1 | HEALTH ASSESSMENT
CULTURE understand and plan for the needs of a
It is the totality of socially transmitted behavioral
patterns, arts beliefs, values, customs, life ways
and all other products of human work and thought
characteristic of a population or people that guide
their world view and decision making.
Culture is:
✔ Learned
✔ Shared
✔ Associated with adaptation to the
environment
✔ universal
✔ Serves as an ever changing frame for
interpreting information and understanding
how the world works
Cultural and Biologic Variations - are those
diverse manifestations of "normal" that exist
between people with respect to, body structure-
skin color- other visible physical characteristics-
enzymatic and genetic variations-
electrocardiographic patterns- susceptibility to
disease- nutritional preferences and deficiencies,
and - psychological characteristics.
Mechanism of Variation
● Humans vary biologically because of
interaction of genes and environment
o Surface variation and anatomic
differences
Developmental Variations:
✔ African american infants tend to be ahead
of other american groups in motor devt
✔ Biochemical variations and differential
disease susceptibilty
✔ Environmentally related variation
ROLE OF CULTURE IN ILLNESS
● Health care is interactive
● Susto (soul loss or magical fright), mal ojo
(evil eye),
● Empacho (blocked intestines), Caida de la
Mollera (fallen fontanelle) falling out and
voodoo illness
CULTURAL COMPETENCE
● It is the capacity of the nurses or health
service delivery system to effectively
culturally diverse client or group
● It develops overtime.
There are five constructs in the process:
Cultural awareness, cultural knowledge, cultural
skill, cultural encounter and cultural desire
Cultural Awareness: Deliberate “cognitive
process in which the health care provider becomes
appreciative and sensitive to the values, beliefs,
life ways and practices and problem solving
strategies of a client’s culture
● Unconscious incompetence
● Conscious incompetence
● Conscious competence
● Unconscious competence
Cultural Desire: It is the motivation to engage in
intercultural encounters to acquire cultural
competence
Cultural Knowledge: the process of seeking and
obtaining a sound educational foundation
concerning the various world views of different
cultures
Cultural skill: Ability to collect relevant cultural
data regarding the client’s health history and
presenting problems as well as accurately
performing physical assessment
Cultural Encounters: engage directly in face to
face interaction.
I. Hispanics
✔ Hispanics are far more emotionally expressive
✔ Birth control methods other than rhythm are
unacceptable
✔ Most Latin Americans see thinness as a
problem and plumpness as the ideal
✔ Hispanics are not accustomed to the
profession of social workers, and rely on their
families, other relatives and close friends for
support and help
✔ Curanderismo – Latin folk healers
✔ To attend a woman during delivery is a
woman's job, ideally the job of her mother and
midwife

✔ Avoiding eye contact with a person in
authority indicates respect and attentiveness
✔ Direct confrontation is disrespectful
✔ members are oriented more to present
✔ Members may be late for an appointment
because relationships and events are valued
more than time
✔ Members are comfortable with close proximity
with family friends and acquintances
✔ Members are very tactile and uses embraces
and handshakes
✔ Extended family is highly regarded
✔ Men are decision makers and breadwinners,
women are caretakers and homemakers
✔ Health may be viewed as a reward from God
and illness as a punishment from God
II. Middle Eastern
✔ Some people wear amulets for protection
against the evil eye or will burn incense to
keep the evil eye away from the sick
✔ Patient and family will not wait long to seek
professional help and are usually anxious to
receive a medication as soon as possible
✔ Once symptoms have improved, many
patients will stop taking the prescribed
medication or will not return for a scheduled
follow-up appointment.
✔ Both male and female Arab patients and their
children prefer to be seen by male doctors
✔ Most Arabs consider childbirth to be a female
issue only. A woman in labor is usually
surrounded by female relatives and friends
III. Asians
✔ Chinese medicine teaches that health is a
state of spiritual and physical harmony with
nature
✔ A healthy body is in a state of balance. When
it gets out of balance illness results.
✔ In Asia the balance is between yin and yang
✔ The Asian patient rarely complains about what
bothers him
✔ Silence is valued
✔ Eye contact may be considered inappropriate
or disrespectful
✔ Criticism or disagreement is not expressed
verbally
✔ The word NO is a form of disrespect for others
✔ Reflects respect for the past but includes
emphasis on the present and the future
✔ Formal personal space except with family and
close friends.
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✔ Usually members do not touch each other
during conversations
✔ Touching is unacceptable to opposite sex
✔ Head is considered to be sacred so touching
someone on the head is disrespectful
✔ Members are devoted to tradition
✔ Men have the power and authority women are
expected to be obedient
✔ Education is viewed as very important
✔ A healthy body is viewed as a gift from the
ancestors
✔ Illness is attributed to prolonged sitting or lying
or overexertion.
IV. Afro African
✔ Perceive the use of first names as a lack of
respect and a form of racism.
✔ The most common and frequently cited
methods of treating illness is prayer.
✔ The traditional Black belief regarding health
does not separate the mind, body, and spirit.
✔ Head nodding doesn’t necessarily mean an
agreement
✔ Direct eye contact may be considered
rudeness or agressiveness
✔ Nonverbal communication is important
✔ Personal questions asked on initial contact
may be viewed as intrusive
✔ Members are comfortable with close personal
space with family and friends
✔ Many households are headed by single parent
woman
✔ Members believe that illness can be
prevented by nutritious meals, rest and
cleanliness
V. Native Americans
✔ Silence indicates respect for the speaker
✔ Members speak in a low tone of voice and
expects listeners to be attentive
✔ Eye contact is a sign of disrespect
✔ Body language & personal space is important
✔ Oriented more to present
✔ Members will lightly touch another person’s
hands during meetings
✔ Massage is used for the newborn infant to
promote bonding between infant and mother
✔ Elders are honored
✔ Children are taught to respect traditions
✔ Members are family oriented
✔ Health is a state of harmony between the
person the family and the environment

✔ Illness is caused by supernatural forces and
disequilibrium between person and
environment
SPIRITUALITY
● It is the search for the meaning and
purpose.
● Unique to each individual
● Individual’s spirituality is acted on by many
forces through the varied experiences of
life
● It affects health in both physiologic and
psychological ways
DIFFERENT TYPES OF RELIGION
A. BUDDHISM
✔ Suffering is part of human existence
✔ Prayer and meditation are used for
cleansing and healing
✔ Death is associated with rebirth, Serene
surroundings is important to the dignity of
the dying
✔ Many are strict vegetarians
B. HINDUISM
✔ Nirvana (oneness with God)
✔ Illness is cause of past and current life
actions
✔ Right hand is seen as holy.
✔ Death marks as a passage because a soul
has no beginning and no end
✔ Many are vegetarians
C. ISLAM
✔ Mohammed is believed to be the greatest
of all prophets
✔ Prayer occur five times a day
✔ Allah is in control in the beginning and the
end of life
✔ All outcomes are predetermined by allah
✔ Consumption of pork and alcohol is
prohibited
✔ Other meats must meet ritual requirements
D. CHRISTIANS
✔ Focus on the teachings at the old and new
testaments
✔ Most view illness as a natural process of
the body and testing of faith
✔ There is belief in miracles, western
medicine is in high regard
✔ No special or universal food beliefs are
common to christian religions
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E. JUDAISM
✔ Tests, signatures and assessment for
medical needs that can be scheduled to
avoid holy days are appreciated
✔ Psalms and the last prayer of confession
are held at the bedside
✔ Any clothing or bandages with clients
blood should be prepared for burial with
the person
✔ Orthodox or Kosher involves no mixing of
meat with dairy products, separate cooking
and eating utensils are use for food
preparation and consumption
FAMILY
● Family is whatever the client say is
● Nurse should focus on assessing rather
than on valuing
● An individual client cannot be completely
separated from the family nor can the
family be considered with any members
omitted
Role of Family in illness:
✔ Family members affect each member of
the family’s decision
✔ Gender and generation roles affect the
members
✔ Family has a profound effect on the health
status of its members
COMMUNITY
● Is determined by natural boundaries, and
communities organized based on the
relationship among a group of people.
● Community affects the families as families
affect the community.
REVIEW OF THE NURSING PROCESS:
TYPES OF ASSESSMENT
1. Comprehensive Assessment – completed
upon admission to health care agency and
includes a complete health history to
determine current needs of the client
2. Focused Assessment – an assessment that
is limited in scope in order to focus on a
particular need or health care problem or
potential health care risks
3. Ongoing Assessment – an assessment that
includes systematic monitoring and
observation related to specific problems

4. Emergency Assessment - very rapid
assessment per formed in life threatening
situations
STEPS IN HEALTH ASSESSMENT
✔ Collecting subjective data
✔ Collecting objective data
✔ Validation of data
✔ Documentation of Data
1. Subjective Data
● the process in which data relating to the
patient's problem are elicited from a patient
or a patient's family
● The interviewer encourages a full
description of the onset, the course, and
the character of the problem and any
factors that aggravate or ameliorate it.
● Sensations, symptoms, perceptions,
desires preferences, beliefs ideas, values
and personal informations
● Examples are: biographical information,
past health history, family history, health
and lifestyle practices
2. Objective Data
● the process in which data relating to the
client's problem are obtained through
direct physical examination, including
observation, palpation, percussion, and
auscultation, and by laboratory analyses
and radiologic and other studies
● Examples are: physical characteristics,
body functions, appearance, behavior,
measurements and laboratory testing
3. Validation Of Data
● Crucial part of assessment
● The process through which data are
validated as being complete and accurate
● Data are reviewed for inconsistencies and
omissions.
● Examining the congruence between
subjective and objective data.
4. Documenting Of Data
● It serves as the database for the entire
nursing process and provides data for all
other members of health care team.
● Proper documentation is vital
PROCESS OF DATA ANALYSIS
Often called as a Nursing Diagnosis; The clinical
judgment about individual, family or community
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responses to actual, or risk health problems,
wellness states or syndromes
1. Identify abnormal data and strength
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
Purposes of Nursing Diagnosis:
✔ Empowerment of the nursing profession
✔ Facilitates effective communication
✔ Provides means to individualize nursing
care
Subjective Data: Can be obtained through
interview
Interview: Therapeutic interaction that has a
specific purpose which is to collect information
about the client’s health history and current status
in order to make determination on the client’s
health care needs
Two Focus of interview:
1. Establish rapport and trusting relationship
2. Gather information on the client’s status
Phases of Interview:
1. Introductory Phase
2. Working Phase
3. Closing Phase
COMMUNICATION TECHNIQUES:
A. Non-verbal Communication
✔ Appearance
✔ demeanor
✔ facial expression
✔ Attitude
B. Verbal communication
1. Open ended questions
● An open-ended question is designed to
encourage a full, meaningful answer
using the subject's own knowledge and/or
feelings
● Typically begins with the word “how or
what”
● Open-ended questions also tend to be
more objective and less leading than
closed-ended questions
2. Close ended Questions

● Closed ended questions are those
questions, which can be answered finitely
by either “yes” or “no.”
● It deals with facts and focus on a specific
information.
● Usually begins with “when and did”
Other ways of verbal communication:
✔ Laundry list
✔ Rephrasing
✔ Well placed phrases
✔ Inferring
✔ Providing information
HEALTH HISTORY OF THE PATIENT
● COLDSPA - Character, Onset, Location,
Duration, Severity, Pattern, Associated
factors
● Lifestyle and Health practices:
o ADL’s
o social activities
o relationships
o education and work
o stress level and coping styles
o environment
OBJECTIVE DATA
✔ Assessing vital signs
✔ Physical assessment
✔ Preparing the equipment for PE
✔ Preparing the physical setting
✔ Preparing the Client
Equipment:
Gloves, Sphygmomanometer, Stethoscope, Calipers,
Tape measure, Weighing scale, Penlight, Snellen’s
Chart, Opthalmoscope, Otoscope, Tuning fork,
Reflex hammer, Speculum
PREPARING ONESELF:
1. Wash hands
✔ Before beginning the examination
✔ Immediately after accidental direct contact
with blood or other body fluids
✔ After completing the physical examination.
2. Wear gloves
✔ if you have an open cut or skin abrasion
✔ if the client has an open wound
✔ if you are collecting body fluids for
specimen
✔ if you are handling contaminated surfaces
✔ when performing an examination of the
mouth an open wound, genitalia, vagina or
rectum
5 | HEALTH ASSESSMENT
✔ Wear mask or protective eye goggles
✔ if you are likely to be splashed with blood
or other body fluids
Inspection
● Uses the sense of vision, smell, and
hearing
● Starts once you meet the client
Guidelines for inspection:
✔ Comfortable room temperature
✔ Good lighting and exposure is essential
✔ Begins with the survey of the clients
appearance and a comparison of the right
and left side of the body
✔ Inspect each body part unhurriedly for the
size, shape, color, texture, symmetry,
movement, eruptions and positions then
compare with the opposites side of the
body
✔ Use additional light (provided by the
penlight) in inspecting cavities
✔ Inspection should not only involve visual
skill but also olfaction (smell), sense of
smell may detect abnormalities that cannot
be seen
✔ Ask a colleague to confirm the assessment
when in doubt
✔ Look and observe before touching
Palpation
● Using parts of the hand to touch and feel
● Light palpation - very little or no
depression ( less than 1cm)
● Moderate palpation - depress the skin
surface (1 to 2 cm)
● Deep palpation - surface depression of
(2.5 cm to 5 cm)
● Bimanual palpation - using two hands
placing one on each side of the body part

Percussion
Involves striking or tapping the body parts to
produce sound waves. It is use to determine size
and shape of organs and masses and to determine
whether the underlying tissues is solid, filled with
fluid or air. Use also to elicit pain and reflexes. It is
most commonly use to assess the thoracic and
abdominal structures.
● Direct percussion - it is the direct tapping
of the fone or two fingertips to determine
tenderness
● Blunt percussion - use to determine
tenderness to organs
● Indirect percussion - most commonly
used method; produces a sound that or
tone that varies with density of the
underlying structures
Techniques On How To Percuss:
✔ Place the middle of your non dominant
hand on the body part you are going to
percuss
✔ Keep the other fingers of the body part
✔ Use the pad of the middle finger of the
other hand to strike the middle finger of the
dominant hand
✔ Withdraw finger immediately after tapping
✔ Deliver two quick taps and listen to the
tone
✔ Use quick sharp taps by quickly flexing
your wrist
Common Errors in Percussion:
● Generating the percussion stroke from the
forearm rather than from the wrist
● Generating the percussion stroke from the
finger rather from the wrist
● Holding the striking finger against the
positioned finger, rather than releasing it
immediately after the impact
● Failing to keep the other fingers from
touching the ‘drum’ finger
● Using excessive force, particularly with
children and elderly clients
● Creation of the ‘woodpecker syndrome’.
This the delivery of more than two rapid
consecutive strikes to the ‘drum’ finger
Auscultation:
It is a skill of listening to the sounds produced by
the with the use of stethoscope.
6 | HEALTH ASSESSMENT
Guidelines on Auscultation:
✔ Eliminate distracting noises
✔ Expose body part you are going to
auscultate
✔ Diaphragm for high pitch sounds
✔ Bell for low pitch sounds
Midstream Catch
Equipments:
✔ Antiseptic solution
✔ Sterile water or saline
✔ Sterile specimen container
✔ Gloves
✔ Soap, water, washcloth and towel
✔ Specimen identification label
✔ Laboratory requisition form
Nursing Considerations:
1. Assess level of client’s understanding on
purpose of the test and method of
collecting.
2. Assess client’s mobility and balance.
3. Refer to medical record for indications of
urinary infection.
Procedure:
a. Identify the client. Perform hand hygiene
b. Provide privacy
c. Give client towel and soap with water to
clean the perineum
d. Open sterile kit, or prepare sterile tray
e. Apply sterile gloves
f. Pour antiseptic sol’n over cotton balls
g. Perform urine collection
Male client:
1. Clean the meatus in circular motion (center
to out)
2. Rinse area with sterile water and dry
3. After client has initiated urine, pass urine
specimen container into stream and collect
30 to 60 ml of urine .
Female Client:
1. Spread labia with thumb and forefinger
using non dominant hand
2. Use dominant hand to clean the area with
the swab moving from front to back
3. Rinse and dry
4. While holding the labia apart, initiate urine
stream into the toilet and after stream is
achieved, pass specime bottle to stream
an collect 30 to 60 ml of urine

Both for male and female:
1. Remove specimen container before flow of
urine stops
2. Replace cap securely on specimen
container
3. Cleanse urine from exterior surface of the
specimen bottle
4. Remove and discard gloves
5. Label specimen and attach laboratory
requisition.
6. Take laboratory specimen within 15 to 20
minutes.
Collecting Sterile Specimen from
an indwelling catheter
Equipments:
✔ 3ml syringe or 20 ml syringe
✔ alcohol, povidone iodine or other
disinfectant swab
✔ Clamp or rubber band
✔ Specimen container
✔ Clean gloves
✔ Specimen identification label
✔ Laboratory requisition form
Procedure:
1. Perform hand hygiene
2. Clamp drainage tubing with clamp or
rubber band for 30 minutes
3. Return to room and inform the client that
procedure is about to begin
4. Perform hand hygiene and put on gloves
5. Position client so that catheter is easily
accessible
6. Clean entry port for needle with a
disinfectant
7. Insert needle at 45 degree angle to the
catheter’s sampling port or to a self sealing
catheter.
8. Draw urine on a 3ml syringe (culture) 20 ml
syringe ( for routine urinalysis)
9. Transfer urine from syringe to a container
10. Place lid tightly on a container
11. Unclamp catheter and allow the flow into
drainage bag.
12. Dispose soiled supplies, discard gloves
13. Secure and attach properly
identification label and requisition form
14. Send specimen label to the laboratory
immediately.
Nursing considerations:
1. Assess client’s understanding the need for
specimen collection
7 | HEALTH ASSESSMENT
2. Assess for signs of urinary tract infection
3. Assess the indwelling catheter for built in
sampling port or type of material which it is
made
Stool Exam:
Used to assess gross appearance of the stool and
presence of ova/parasites
1. Secure sterile specimen container
2. Instruct the patient to defecate in a bedpan
3. Use tongue depressor to collect the
specimen.
4. Collect one teaspoonful or 1 inch of well
formed stool.
5. Label the specimen immediately to the
laboratory.
Other Diagnostic Exams
1. Radiology: is the branch or speciality of
medicine that deals with the study and application
of imaging technology like x-ray and radiation to
diagnosing and treating disease.
● Originally it was the aspect of medical
science dealing with the use of
electromagnetic energy emitted by X-ray
machines or other such radiation devices
for the purpose of obtaining visual
information as part of medical imaging.
Radiology that involves use of x-ray is
called roentgenology. The modern day
radiological imaging is no longer limited to
the use of x-rays, and now includes
technology-intensive imaging with high
frequency sound waves, magnetic fields,
and radioactivity.
o Wilhelm Conrad Röntgen first
discovered x-radiation on 8
November 1895 at the Physical
Institute of Würzburg University.[1]
He named the radiation he had
discovered "X-radiation". This term
is still in use today in the
Anglo-American region.
the 2. Ultrasound: High-frequency sound waves.
Ultrasound waves can be bounced off of tissues
using special devices. The echoes are then
converted into a picture called a sonogram.
Ultrasound imaging, referred to as
ultrasonography, allows physicians and patients to
get an inside view of soft tissues and body
cavities, without using invasive techniques.
Ultrasound is often used to examine a fetus during
 8 | HEALTH ASSESSMENT

pregnancy. There is no convincing evidence for

any danger from ultrasound during pregnancy.

3. CT Scan: it allows for a detailed image to be

taken of the internal tissues of the body.CT is an
abbreviation for computed tomography. In fact a
powerful computer works to put up together the
large amount of information obtained by this test
into a detailed picture of the body.

● CT scan uses xrays from, multiple different

points around the patient to obtain their
images and therefore expose the patient to
some radiation

4. Magnetic resonance imaging (MRI): Magnetic

resonance imaging (MRI) is the newest, and
perhaps most versatile, medical imaging
technology available. Doctors can get highly
refined images of the body's interior without
surgery, using MRI. By using strong magnets and
pulses of radio waves to manipulate the natural
magnetic properties in the body, this technique
makes better images of organs and soft tissues
than those of other scanning technologies. MRI is
particularly useful for imaging the brain and spine,
as well as the soft tissues of joints and the interior
structure of bones. The entire body is visible to the
technique, which poses few known health risks.