Health Assessment
Patient answers to
What is Health Assessment?
• The gathering of information concerning the
patient’s individual physiological,
psychological, sociological and spiritual needs.
• It helps identify the medical needs of the patient.
• It is the evaluation of the health status by
performing a physical exam and taking a health
history.
Physiological - includes basic functions of living like
breathing eating and walking
Psychological- involves the intellect, self-concept,
emotions and behavior.
Sociological- includes relationships and interaction
among family, friends and colleagues
Spiritual- focuses on the belief of a higher being,
personal interpretations of the meaning of life and
attitudes towards moral decisions and personal conduct.
Purpose of Health Assessment
• To obtain baseline data about the client’s
functional abilities
• To supplement, confirm or refute data obtained
in the nursing history
• To obtain data that will help establish nursing
diagnoses and plans of care
• To evaluate the physiologic outcomes of health
care and thus, the progress of the client’s
problem
• To make clinical judgments about the client’s
health status.
• To identify areas for health promotion and
disease prevention.
Considerations in performing nursing assessment:
• Prepare the patient
• Prepare the environment
• Position the patient
• Drape the patient
• Prepare instruments to be used
Health Taking History
To gather subjective data from the patient so that the
health care team and the patient can collaboratively
create a plan that will promote health, address acute
health problems, and minimize chronic health
conditions.
What to take note?
• Biographic Data: such as the patient’s name.
address, birth date, profession, emergency
contact or telephone number, age, marital status,
religion and nationality
• Reasons for seeking Health care: This will be
helpful why admission was sought. To explore
past and present problems.
basic questions can provide important clues
about his personality, medical problems, and
reliability.
• Chief Complaints: try to point out why the
patient is seeking health care or his chief
complaint. It is important for the nurse to
document this information in the patient’s exact
words to avoid misinterpretation. Ask how the
symptoms developed. What led the patient or
his/her family to seek medical attention and how
the problem has affected his life and ability to
function.
• Medical history, history of present illness,
family health history, psychosocial history,
activities of daily living, diet and elimination,
sleep and exercises, use of drugs, alcohol and
other substances.
Effective Communication
Tips in making an interview more pleasing to the patient:
1.Choose a quiet private place.
2.Making the patient and family comfortable as much as
possible.
3.Introduce self and explain the purpose of the interview.
4.Assure the patient and family that information
gathered will be held confidential.
5.Avoid touching. Not all patient is comfortable.
6.Assess /identify the patient to see if language barriers
exist. Be aware of cultural differences and responses of
the patient.
7.Listen attentively and make eye contact.
8.Use reassuring gestures, such as nodding of head to
encourage the patient to keep talking.
Watch out for nonverbal clues that may indicate the
patient is uncomfortable or unsure about on how to
answer a question.
9.Be aware of non- verbal behaviors that might cause the
patient to stop talking or become defensive.
10.Observe the patient closely to see if he understands
each question
2 types of Communication
Verbal
• provides patient to answer to many questions.
• Open –ended questions allows the patient to
continue to open and answer freely.
Closed -ended questions elicit a YES or NO answer or
one-to-two-word responses only. They limit the
development of nurse-patient rapport
Non verbal
• a more accurate expression of a person’s
thoughts and feelings than verbal
communication. uses gestures, facial
 expression, posture/gait, body movements, spleen) being palpated. Use one hand to apply
physical appearance, body language, eye contact pressure and the other hand to feel the structure.
and tone of voice. Note the size, shape, consistency and mobility of
TRUST : IS THE FOUNDATION OF A POSITIVE the structures palpated
NURSE-CLIENT RELATIONSHIP. 5 Percussion tones
• Tympany – drum like sound heard over
COMMUNICATION IS A RECIPROCAL enclosed air (air in bowel) – liver and
INTERACTION (TWO WAY PORCESS), IT IS diaphragm.
BASED ON TRUST AND IS AIMED AT • Resonance – hollow sound over areas of part
IDENTIFYING CLIENT NEEDS AND DEVELOPING and part solid organs (normal lungs).
MUTUAL GOALS. • Hyper resonance – booming sound heard over
areas filled with air like in lungs with
Physical Examination emphysema.
It is the process of evaluating objective anatomic • Dull – sound over solid tissue like liver, spleen
findings through the use of inspection/observation, and heart.
palpation, percussion and auscultation. • Flat – flat sound heard over dense tissue like
Methods of examining: muscle and bones.
• Inspection- it is the visual examination; Most common equipment needed for physical
assessing by using the sense of sight. It begins examination
when the nurse first meets the patient and Cotton balls Thermometer
continues throughout the health history and Sphygmomanometer Stethoscope
physical examination. Gloves Pen light
• Palpation- examination of the body using the Tongue depressor Tunning fork
sense of touch more commonly with the use of Percussion hammer Vaginal speculum
the finger pads. To do this, the nurse need short
fingernails and warm hands. Always palpate Different position during physical examination
tender areas last. Fowlers position
• Percussion- it is the act of striking the body
surface to elicit sounds that can be heard, also
vibrations that can be felt or actions that can known as
elicit a body response. semi-
Auscultation- It is the process of listening to sounds sitting
produced within the body position,
Types of palpation is a bed
• Light palpation: is performed to feel for surface position wherein the head of the bed is
abnormalities. Depress the skin ½ or ¾ with elevated 45 to 60 degrees. Variations of
your finger pads, using the lightest touch Fowler’s position include: low Fowler’s
possible. Assess for texture, tenderness, (15 to 30 degrees), semi-Fowler’s (30 to
temperature, moisture, elasticity, pulsations, 45 degrees), and high Fowler’s (nearly
superficial organs and masses. vertical)
• Moderate palpation: depress the skin surface 1 to • Promotes lung expansion.
2 cm with dominant hand, use a circular motion Supine Position
to feel for easily palpable body organs and
masses. • back lying
• Deep palpation: used to feel for internal organs position with
and masses for size, shape, tenderness, legs extended,
symmetry and mobility. Depress the skin 1 ½ to with or without
2 inches with firm, deep pressure. If necessary, pillow under
use one hand on top of the other exert firmer the head.
pressure. • Most commonly used position
• Bimanual palpation: use two hands, placing one
on each side of the body part (uterus, breasts,
 pillow under the bed, soles of feet on the
surface.
Trendelenburg
Lithotomy Position
• involves lowering the head of the bed and
•
is a patient position raising the foot of the bed of the patient. The
in which the patient patient’s arms should be tucked at their sides
is on their back • Promotes venous return.
with hips and knees
flexed and thighs apart and are placed on Reverse Trendelenburg
stirrups
Sims Position •is a patient position
wherein the head of

or semi-prone the bed is elevated
position is with the foot of the
when the bed down. It is the
patient opposite of Trendelenburg’s position
assumes a Knee-chest position
posture
halfway •
can be in lateral or
between the lateral and the prone prone position. In
positions. The lower arm is positioned lateral knee-chest
behind the client, and the upper arm is position, the patient
flexed at the shoulder and the elbow. lies on their side,
The upper leg is more acutely flexed at torso lies diagonally across the table, hips and
both the hip and the knee, than is the knees are flexed. In prone knee-chest position,
lower one the patient kneels on the table and lower
Lateral Position shoulders on to the table so chest and face rests
on the table
• or side-lying Orthopneic Position
position, the patient
lies on one side of •or tripod
the body with the position places
top leg in front of the bottom leg and the hip and the patient in a
knee flexed. Flexing the top hip and knee and sitting position
placing this leg in front of the body creates a or on the side of
wider, triangular base of support and achieves the bed with an
greater stability. Increase in flexion of the top over-bed table in front to lean on and several
hip and knee provides greater stability and pillows on the table to rest on
balance. This flexion reduces lordosis and • Maximum lung expansion.
promotes good back alignment. Prone Position
Dorsal Recumbent
• the patient
• back lying lies on the
position abdomen
with knees with head
flexed and turned to one
hips side and the
externally hips are not
rotated. Small flexed
• Contraindicated for spine problems.
Jack-knife Position
 • also known
as Kraske, is
wherein the
patient’s
abdomen lies
flat on the bed. The bed is scissored so the hip is
lifted and the legs and head are low.

ENDOMORPH
✔ A pear-shaped body
✔ A rounded head
✔ Wide hips and shoulders
✔ Wider front to back rather than side to side
General Survey ✔ A lot of fat on the body, upper arms and thighs
Health Assessment begins with a general survey that MESOMORPH
involves observation of the client’s general appearance ✔ A wedge-shaped body
and vital signs, nutritional status, observation of the ✔ A cubical head
mental status and assessment of the psychosocial, ✔ Wide broad shoulders
cognitive and moral development. ✔ Muscled arms and legs
1. Over-all Impression/ General Appearance ✔ Narrow Hips
• Body Build, Height and Weight ✔ Narrow from front to back rather than side to
• Dressing side
• Hygiene ✔ A minimum amount of fat
• Posture and Gait ECTOMORPH
2. Level of consciousness ✔ A high forehead
3. Level of Comfort ✔ Receding chin
4. Behavior, body movement and affect ✔ Narrow shoulders and hips
5. Facial Expression ✔ A narrow chest and abdomen
6. Speech ✔ Thin arms and legs
7. Vital Signs ✔ Little muscle and fat
General Appearance General Survey: Height and Weight
There a three extremes of body types according to There is no distinct average height and weight for men
Beashel and Taylor (1997) and
• Endomorph women but different factors contribute to their stature.
An endomorph typically has short arms and legs Men are generally taller than women
and a large amount of mass on their frame. • Average Filipino Height in males: 5 feet and 5
• Mesomorph inches
A mesomorph has a medium structure and • Average Filipino Height in females: 4 feet and
height. 11 inches
• Ectomorph Considerations when taking measurements of height:
A predominantly ectomorphic individual is long, ✔ Ask the client to remove their shoes prior to
slender and taking the measurement
thin. ✔ Ask the client to stand with their back to the
wall and look directly forward. The back of their
feet, calves, bottom, upper back and the back of
their head should all be in contact with the wall.
They should be positioned directly underneath
the drop-down measuring device
✔ Lower the measuring device until it rests gently
on the top of the client’s head and record the
measurement
 ✔ Zero the scales before the client steps onto them
✔ Ask the client to remove any ‘heavy’ items from
their pockets (keys, wallets etc.) and remove any
heavy items of clothing or apparel (big jackets,
shoes, woolen jerseys etc.)
✔ Ensure to note the client’s state and time of day
for testing to ensure any subsequent tests can be
taken under identical conditions (check state of
hydration, food consumed recently etc.)
✔ When measuring weight – ask client to look
straight ahead and stay still on the scales. Wait
for the needle/digital screen to settle before
recording the measurement
Body Mass Index (BMI)
✔ Categorization apply to adults of age 20 years
and upwards. The World Health Organization
(WHO) regards a healthy adult BMI to be
between 18.5 and 25.
General Survey: Dressing
• Assessing how the person dresses will be able to
check for his ability to perform self care and
activities to maintain an independent life.
• An individual’s dressing sense speaks volumes
of his character and personality.
• The way the person dresses may identify health
problems in a matter of degree.
• The mental state affects the way the person
dress.
General Survey: Hygiene
• Assessing patient hygiene and personal care is
important to ascertain how well patients care for
themselves or a caregiver cares for them.
• Hygiene is necessary for health, comfort, well-
being, and safety.
• Hygiene in a variety of settings, plays an
important role in preventing the spread of
infectious diseases.
• Assess for the skin, hair , nails, ear, mouth and
genitalia condition as well as the person’s body
odor.
General Survey: Posture
• Healthy posture is based on natural positions
that balance and support the skeletal system’s
curves and weight-bearing abilities against the
force of gravity.
• The American Physical Therapy Association
(APTA) delineates good standing posture as
alignment of the ear, shoulder, hip, knee and
ankle, as seen from the side.
Types of Posture
• Kyphosis
• or hunchback, is an unbalanced posture
that can cause neck and back pain. The
head is pushed forward, in front of the
gravitational center. The upper back is
rounded, accentuating the thoracic
curve.
• Lordosis
• is a back posture that exaggerates the
lumbar curve into a position often
termed as “swayback”. Standing with
locked knees contributes to this
unhealthy posture that aligns the head
behind the center of gravity. Shoulders
may also be pulled back too tightly.
• Scoliosis
• is an abnormal sideways curve of the
spine that results in improper alignment
of the spine, shoulders and neck. Visible
symptoms may include uneven shoulder
height or a non vertical neck angle.
Other types of posture:
 • Waddling gait

• A person with this gait waddles from

side to side when walking.
General Survey: Level of Consciousness (LOC)
Level of consciousness (LOC) is a measurement of a
person's arousability and responsiveness to stimuli from
the environment
• Decorticate
• is a body position in which the arms and
hands are curled inward, and the legs are
held straight outward.
• Decerebrate
• Leaves arms and legs extended, toes
pointed downward and head pushed
backward.
General Survey: Gait
• Propulsive gait

• A slouched, rigid posture characterizes

this gait.
• A person with this condition walks with
their head and neck thrust forward.
• Scissors gait

• A person with this

gait walks with General Survey: Level of Comfort
their legs bent • Comfort is a sense of physical or psychological
slightly inward. ease, often characterized as a lack of pain,
As they walk, suffering or affliction, and requires alleviation
their knees and from that state.
thighs may cross Wong-Baker Faces Pain Scale
or hit each other
in a scissor-like
movement.
• Spastic gait

• A with spastic
gait drags their • Is used to assess a patients level of pain
feet while • It is developed to assist children in
walking. They rating pain
may also appear to Numerical Pain Scale
walk very stiffly.
• Steppage gait

• A person with this condition walks with

their toes pointing downward, causing
their toes to scrape the ground while
walking.

• is a numerical scale from 0 to 10

 • 0 means you have no pain; one to three
means mild pain; four to six is
considered moderate pain; seven and
above is severe pain
General Survey: Behavior, Body Movement and
Affect
• Behavior- is the range of actions and
mannerisms made by individuals, in
conjunction with themselves or their
environment
• Body movement-
motion of all or part of the body, especially at a j
oint or joints. Body movements include,
abduction,
adduction, extension, flexion, rotation, a
nd circumduction
• Affect-
Feeling or emotion, especially as manife
sted by facial expression or  body language
General Survey: Facial Expression
• Facial Expression-is one or more motions or
positions of the muscles beneath the skin of the
face. These movements convey the emotional
state of an individual to observers.
General Survey: Speech
• Speech- The expression of the ability to express
thoughts and feelings by articulate sounds.
• Common Types:
1. Muteness is complete inability to speak.
2.Stuttering, also known as stammering. The flow
of speech is disrupted by involuntary repetitions and
prolongations of sounds, syllables, words or phrases as
well as involuntary silent pauses or blocks in which the
person who stutters is unable to produce sounds.
3. Cluttering- is a speech and fluency disorder
characterized primarily by a rapid rate of speech, which
makes speech difficult to understand.
4. Voice disorders- are impairments, often physical, that
involve the function of the larynx or vocal resonance.
5. Dysarthria- is a weakness or paralysis of speech
muscles caused by damage to the nerves or brain. 
PQRSTU
To ensure that nurses do not omit pertinent data.
To provides a systematic approach in obtaining
information.
P= Provocative or Palliative. Ask the patient:
1.What provokes or relieves the symptoms
2.Do stress, anger, certain physical positions or
other factors trigger the symptoms?
3.What makes the symptom worsen or subside
or lessen or disappear?
Q= Quality or quantity. Ask the patient:
1.What does the symptom feel like, or sound
like?
2.Are you having the symptom right now? If so,
is it more or less severe than usual?
3.To what degree does the symptom affect your
normal activities
R = Region or Radiation. Ask the patient:
1.Where in the body does the symptom occur?
2.Does the symptom appear in other regions of
the body? If so, where?
S = Severity. Ask the patient:
1.How severe is the symptom?
2.From the scale of 1 to 10 being the most
severe?
T = Timing. Ask the patient:
1.When did the symptom begin?
2.Was the onset sudden of gradual?
3.How often does the symptom occur?
4.How long does the symptom last?
U = Understanding. Ask the patient:
1.What do you think caused the symptom?
2.How do you feel about the symptom?
3.Do you have fears associated with it?
4.How is the symptom affecting your life?
VITAL SIGNS
•The vital signs provide data that reflect the
status of several body systems including but not
limited to the cardiovascular, neurologic,
peripheral vascular and respiratory systems.
• This includes the assessment of the following:
• a. Body Temperature
• b. Pulse Rate/ Cardiac rate
• c. Respirations
• d. Blood Pressure
VITAL SIGNS: Body Temperature
 • ORAL – most accessible and convenient. Taken and there will be one or two days of normal
2-3 minutes. 36.5 – 37.5 DEGREE temperature.
CENTIGRADE 4. Remittent fever- is the type of fever where the
• RECTAL – most accurate. Taken 2 mins for temperature fluctuates several degrees above
adult. 5 mins for neonates. 37 – 38.1 DEGREE normal but does not reach normal temperatures
CENTIGRADE between fluctuations
• AXILLARY – safest and most noninvasive. 9
mins adults, infants and children 5 mins. 35.8 -
37 DEGREE CENTIGRADE
• TYMPANIC-36.8 – 37.9 DEGREE
CENTIGRADE

Vital Signs: Pulse

• Pulse- It is the wave of blood created by
contraction of the left ventricle of the heart. The
pulse rate is regulated by the autonomic nervous
system.
9 Pulse points

Vital Signs: Body Temperature

• Types of Fever
1. Intermittent or quotition fever- is the type where
the temperature alternates regularly between
period of pyrexia and a period of a normal or
subnormal temperature.
2. Constant or Continuous fever- a type of fever
where the temperature remains constantly high Vital Signs: Respiration
during the day. It may vary slightly in degrees
but does not fall below moderately high fever.
3. Relapsing fever- is the type of fever where the
body temperature is elevated for several days
 2. Allow 30 minutes to pass if the client had
engaged in exercise or had smoked or
ingested caffeine before taking the bp.
3. Use appropriate size of the BP cuff. Too
narrow cuff causes false high reading.
4. Two wide cuff causes false low reading.
5. Position the client in sitting or supine
position.
6. Position the arm at the level of the heart with
the palm of the hand facing up. The left arm
is preferably used because it is nearer the
heart.
7. Apply BP cuff snugly, 1 inch above the
antecubital space.
8. Determine palpatory BP before auscultatory
BP to prevent auscultatory gap.
9. Use the bell of the stethoscope since the
blood pressure is a low-frequency sound.
10. Inflate and deflate BP cuff slowly, 2-3
mmHg at a time.
11. Wait 1-2 minutes before making further
determinations.
12. The sound during the BP taking is Korotkoff
Vital Signs: Blood Pressure sound.
13. Read lower meniscus of the mercury level of
the sphygmomanometer at eye level to
prevent error of parallax. *it occurs when
the eye level is higher than the level of lower
meniscus of the mercury, this cause false
low reading: if the eye level is lower, this
causes false high reading.
14. The systolic pressure in the popliteal artery
is usually 10-40 mmHg higher than that in
brachial artery; the diastolic pressure is
usually the same.

Vital Signs: Pain

THE 5TH VITAL SIGN – evaluation of pain becomes a
requirement of proper patient care as important and basic
as the assessment and management of temperature,
blood pressure, respiratory rate and pulse rate.
PAIN IS A SYMPTOM THAT MAY AFFECT
NORMAL RESULT OF VITAL SIGNS.
It measured on a scale of 0 – 10 pain scale based on
subjective patient reporting.

Vital Signs: How to assess BP

1. Ensure that client is rested.