the body.
 Physiology is the study of functions and relationships of different body parts, deals with
the functioning of the human body, study of the inner functioning of cells, tissues and
organs.

Focus of Health Assessment in Nursing

 Health Assessment are performed by heath care professional to make professional

judgments related to clients.
  However, nursing health history and physical examination differs greatly from a
medical or other type of health care assessment

The purpose of nursing health assessment:

 Collect holistic subjective & objective data to determine a client’s overall level of
functioning in order to make a professional clinical judgment.
 The nurse collects physiologic, psychological, sociocultural, developmental and
spiritual data about the client.
 The mind , body and spirit are considered to be interdependent factors that affect a
person’s level of health.
 Nurse focus on how the client’s health status affects activities of daily living (ADL)
and how those ADL affects the client’s health.
 Nurse assesses how clients interact within their family and community and how the
client’s health status affects the family.
 The nurse also assesses how family and community affect the individual client’s
health status.

Framework for Health Assessment in Nursing

 Nursing framework helps to organize information and promotes the collection of

holistic data.
 This provides clues that helps to determine human responses.

Nursing Health Framework 4 sections;

1. History of present health concern

2. Personal health history
3. Family history
4. Lifestyle and health practices

Nursing History Assessment

 In order to participate in health promotion and disease prevention. The nurse

needs knowledge of physiology as well as factors affecting a client risk of
developing a disease and factors affecting client behavior.
 Following health history and health promotion, the physical assessment section
provides the procedures, normal and abnormal findings for each step of
examining a particular body part or system.

“Nursing History”, along with the physical assessment, will enable the nurse to;

1. Make informed judgment about the client

2. Nursing diagnosis
3. Collaborative problems
4. Referrals
5. Need for client teaching.
 TYPES OF HEALTH ASSESSMENT
Four Basic types of Assessment;
1. Initial comprehensive assessment
2. Ongoing or partial assessment
3. Focused or problem-oriented
4. Emergency assessment

1. Initial Comprehensive Assessment:

 Involves collection of subjective data about the client’s perception of his/her
health of all body parts or system, past health history, family history, and lifestyle
and health practices.
 Objective data, gathered during a step by step physical examination.
 An Initial Comprehensive Assessment describes in detail the client's medical,
physical and psychosocial condition and needs.
 It identifies service needs being addressed and by whom; services that have not
been provided; barriers to service access; and services not adequately coordinated.
 Involves collection of subjective data about the client’s perception of his/her
health of all body parts or system, past health history, family history, and lifestyle
and health practices.
 A comprehensive health assessment gives nurses insight into a
patient's physical status through observation, the measurement of vital signs and
self-reported symptoms. It includes a medical history, a general survey and a
complete physical examination.
 Regardless of who collects the data, a total health assessment is needed,
(subjective and objective data regarding functional health and body system).
 When client enter a health care facility, an establish baseline data is needed for
future health status changes can be measured and compared.
 Frequency of comprehensive assessments depends on the client’s age, risk factors,
health status, health promotion practices and lifestyle.
2. Ongoing or partial assessment

 Consist of data collection that occurs after the comprehensive database is established
 This consists of a mini overview of the client’s body system and holistic health patterns
as a follow-up on health status.
 Any problems that were initially detected in the client’s body system or holistic health
patterns are reassessed to determine any changes (deterioration or improvement) from the
baseline data.
 This type of assessment is usually performed whenever and wherever the nurse or
another healthcare professional has an encounter with the client, whether in the hospital,
community, or home setting.
 ONGOING assessments alert the nurse to: changes in the patient's responses to health
and illness, and suggest necessary changes in the plan of nursing care or care offered by
other healthcare professionals.
3. Focused or problem-oriented assessment

 does not replace the comprehensive health assessment.

 It is performed when a comprehensive database exist for a client who comes to the health
care agency with a specific health concern.
 A focused assessment consists of a thorough assessment of a particular client problem
and does not address areas not related to the problem.
 A problem focus assessment collects data about a problem that has already been
identified.
 Problem Oriented Assessment of patient complaint area only. --Patient complains of
chest pain, you perform vital signs, assess the patient's pain and perform an EKG.
Focused. -Assessment of a particular body system or body process.
 This type of assessment has a narrower scope and a shorter time frame than the
initial assessment.

4. Emergency Assessment

 An emergency assessment is a very rapid assessment performed in life-threatening

situations.
 In such situations, (choking, cardiac arrest, drowning), an immediate assessment is
needed to provide prompt treatment.
 Clinical examination in emergency nursing usually follows the ABCD mnemonic.
 This guides the nurse to assess potential or actual threats to Airway, Breathing,
Circulation and Disability (or Neurological function).
 Interventions may need to be undertaken if a threat to these elements is discovered (when
cardiac arrest is suspected).
 The rapid triage assessment in the emergency nursing environment is a
quick assessment that helps the triage nurse identify those patients requiring immediate
care from those who can safely wait.

TRIAGE SYSTEM

 Triage is the prioritization of patient care (or victims during a disaster) based on
illness/injury, severity, prognosis, and resource availability.
 The purpose of triage is to identify patients needing immediate resuscitation; to assign
patients to a predesignated patient care area, thereby prioritizing their care; and to
initiate diagnostic/therapeutic measures as appropriate.
 The rapid triage assessment in the emergency nursing environment is a
quick assessment that helps the triage nurse identify those patients requiring
immediate care from those who can safely wait.
 The intention behind triage is to improve the emergency care and to prioritize cases in
terms of clinical urgency.
HEALTH ASSESSMENT EQUIPMENT

 The nurse should be familiar with the otoscope, penlight, stethoscope (bell and
diaphragm), thermometer, bladder scanner, speculum, eye charts, cardiac and blood
pressure monitors, fetal doppler and extremity doppler, and sphygmomanometer
 Stretcher or bed for proper positioning during a physical exam
 Hand hygiene products, personal protective equipment if required
 Alcohol swabs, sanitizer, or soapy water to clean equipment after use, such as with
stethoscopes, to decrease the likelihood of cross-contamination of pathogens from
inanimate objects (follow any manufacturer guidelines or institutional policies).
 Computer or paper chart to document findings.
 Calculation devices for BMI, conversion from pounds to kilograms, kilograms to pounds,
Celsius to Farenheight.

HEALTH ASSESSMENT TECHNIQUES

1. Inspection
 Look at all areas of the skin, including those under clothing or gowns
 Ensure patient is undressed, allowing for privacy, uncover one body part at a time if
possible
 Lighting should be bright
 Be alert for any malodors from the body including the oral cavity; fecal odor, fruity-
smell, odor of alcohol or tobacco on the breath.
 Compare one side to the other, and ask the patient about any asymmetrical areas.
 Observe for color, rashes, skin breakdown, tubes and drains, scars, bruising, burns.
 Grade any edema present.
 Document pertinent normal and abnormal findings.

2. Palpation
 Texture, Size, Consistency, Crepitus, Any masses, Palpation. Texture. Size,
Consistency. Crepitus. Any masses
3. Percussion.
 Good hand and finger technique
 Good striking and listening technique
 Especially important in the pulmonary and gastrointestinal systems
 Dull, flat, resonance, hyper-resonance, or tympany sounds
 Percussion is an advanced technique requiring a specific skill set to perform.
Therefore, it is a skill practiced by advanced practice nurses as opposed to a bedside
nurse on a routine basis.
4. Auscultation
 Listening to body sounds such as bowel sounds, breath sounds, and heart sounds
 Important in examination of the heart, blood pressure, and gastrointestinal system
 Listen for bruits, murmurs, friction rubs, and irregularities in pulse
Assessment tools = Assessment tools are standardized systems that help to identify and gauge the
extent of specific conditions and provide a fair approach in response. They can be the means whereby
individual and particular assessments contribute to the overall picture.

Example:

 Activities of daily living scale

 Cough assessment
 Health questionnaires such as those that address recent travel and exposure risks
 Water low or Braden scale for assessing pressure ulcer risk
 Glasgow coma scale/AVPU for assessment of consciousness
 Pain scales such as the Faces Pain Scale (FPS), Numeric Rating System (NRS), Visual
Analogue Scales (VAS), Wong-Baker Faces Pain Rating Scale (WBS), and the (MPQ)
McGill Pain Questionnaire
 CAGE assessment/CIWA scoring
 Morse Fall Risk
 Standard vital sign flow charts for different age groups
 NIH Stroke Scale (NIHSS)
 Dysphagia Screen
 4AT Assessment for Delirium

Steps of Health Assessment

4 Major Steps of Health Assessment

1. Collection of subjective data

2. Collection of objective data
3. Validation of data
4. Documentation
Preparing for Assessment

 Review client’s “medical record” (if available), it provides information like;

Biographical data (name, age, sex, religion, occupation).
 Information about chronic diseases, medications, allergies and so on.
To guide your interactions with the client.
 Information from other health care team and client’s family.

After reviewing medical record remember;

 To keep an open mind
 Avoid premature judgement that may alter your ability to collect accurate data.
 Validate information with the client
 Be prepared to collect additional information
 To educate yourself about the client’s diagnoses or test performed.
 Take a minute to reflect on your own feeling regarding your initial encounter with the
client.
 To obtain and organize materials that you will need for the assessment
 Gather equipment necessary to perform a nursing health history.
Collection of Subjective data

 Sensation or symptoms – (pain, hunger)

 Feelings – (happiness, sadness)
 Perceptions – (the way one understand the world)
 Desires – strong wish for or want for something
 Preferences – greater liking.
 Beliefs – faith, trust
 Ideas – aim or purpose
 Values – one’s judgment of what is important in life.
 Personal Information – personal information of opinion.
- To elicit accurate subjective data, learn to use effective interview skills with a variety of
clients in different settings.
- Communication skills is also essential.

Subjective Data consist of:

1. Biographic data – name, age, date of birth, marital status, religion, occupation,
educational attainment
2. Reasons for seeking Health Care – why seek medical care, reason for coming to
the hospital, clinic, rehab center and other health care facility.
3. Chief Complaint - concise statement describing the symptom, problem,
condition, diagnosis, physician-recommended return, or other reason for a
medical encounter.
4. History of
a. Present Illness – physical symptoms related to each body part or system.
b. Past Health History- is the total sum of a patient's health status prior to the
presenting problem. 
c. Current Medications – taking antihypertensive drug, taking insulin, meds to
lower cholesterol, etc.
d. Lifestyle – health practices that put client at risk, nutrition, activity,
relationships, cultural beliefs, family structures and functions, community
environment.
e. Developmental Level - are assessed to determine if the client is at the
expected level of growth and development (newborn to late adulthood).
f. Psychological History – to know the cognitive, emotional, intellectual, and
social capabilities and functioning over the course of a normal life span, from
infancy through old age.