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INTRODUCTION TO HEALTH ASSESSMENT
The Nurse’s Role in Health Assessment: Collecting
and Analyzing Data
Case Study
Mrs. Gutierrez, age 52, arrives at the clinic for
diabetic teaching. She appears distracted and sad,
uninterested in the teaching. She is unable to focus, and
paces back and forth in the clinic wringing her hands.
What should the nurse suspect of Mrs. Gutierrez?
-A professional nurse should constantly observe situations
and collect information to make nursing judgements. It can
occur no matter what the setting: hospital, clinic, home,
community or long-term care.
Introduction to Health Assessment in Nursing
Nursing – the protection, promotion, and optimization of
health and abilities, prevention of illness and injury,
alleviation of suffering through the diagnosis and
treatment of human responses and advocacy in the care of
individuals, families, communities and populations.
(Nursing: Scope and Standards of Nursing Practice (American Nurses
Association (ANA), 2010)
-Nursing Scope and Standards of Practice Standard 1
– The RN collects comprehensive data pertinent to the
patient’s health or situation. (ANA p.21)
- To accomplish this pertinent and comprehensive
data collection, the nurse:
o Collects data in a systematic and ongoing process
o Involves the patient, family, other health care
providers, and environment, as appropriate, in
holistic data collection.
o Prioritizes data collection activities based on the
patient’s immediate condition, or anticipated
needs of the patient or situation.
o Uses appropriate evidence-based assessment
techniques and instruments in collecting pertinent
data.
o Uses analytical models and problem-solving tools
o Synthesizes available data, information, and
knowledge relevant to the situation to identify
patterns and variances.
o Documents relevant data in an retrievable format
(ANA 2010, p.21)
Dianna Rose O. Belen, RN, LPT NCM 101 HEALTH ASSESSMENT
-Nursing Scope and Standards of Practice Standard 2
– The RN analyses the assessment data to determine the
diagnosis or issues. To accomplish this, the RN:
o Derives the diagnosis or issues based on
assessment data
o Validates the diagnosis or issues with the client,
family, and other healthcare providers when
possible and appropriate.
o Documents diagnoses or issues in a manner that
facilitates the determination of the expected
outcomes and plan (ANA, 2010, p.22)
EVOLUTION OF THE NURSE’S ROLE IN
HEALTH ASSESSMENT
Physical assessment has been an integral part of nursing
since the days of Florence Nightingale.
Late 1800s – Early 1900s
- Nurses relied on their natural senses; the client’s
face and body would be observed for “changes in
color, temperature, muscle strength, use of lims,
body output and degrees of nutrition, and
hydration.
- Palpation was used to measure pulse rate and
quality to locate the fundus of the puerperal
woman.
- Examples of independent nursing practice using
inspection, palpation, and auscultation have been
recorded in nursing journals since 1901. Some
examples reported include gastrointestinal
palpation, testing eighth cranial nerve function,
and examination of children in school systems.
1930 – 1949
- The American Journal of Public Health documents
routine client and home inspection by public
health nurses in the 1930s.
- This role of case finding, prevention of
communicable diseases, and routine use of
assessment skills in poor inner-city areas was
performed through the Frontier Nursing Service
and the Red Cross.
1950 – 1969
- Nurses were hired to conduct pre-employment
health stories and physical examinations for major
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companies, such as New York Telephone, form organizations (HMOs) and preferred provider
1953 through 1960 organizations (PPOs).

1970 – 1989 Assessment: Step One of the Nursing Process

- The early 1970s prompted nurses to develop an - Assessment is the first and most critical phase of
active role in the provision of primary health the nursing process.
services and expanded the professional nurse role - Although the assessment phase of the nursing
in conducting health histories and physical and process precedes the other phases in the formal
psychological assessments nursing process, be aware that assessment is
- Joint statements of the American Nurses ongoing and continuous throughout all phases
Association and the American Academy of of the nursing process.
Pediatrics agreed that in-depth client assessments - The nursing process should be thought of as
and on-the-spot diagnostic judgments would circular, not linear.
enhance the productivity of nurses and the health
care of clients. Phases of the Nursing Process
- Acute care nurses in the 1980s employed the
Phase Title Description
“primary care” method of delivery of care. Each
nurse was autonomous in making comprehensive
I Assessment Collecting subjective and
objective data
initial assessments from which individualized II Diagnosis Analyzing subjective and
plans of care were established. objective data to make a
professional nursing judgment
1990 – present (nursing diagnosis,
collaborative problem, or
- Over the last 20 years, the movement of health referral)
care from the acute care setting to the community III Planning Determining outcome criteria
and the proliferation of baccalaureate and graduate and developing a plan
education solidified the nurses’ role in holistic IV Implementation Carrying out the plan
assessment. V Evaluation Assessing whether outcome
- Downsizing, budget cuts, and restructuring were criteria have been met and
the priorities of the 1990s. In turn, there was a revising the plan as necessary
demand for documentation of client assessments
by all health care providers to justify health care
services.
- In the 1990s, critical pathways or care maps
guided the client’s progression, with each stage
based on specific protocols that the nurse was
responsible for assessing and validating.
- Advanced practice nurses have been increasingly
used in the hospital as clinical nurse specialists and
in the community as nurse practitioners.
- While state legislators and the American Medical
Association struggled with issues of
reimbursement and prescriptive services by
nurses, government and societal recognition of the
need for greater cost accountability in the health
care industry launched the advent of diagnosis-
related groups (DRGs) and promotion of health
care coverage plans such as health maintenance

Dianna Rose O. Belen, RN, LPT NCM 101 HEALTH ASSESSMENT 2018

FOCUS OF HEALTH ASSESSMENT IN
NURSING
- The purpose of a nursing health assessment is to
collect holistic subjective and objective data to
determine a client’s overall level of functioning in
order to make a professional clinical judgment.
- In contrast to a physician performing a medical
assessment, its focus is only client’s physiologic
status.
FRAMEWORK FOR HEALTH ASSESSMENT IN
NURSING
- A nursing framework helps to organize
information and promotes the collection of
holistic data.
- Head – to – toe assessment
- The questions asked in each physical systems
focus on that particular body system and are
broken down into four sections:
o History of Present Health Concern
o Personal Health History
o Family History
o Lifestyle and Health Practices
- The end result of a nursing assessment is the
formulation of nursing diagnoses to know:
o nursing care
o identify collaborative problems requiring
interdisciplinary care
o identify medical problems that require
immediate referral
o client teaching for health promotion.
USING EVIDENCE TO PROMOTE HEALTH
AND PREVENT DISEASE
- There are many models used to analyze health
promotion and disease prevention.
- Two of the major models are:
o The Health Belief Model (Becker &
Rosenstock)
o The Health Promotion Model (Pender)
The Health Belief Model
- based on three concepts:
o the existence of sufficient motivation;
o the belief that one is susceptible or
vulnerable to a serious problem;
Dianna Rose O. Belen, RN, LPT NCM 101 HEALTH ASSESSMENT
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o the belief that change following a health
recommendation would be beneficial to
the individual at a level of acceptable cost.
The Health Promotion Model
- also focused on behavioral outcomes.
- Pender proposes that individual characteristics and
experiences (prior related behavior and personal
biologic, psychological, and cultural factors) affect
behavior-specific cognitions and affect
(perceptions of benefit, barriers, self-efficacy, and
activity-related affect; as well as interpersonal and
situational influencers), which in turn yield the
level of commitment to a plan.
TYPES OF HEALTH ASSESSMENT
- Initial comprehensive assessment
- Ongoing or partial assessment
- Focused or problem-oriented assessment
- Emergency assessment
1. Initial Comprehensive Assessment
- involves collection of subjective data about the
client’s perception of his or her health of all body
parts or systems, past health history, family
history, and lifestyle and health practices (which
includes information related to the client’s overall
function) as well as objective data gathered
during a step-by-step physical examination.
- a total health assessment (subjective and
objective data regarding functional health and
body systems) is needed when the client first
enters a health care system and periodically
thereafter to establish baseline data against
which future health status changes can be
measured and compared.
2. Ongoing or Partial Assessment
- consists of data collection that occurs after the
comprehensive database is established.
- consists of a mini-overview of the client’s body
systems 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.
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- usually performed whenever the nurse or another
health care professional has an encounter with the
client.
- Ex. a client admitted to the hospital with lung
cancer requires frequent assessment of lung
sounds.
3. Focused or Problem-Oriented Assessment
- does not replace the comprehensive health
assessment.
- performed when a comprehensive database exists
for a client who comes to the health care agency
with a specific health concern.
- consists of a thorough assessment of a particular
client problem and does not cover areas not
related to the problem.
- Ex. if your client, John P., tells you that he has
pain you would ask him questions about the
character and location of pain, onset, relieving and
aggravating factors, and associated symptoms.
4. Emergency Assessment
- a very rapid assessment performed in life-
threatening situations.
- Ex. choking, cardiac arrest, drowning
- Check for ABCs.
STEPS OF HEALTH ASSESSMENT
Four major steps:
1. Collection of subjective data
2. Collection of objective data
3. Validation of data
4. Documentation of data
Preparing For The Assessment
- Before actually meeting the client it is helpful to
review the client’s medical record.
- After reviewing the record or discussing the
client’s status with others, remember to keep an
open mind and to avoid premature judgments that
may alter your ability to collect accurate data.
- Use this time to educate yourself about the client’s
diagnoses or tests performed.
- Consult the necessary resources (laboratory
manual, textbook, or electronic reference resource,
Dianna Rose O. Belen, RN, LPT NCM 101 HEALTH ASSESSMENT
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such as a smart phone application) to learn about
the test and the implications of its findings.
- Once you have gathered basic data about the
client, take a minute to reflect on your own
feelings regarding your initial encounter with the
client.
- Remember to obtain and organize materials that
you will need for the assessment.
STEP 1 COLLECTING SUBJECTIVE DATA
- Subjective - sensations or symptoms (e.g., pain,
hunger), feelings (e.g., happiness, sadness),
perceptions, desires, preferences, beliefs, ideas,
values, and personal information that can be
elicited and verified only by the client.
- For accurate subjective data, learn to use effective
interviewing skills with a variety of clients in
different settings.
o Biographical information (name, age,
religion, occupation)
o History of present health concern:
Physical symptoms related to each body
part or system (e.g., eyes and ears,
abdomen)
o Personal health history
o Family history
o Health and lifestyle practices (e.g., health
practices that put the client at risk,
nutrition, activity, relationships, cultural
beliefs or practices, family structure and
function, community environment)
Case Study
As the assessment progresses, the nurse learns through the
interview with Mrs. Gutierrez that she has no appetite and
no energy. She feels as though she wants to stay in bed all
day. She misses her sisters in Mexico, and cannot do her
normal housekeeping or cooking. The nurse thinks that
Mrs. Gutierrez is probably suffering from depression. But
when the nurse asks Mrs. Gutierrez what she believes is
causing her lack of appetite and low energy, Mrs. Gutierrez
says she was shocked when her husband was hit by a car.
He could not work for a month.
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STEP 2 COLLECTING OBJECTIVE DATA - Nursing Diagnosis - “a clinical judgment

- This type of data is obtained by general
observation and by using the four physical
examination techniques:
- Inspection
- Palpation
- Percussion
- Auscultation.
- Another source of objective data is the client’s
medical/health record, which is the document
that contains information about what other health
care professionals.
- Objective data may also be observations noted
by the family or significant others about the
client.
STEP 3 VALIDATING ASSESSMENT DATA
- crucial part of assessment that often occurs along
with collection of subjective and objective data.
- It serves to ensure that the assessment process is
not ended before all relevant data have been
collected, and helps to prevent documentation of
inaccurate data.
STEP 4 DOCUMENTING DATA
- Documentation of assessment data is an
important step of assessment because it forms the
database for the entire nursing process and
provides data for all other members of the health
care team.
- Thorough and accurate documentation is vital
to ensure that valid conclusions are made when
the data are analyzed in the second step of the
nursing process.
Analysis of Assessment Data/ Nursing
Diagnosis: Step Two of the Nursing Process
about individuals, family or community
responses to actual and potential health
problems and life processes. A nursing
diagnosis provides the basis for selecting
nursing interventions to achieve outcomes for
which the nurse is accountable.” (North
American Nursing Diagnosis Association (NANDA,
2012–2014)
- Collaborative Problem - “physiological
complications that nurses monitor to detect
their onset or changes in status. Nurses
manage collaborative problems by
implementing both physician- and nurse-
prescribed interventions to reduce further
complications.
- Referrals - occur because nurses assess the
“whole” (physical, psychological, social,
cultural, and spiritual) client, often identifying
problems that require the assistance of other
health care professionals.
PROCESS OF DATA ANALYSIS
- This process requires diagnostic reasoning
skills, often called critical thinking. The
process can be divided into seven major
steps:
1. Identify abnormal data and strengths
2. Cluster the data.
3. Draw inferences and identify problems.
4. Propose possible nursing diagnoses.
5. Check for defining characteristics of those
diagnoses.
6. Confirm or rule out nursing diagnoses.
7. Document conclusions.

- Analysis of data (often called nursing

Case Study
diagnosis) is the second phase of the nursing
process.
Consider Mrs. Gutierrez, introduced at the beginning
- During this phase, you analyze and synthesize
of the chapter, to help illustrate the reason for seeing
data to determine whether the data reveal a
the client in context. The nurse continues to listen to
nursing concern (nursing diagnosis), a
Mrs. Gutierrez and learns that she is also suffering
collaborative concern (collaborative
from “susto.” Mrs. Gutierrez states that a few days in
problem), or a concern that needs to be
bed will help her recover her soul and her health. The
referred to another discipline (referral).
nurse decides to reschedule the diabetic teaching for a
Dianna Rose O. Belen, RN, LPT NCM 101 HEALTH ASSESSMENT 2018
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later time and provide only essential information to c. "Is it possible that your child might be
Mrs. Gutierrez at this visit. taking drugs?"
d. "Independence is really important for this
Questions: age group. Try to be extra attentive when
1. The nursing process is utilized to: your child does spend time at home."
a. Provide a systemic, organized and
comprehensive approach to meeting the
needs of clients.
b. Encourage the family to make decisions
regarding patient's care.
c. Increase involvement of allied healthcare
professionals in decision-making
d. None of the above

2. Objective data might include:

a. Chest pain.
b. An evaluation of BP
c. Complaint of dizziness
d. None of the above

3. The following is the most important purpose

of documentation except
a. For Communication
b. For Reimbursement
c. For Quality assurance
d. To provide comfort

4. Subjective data might include:

a. Heart rate
b. Oral temperature of 37.7 C
c. Pain Scale of 4/10
d. Poor hygiene

5. A teenage girl spends most of her free time

with friends or at school. Sharing their
concerns about this behaviour with the school
nurse, the parents are worried about their
child seeming to draw away from them. The
nurse's best reply is:
a. "You should really keep better track of
your child. It's hard to tell what kinds of
trouble they may be getting into.
b. "Use stricter guidelines for curfew and
punishment if curfew is broken."
Dianna Rose O. Belen, RN, LPT NCM 101 HEALTH ASSESSMENT 2018