HEALTH ASSESSMENT  History of present health concern; physical

symptoms related to each body part or system

Assessment: Important for Every Situation  Personal health history
 Current focus on managed care and internal case  Family history
management has had a dramatic impact on the  Health and lifestyle practices 
assessment role of the nurse.  Review of systems
o Acute care
o Critical care Collection of Objective Data
 Physical characteristics
o Ambulatory care
 Body functions
o Home health
 Appearance
 Holistic nursing assessment
 Behavior
o Collects holistic subjective and objective
 Measurements
data to determine a client’s overall level of
 Results of laboratory testing
functioning in order to make a professional
clinical judgment
Steps of Health Assessment #2
 Physical medical assessment
 Validation of assessment data
o Focuses primarily on the client’s
 Documentation of data
physiologic development status
 Analysis of data

Phases of Nursing Process

Analysis Phase of Nursing Process
 Identify abnormal data and strengths.
 Assessment: Collecting subjective and objective
 Cluster the data.
data
 Draw inferences and identify problems.
 Subjective Data - information from the
 Propose possible nursing diagnoses.
client's point of view (“symptoms”),
 Check for defining characteristics of those
including feelings, perceptions, and
diagnoses.
concerns obtained through interviews.
 Confirm or rule out nursing diagnoses.
 Objective data -  are observable and
 Document conclusions.
measurable data (“signs”) obtained
through observation, physical
Types of Assessment
examination, and laboratory and
diagnostic testing.
 Initial comprehensive assessment: Collection of
subjective data about the client’s perception of
 Diagnosis: Analyzing subjective and objective
health of all body parts or systems, past medical
data to make a professional nursing judgment
history, family history, and lifestyle and health
(nursing diagnosis, collaborative problem, or
practices.
referral)
 Ongoing or partial assessment: Data collection
 Planning: Determining outcome criteria and
that occurs after the comprehensive database is
developing a plan
established.
 Implementation: Carrying out the plan
 Focused/problem-oriented assessment:
 Evaluation: Assessing whether outcome criteria
Thorough assessment of a particular client
have been met and revising the plan as
problem, which does not cover areas not
necessary
related to the problem.
 Emergency assessment: Very rapid assessment
Steps of Health Assessment #1
performed in life-threatening situations.
 Preparing for the assessment
o Review client’s record
Evolution of the Nurse’s Role in Health Assessment:
o Review client’s status with other health
Past
care team members
o Educate about client’s diagnosis and
 Physical assessment integral part of nursing
tests performed  Nurses relied on natural senses
 Palpation
Collection of Subjective Data
 Biographical information
  Movement of health care from acute care
setting to community care and proliferation of
baccalaureate and graduate education
 Advanced practice nurses
Evolution of the Nurse’s Role in Health Assessment:
Present
 Managed care and internal case management
has impact on assessment role of the nurse
o Acute care nurses
o Critical care outreach nurses
o Ambulatory care nurses
o Home health nurses
o Public health nurses
o School and hospice nurses
Evolution of the Nurse’s Role in Health Assessment:
Future
 Rising educational cost
 Increasing complexity of acute care
 Growing aging population with complex
comorbidities
 Expanding health care needs of single parents
 Increasing impact of children and homeless
 Intensifying mental health issues
 Expanding health services network
 Increasing reimbursement for health promotion
and preventive care services
 Limited number of medical students pursuing
practice in primary care settings
 Aging of the baby boomer generation
Collecting Subjective Data: The Interview and Health
History
Interviewing
In the pre-introductory phase the nurse reviews the
medical record which may reveal the client's past health
history and reason for seeking health care before
meeting with the client to assist with conducting the
interview.
 Phases of the interview
o Introductory
o Working
o Summary and closing
Introductory Phase
 Introduction
 Explaining the purpose of the interview
 Discussing the types of questions that will be
asked
 Explaining the reason for taking notes
 Assuring the client that confidential information
will remain confidential
 Making sure that the client is comfortable and
has privacy
 Developing trust and rapport using verbal and
nonverbal skills
Working Phase #2
 Biographical data
 Reasons for seeking care
 History of present health concern
 Past health history
 Family history
 Review of body systems for current health
problems
 Lifestyle and health practices and
developmental level
Working Phase #3
 Listening, observing cues, and using critical
thinking skills to interpret and validate
information received from the client
 Collaborating with the client to identify the
client’s problems and goals
Summary and Closing Phase
 Summarizing information obtained during the
working phase
 Validating problems and goals with the client
 Identifying and discussing possible plans to
resolve the problem with the client
 Making sure to ask if anything else concerns the
client and if there are any further questions
Nonverbal Communication
 Appearance – making sure that your
appearance is professional. Wear
comfortable, neat clothes, and a
laboratory gown or a coat.
 Demeanor – when entering a room to interview
a client, display poise. Focus on the client
and the upcoming interview and
assessment.
 Facial expression – No matter what you think of
the client or what kind of a day you are having,
keep your expression neutral and friendly .
 Attitude – one of the most important non verbal
skills. All the clients should be accepted,
regardless of the beliefs, ethnicity,
lifestyle and health care practices.
 Silence - period of silence to allow the client to
reflect and organize thought which facilitate
more accurate reporting and data collection .
 Listening - Avoid preconceived ideas or biases
about your client. To listen effectively, you
must keep an open mind.
  Differentiate between manipulation and a
Nonverbal Communication to Avoid reasonable request.
 Excessive or insufficient eye contact  Obtain an objective opinion from other nursing
 Distraction and distance colleagues.
 Standing
Interacting With a Seductive Client
Verbal Communication  Set firm limits on overt sexual client behavior
 Open-ended questions and avoid responding to subtle seductive
 Closed-ended questions behaviors.
 Laundry list  Encourage client to use more appropriate
 Rephrasing methods of coping in relating to others.
 Well-placed phrases  If the overt sexuality continues, do not interact
 Inferring without a witness.
 Providing information  Report inappropriate behavior to a supervisor

Verbal Communication to Avoid Discussing Sensitive Issues

 Biased or leading questions  Be aware of your own thoughts and feelings
 Rushing through the interview regarding dying, spirituality, and sexuality.
 Reading the questions   Ask simple questions in a nonjudgmental
manner.
Special Considerations  Allow time for ventilation of client’s feelings as
 Gerontologic variations needed.
 Cultural variations  If you do not feel comfortable or competent
 Emotional variations discussing personal, sensitive topics, you may
make referrals as appropriate.
Interacting with an Anxious Client
 Provide the client with simple, organized Health History
information in a structured format.  Biographical data
 Explain who you are and your role and purpose.  Reasons for seeking health care
 Ask simple, concise questions.  History of present health concern
 Avoid becoming anxious like the client.  Past health history
 Do not hurry.  Family health history
 Decrease any external stimuli.  Review of systems for current health problems
 Lifestyle and health practices
Interacting with an Angry Client  Developmental level
 Approach the client in a calm, reassuring, in- Health History—Biographical Data #1
control manner.  Name
 Allow the client to vent feelings.  Address
 Avoid any arguments with or touching the  Phone
client.  Gender
 Obtain help from other health care  Provider of history (patient or other)
professionals as needed.  Birth date
 Facilitate personal space so that the client does  Place of birth
not feel threatened or cornered. Health History—Biographical Data #2
 Never allow the client to position him or herself  Race or ethnic background
between you and the door.  Primary and secondary languages (spoken and
read)
Interacting with a Depressed Client  Marital status
 Express interest in and understanding of the  Religious or spiritual practices
client and respond in a neutral manner.  Educational level
 Take care not to communicate in an upbeat,  Occupation
encouraging manner.  Significant others or support persons
(availability)
Interacting with a Manipulative Client Review of Body Systems #1
 Provide structure and set limits.  Skin, hair, nails
  Head, neck Client Approach and Preparation #1
 Eyes  Establish nurse–client relationship.
 Ears  Explain the procedure and the physical
 Mouth, throat, nose, sinuses assessment that will follow, describing the steps
 Thorax, lungs of the examination.
 Breasts, regional lymphatics  Respect client’s requests and desires.
 Heart, neck vessels  Explain the importance of the examination.
 Peripheral vascular  Leave room while client changes clothes.
 Abdomen  Provide necessary container in case of need for
 Genitalia sample.
 Anus, rectum, prostate  Begin exam with less intrusive procedures.
 Musculoskeletal  Explain procedure being performed.
 Neurologic  Explain to client why position changes are
necessary.
Lifestyle and Health Practices #1
 Description of typical day (AM to PM) Client Positioning
 Nutrition and weight management  Sitting position
 24-hour dietary intake (foods and fluids)  Supine position
 Who purchases and prepares meals  Dorsal recumbent position
 Activity on a typical day and exercise habits and  Sims’ position
patterns  Standing position
 Rest and sleep habits and patterns  Prone position
 Medication and substance use  Knee–chest position
 Self-concept and self-care responsibilities  Lithotomy position
 Social activities
 Relationships Physical Examination: Inspection
 Values and belief system  Room at comfortable temperature
 Past, present and future education and work  Good lighting
 Type of work, level of job satisfaction, work  Look and observe before touching
stressors  Completely expose part being examined while
 Stress levels and coping strategies draping the rest of client as appropriate
 Residency, environment, neighborhood,  Note characteristics
environmental risks  Compare appearance

Collecting Objective Data: The Physical Examination Physical Examination: Palpation

 Light palpation
Physical Examination Preparation  Moderate palpation
 Comfortable, warm temperature  Deep palpation
 Private area free of interruption  Bimanual palpation
 Quiet area with adequate lighting Palpation consists of using parts of the hand to touch
 Firm examination table or bed and feel for the following characteristics:
 Beside table/tray to hold equipment  Texture (rough/smooth)
 Temperature (warm/cold)
Standard Precautions  Moisture (dry/wet)
 Hand hygiene  Mobility (fixed/movable/still/vibrating)
 Gloves  Consistency (soft/hard/fluid filled)
 Mask, eye protection, face shield  Strength of pulses
 Gown (strong/weak/thready/bounding)
 Patient care equipment; patient placement  Size (small/medium/large)
 Linen; occupational health and blood-borne  Shape (well defined/irregular)
pathogens  Degree of tenderness

Physical Examination: Percussion Purposes

 Eliciting pain
 Determining location, size, and shape
  Determining density
 Detecting abnormal masses
 Eliciting reflexes
Physical Examination: Percussion Types
 Direct
 Blunt
 Indirect or mediate
 Sounds elicited by percussion
 Resonance
 Hyper resonance
 Tympany
 Dullness
 Flatness
Physical Examination: Auscultation
 Eliminate distracting noise.
 Expose the body part being auscultated.
 Diaphragm, high-pitched sounds; bell, low-
pitched sounds
 Place earpieces into outer ear canal.
 Angle binaurals down toward nose.
Correct Use of a Stethoscope
 Warm diaphragm and bell before use.
 Explain what you are listening to and answer
any questions.
 Don’t apply too much pressure when using the
bell as it will cause the bell to work like the
diaphragm.
 Avoid listening through clothes.
Chapter 4 Validating and Documenting Data
Purpose of Validation
Validation of data is the process of confirming or
verifying that the subjective and objective data you
have collected are reliable and accurate.
Start by deciding whether the data requires validation,
determining ways to validate the data, and identifying
areas for which data are missing
Data requiring Validation
 Discrepancies or gaps between the subjective
and objective data.
 Discrepancies or gaps between what the client
says at one time versus another time.
 Finding that are highly abnormal and/or
inconsistent with other findings.
Methods of Validation
There are several ways to validate your data:
 Recheck your own datathrough a repeat of
assessment.
 Clarify the data with the client by asking
additional questions
 Verify the data with another health care
professional.
 Compare your objective findings with your
subjective findings to uncover discrepancies.
Purpose of Documentation
 The primary reason is to promote effective
communication among multidisciplinary health
team members to facilitate safe and efficient
care
 -Provides a chronological source of client
assessment data and a progressive record of
assessment findings that outline the client's
course of care
 Ensures that information about the client and
family is easily accessible to members of the
healthcare team; provides a vehicle for
communication to my: and prevents
fragmentation, repetition, and delays in
carrying out a plan of care
 Establishes a basis for screening and validating
purpose diagnosis
 Acts as a source of information to help
diagnose problems
 Offers a basis for determining the educational
needs of the client, family, and for others
 Provides a basis for determining eligibility for
care and reimbursement. careful recording of
data can support financial reimbursement or
gain additional reimbursement for transitional
or skilled care needed by the client-
 Constitutes a permanent legal record of the
care that was or was not given to the client
 Forms a component of client security system
or client classification systems. numeric values
may be assigned to various levels of care to help
determine the staffing mix for the unit
 Provides access to significant epidemiologic
data for future investigations and research and
educational endeavors
 Promotes compliance with legal, accreditation,
reimbursement, and professional standard
requirements
EMR - Referred to medical records supplied by physician
who made medical diagnoses and prescribed
treatments
EHR - Focus on the total health of the client and are
designed to reach out and beyond the health
organization that originally obtains the clients data
Information Requiring Documentation
Two key elements needed to be included in every
documentation: Nursing history and Physical
assessment also known as subjective and objective data

Subjective data
 Typically includes: Biographic data, present
health concerns, symptoms, personal health
history, family history, lifestyle and health
practice information
COLDSPA – Symptom analysis
C- Character - Describing the sign ir the symptoms
O- Onset - When did it begin?
L- Location – Where does the pain radiate?
D- Duration – How long does it lat? Does it Occur?
S-Severity – How bad is it? The pain scale
P- Pattern - What makes it better or worse?
A- Associated Factors – What other symptoms
occur with it? How does it affect you?
Objective data
 Inspection, Palpation, Percussion, and
Auscultation; all help validate subjective data
 Variety of systematic process to obtain
objective data: Head to toe, major body system,
functional health patterns, or human pattern
process
No matter which approach is going to use, general rules
must be apply:
 Make notes as ypu perform the assessment and
document as concisely as possible
 Avoid documenting with general non-
desscriptive or non measurable terms such as
normal, abnormal, good, fail, satisfactory, or
poor
 Instead, use specific descriptive and measurable
terms
Documenting Data: Guidelines
 Keep all client information confidential
 Write legibly
 Correct grammar and spelling
 Avoid wordiness
 Use phrases over sentences
 Record data findings
 No premature judgments or diagnosis
 Client's understanding and perception of issues
 Avoid the word normal
 Report completely
 Support objective data with evidence
Assessment forms for documentation
 Initial assessment form - Nursing admission or
admission database. Four types of frequently
used initial assessment documentation forms are
known as open-ended
1. Open Ended Forms (Traditional Form)
– calls for narrative description of
problem and listing of topics
- Provide lines for comments
- Individualizes informations
- provides ‘total picture’ including specific
complaints and symptoms in the clients own
word
- increase risk of failing to ask a pertinent
questions because questions are not
standardize.
- requires a lot of time to complete the
database
Cued or Checklist Forms
- Standardize data collection
- List (categorize) informations that alerts the
nurse to specific problems or symptoms
assessed for each client
- Usually includes comments
- Prevents missed questions
- Promotes easy and rapid documentation
- Makes the documentation somewhat like data
entry because it requires nurse to place check
marks in boxes instead of writing narrative
Integrated Cued Checklist
- Combines assessment data with identified
nursing diagnoses
- Helps cluster data focuses on nursing diagnosis,
assists in validating nursing diagnosis labels, and
combine assessment with problems listig in one
form.
- Promotes used by different levels of caregivers,
resulting in enhanced communication among the
dicipline.
Nursing Minimum Data Set
- Compromises format commonly used in long term
facilities
- Has a cued format that prompts nurse for a
specific criteria, usually computerized
- Includes specialized informations such as
cognitive patterns, communication (hearing,
vision) patterns, activity, patterns, physical
function and structural patterns
- Meets the needs of multiple data users in the
health care system
- Establish compatibility of nursing data across
clinical populations, settings, geographical areas,
and time
 Frequent or ongoing assessment form
- flow charts designed to help staff
record/retrieve data for frequent
reassessments
examples: frequent vital signs sheet and
assessment flow chart
 - Progress notes -part of the frequent/ongoing
assessment
used to document unusual events, responses,
significant observations, or interactions
because data are inappropriate for flow
records

 Focus for specialty area assessment form

- focus on one major area of the body for clients
who have a particular problem (i.e.
cardiovascular or neurologic)

Verbal communication of findings

 Use a standardized method of data
communication suc as a SBAR
 Communicate face-to-face with good eye
contact
 allow time for the receiver to ask questions
 provide documentation of the data you are
sharing
 validate what the receiver has heard by
questioning or asking receiver to summarize
your report
 when reporting over a telephone asked the
receiver to read back what the receiver heard
you report and document the phone call with
the time, receiver, sender and information
shared

SBAR – Situation, Background, Assessment, and

Recommendation

S: Situation - state exactly what you need to get across

B: Background - Describe the events that led up to the
situation
A: Assessment - state the subjective and objective data
you have collected
R: Recommendation - suggest what needs to be done
to the client based on your assessment