BACHELOR IN NURSING

NBNS1214
NURSING HEALTH ASSESSMENT
MAY SEMESTER 2022

MATRIX NUMBERS : 9202708550000001

IDENTIFICATION NUMBERS : 920827-08-5500

PHONE NUMBERS : 013-7792920

EMAILS : jannah2708@oum.edu.my

LEARNING CENTERS : OUM ALOR SETAR

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 TABLE OF CONTENT

INTRODUCTION 3

HEALTH ASSESMENT RELATED TO NURSING 4

TYPE OF ASSESMENT 5

COMPONENT OF HEALTH ASSESMENT 7

METHOD OF HEALTH ASSESMENT 9

ASSESMENT TECHNIQUE 10
IMPORTANT OF HEALTH ASSESMENT 11

CONCLUSION 12

PART II (ONLINE CLASS PARTICIPTATION) 13

REFERENCES 15

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INTRODUCTIONS.
The founder of modern nursing Florence Nightingale (12 May 1820 - 13 August 1910)
recorded the history of nursing through her contributions during the Crimean war (1852 - 1854).
She get the title of Lady With The Lamp because by lighting the lamps in dark and cold weather
she had treated and cared for wounded and in pain soldiers. Beginning from this , women were
given higher education and had commendable qualities and were given training in the field of
nursing. Thus, the field of nursing continues to grow rapidly and is given worldwide recognition.

The role of the nurse generally encompasses primary, secondary and tertiary health care
activities. For primary health care activities, covering health promotion activities, disease
prevention and control, care and rehabilitation. While for secondary and tertiary health care it
involves health care activities in hospitals. In line with the task of holistic care, nurses need to
monitor the patient's condition from time to time, document care progress records and take
appropriate action and report unusual matters to those responsible. In performing daily duties and
responsibilities, nurses are subject to the Nurses Act 1950, Midwives Act 1966, Professional
Code, Nursing Conduct, Policies, Rules and Guidelines that have been set in improving the
quality of health care as well as community, family and community involvement.

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HEALTH ASSESMENT RELATED TO NURSING.
Assessment is the systematic determination, value and importance of a subject, using
criteria governed by a single standardization setting. It can assist in organizing, programming,
designing, projecting or any other intervention or initiative to evaluate any achievable goals,
concepts or proposals, or any alternatives, to assist in decision making. assessment with respect
to the goals and objectives as well as the outcome of such actions that have been completed.

Health assessment is the process of identifying a patient’s specific needs and ways of
providing care by the health care system or professional nurses. A health assessment is an
assessment of a patient to find out his or her health status after taking a health history. Health
assessment helps in detecting the early signs of the disease in individuals who appear lifeless
thus being able to see the health status of the individual. With this, prevention, treatment and
care can be determined according to the disease status of the individual so that health and well -
being can be maintained. General health status and broader concepts of quality of life can be
viewed by including physical, mental, social and functional measures of roles and perceptions of
general health recorded for a comprehensive health assessment.

“Nursing assessments should include the client’s perceived needs, experiences related to
health problems, the value of health practices and lifestyles” (Bandman and Bandman, 1995).
Nursing assessment is the collection of information about the physiological, psychological,
sociological and spiritual status of a patient. It is different from a medical assesment. Medical
assessment is a diagnosis and treatment. Nursing assessments are used to identify current and
future patient care needs. This combines the recognition of normal and abnormal body
physiology. Immediate detection of appropriate changes in critical thinking skills allows nurses
to identify and prioritize appropriate interventions. Assessment formats may already be available
for use in certain facilities and in certain circumstances. Therefore nurses should think critically
about what treatment should give to patient.

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TYPES OF ASSESMENT
There are four type of assessment :

 Initial assessment is also known as assessment triage.Its is to determining the type of

patient problems and submit to evaluation into the problem faced.Initial assessment will
be far away more thorough than other assessments that used by nurses.Its include
obtaining assessment of the patient's medical history, perform physical examination, and
completing an assessment psychosocial for health patients mental.Other components
include obtaining vital signs of the patient and hearing complaint (subjective statement)
from patients, as well as reexamining the data subjective and objective data of the
situation.
 Emergency assessment is an examination physical assessment performed when the
factors of the time, treatment must be started immediately,or priority for necessary care
determined in minutes.Treatment of patients based on quick survey about the
incident.During an emergency procedure, nurse assessment is responsible for making
assessments and focus quickly to identify the causes of problems are related in airways
and respiratory patterns as well as the circulation (ABC circulation) of the patient.When
ABC’s circulation is stable,the assessment made may change and may be an initial
assessment or focus(focused assessment), depending on situations.
 Focused assessment is where assessment of the problem is already known and when the
process treated.When the process is being treated,there may be a change in the sign of
pain type, mental status or the patient’s level of awareness.Early treatment is depending
of the disease. Purpose of a focused assessment are to diagnose and treat patients for
stabilize the situation. Focus assessment can also include X-rays or other types of tests.
Focus assessment is a nursing assessment specifically in related body systems by
acquiring problems or abnormalities depending on the physical examination performed.
 Time-Lapsed Assessment also must be done to ensure the patient recovers from his
illness and his condition is stable. Depending on the type of illness, the assessment is
continued may take a time or two hours or months. During the completed assessment, the
status of the patient current compared to the guidelines before during and before

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treatment. Same as focused assessment, evaluation which has been delayed may also
include laboratory work, X-rays or diagnostic medical tests or another.

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COMPONENTS OF HEALTH ASSESSMENT IN NURSING

Prior the assesment, nurses must establish professional communication methods and a
therapeutic atmosphere. This builds relationships and lays the foundation for relationships of
mutual trust and non -judgment. Its may allows the patient to feel comfortable when disclosing
his or her personal information. Nurses can start by introducing themselves. The interviewer
continues to ask the client how they would like to be handled and the general nature of the topics
to be included in the interview. Therapeutic communication methods of nursing assessment take
into developmental stage (young children vs. the elderly), privacy, disturbances, age-related
barriers to communication such as sensory and language deficits, place, time, nonverbal cues.
Therapeutic communication is also facilitated by avoiding the use of medical terms and instead
using general terms used by patients. During the first part of the personal interview, the nurse
conducted an analysis of the patient’s needs. In most cases, clients require a focused assessment
rather than a comprehensive nursing assessment of the entire body system. In a focused
assessment, key complaints are assessed.

 HISTORY AND PATIENT INTERVIEWS

Patient history and interviews were considered subjective. The use of open -ended
questions is strongly encouraged. An open -ended question is a question that cannot be
answered with a simple “yes” or “no” answer. If the person is unable to answer the
question, the family or guardian will be given the opportunity to answer the question.
Special nursing assessment in a clinical setting is the collection of data on the following
such as complaints and symptoms, health history, family history, social history,
medication in use or current nursing.The patient’s history is documented through
personal interviews with the client and or the client’s family. If there is an urgent need for
a focused assessment, the most obvious or troubling complaints will be addressed first.
This is especially important in the event of severe pain.

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 PHYSICAL EXAMINATIONS
Nursing assessments include physical examination and observation or taking of vital
signs, or observable or measurable, such as nausea or vertigo, that may be felt by the
patient. Techniques used can include examination, palpitations, auscultation and
percussion in addition to the “vital signs” of temperature, blood pressure, pulse rate and
respiration, and further examination of body systems from head to toe .
a) Neurvascular system
Nurses perform neurovascular assessments to determine sensory function in addition
to peripheral circulation. Focused neurovascular assessment includes objective
observation of the pulse, capillary filling, skin color and temperature, and sensation.
During the neurovascular assessment, measurements between the limbs were
compared. Neurovascular assessment is the assessment of the limbs along with
sensory, circulatory and motor functions.
b) Mental status
During the assessment, interactions and functions are evaluated and documented.

c) Pain
As we kow pain is the 5th vital sign. However, assessment for pain is very important.
Assessment of a patient’s pain experience is an important component in providing
effective pain management. Pain is not a simple sensation that can be easily assessed and
measured. Nurses should be aware of many factors that can influence a patient’s overall
experience and expression of pain, and these should be considered during the assessment
process. The systematic process of pain assessment, measurement, and reassessment
(reassessment), improves the health team’s ability to achieve. Pain was assessed for its
provocative and palliative relationship; quality, area or radiation, severity (numerical or
pictorial scale, Wong-Baker Faces scale); and timing-the onset, duration, frequency, and
length of provocative and relief measures.

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 d) Psychosocial assessment
The main areas considered in a psychological examination are intellectual health and
emotional health. Assessment of cognitive function, examining hallucinations and
delusions, measuring concentration levels, and examining clients ’hobbies and
interests is an assessment of intellectual health. Psychological examinations can also
include client perceptions. Religion and belief are also important areas to consider.
The need for physical health assessment is always included in psychological
examinations to rule out structural damage or anomalies.

 LABORATORY TEST AND RADIOGRAPHIC TEST

In addition, laboratory tests and radiographic tests also play an important role in
describing any signs of a disease and obtaining an accurate and effective treatment
diagnosis. There are several categories of laboratory tests performed namely hematology,
biochemistry, parasitology, urinalysis, blood group, AFB (direct smear,) skin scrapping,
fungal screening test, serological dengue, urine drug and RTK Antibody for Covid19.
Laboratory tests also help in the selection of drugs especially antibiotics to be given to
patients. While radiographic tests consist of radiography or x -ray, computer tomography,
magnetic resonance imaging, ultrasonography, mammogram, and fluoroscopy. With this
radiographic test helps detect the effectiveness of treatments or procedures performed
such as intubation and chest tube insertion.
 RECORDS AND REPORT
Is a permanent written communication that documents information relevance to a
clients .It is important to nurses to indicate future plan .Its also shows the patient progress
of treatment that given.

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METHOD OF ASSESMENT
The primary method of assessment including are :
a) observing – observing data collected with 4 senses –vision , hearing , smell and touch
b) interviewing – is a conversation between two person : client and nurses .To take
history , biographical data , and complaint of .
c) examining – is a physical examination wgich systemic datat collected to detect health
problem .Eg : Head to toe assessment .

ASSESMENT TECHNIQUE.
a) Inspection : which are close and careful visualization of the person and each of the
body system such as : rashes , edema
b) Palpation : Palpation is a method of examination in which the examiner senses the
size, strength, or position of an object (of the part of the body where the examiner is a
medical practitioner). Palpation is performed by medical doctors, chiropractors,
osteopaths, and even acupuncturists and herbalists especially for thoracic and
abdominal tests, as well as edema testing and vein palpation.
c) Percussion : Is the process which to assess underlying structures of location , size and
density of underlying tissues ,
d) Auscultation : listening the sound in the body using a stethoscope , Doppler and
fetoscope .Such are to hear for lung (rhonci ) , abdomen (bowel sound) .

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IMPORTANT HEALTH ASSESMENT
Nursing assessment plays an important role in the care and treatment of patients
in order to prevent recurrence of the disease and control the disease from getting worse.
Through a complete and authentic nursing assessment treatment can be done in a quality
and systematic manner to patients. For example, in terms of vital signs such as blood
pressure, pulse, temperature, respiration, oxygen levels in the blood and the level of pain
scores that can be seen the presence of abnormalities show symptoms of infection to the
patient. Having detailed information allows doctors to treat and give medications such as
antibiotics according to the pain and the part experienced by the patient. At the same time
this can save the lives of patients and mortality can also be avoided.

The importance of health assessment to the healthcare sector is to maintain,

restore and improve the health of patients so that the comfort needs of patients' lives are
met. For example, there is a fracture wound, it requires continuous treatment to speed up
the healing process in order to restore function to the maximum level possible. The
treatment given must be carefully and accurately evaluated in order to maintain and
improve the patient's health.

In addition, nursing evaluation can prevent and reduce treatment complications.

This is because the patient's complaints and history can be identified in advance before
the final treatment is performed. General observations are also performed to ensure
proper and effective treatment is given to patients. Examples of the patient's medical
history and the history of surgery that have been performed should be emphasized
because it is an important issue for the patient's health. Excessive drug doses and errors in
examining laboratory tests can lead to incorrect treatment of patients. Therefore, nursing
assessment is critical to ensure patients are in safe care to continue living necessities.
Through nursing assessment, it also helps in eliminating or reducing the effects of
the disease. The knowledge and skills learned of nursing interventions can be done to
treat patients effectively according to the patient's condition and illness before being
treated by a doctor.

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CONCLUSIONS

Health assessment is used to assist in identifying patients' treatment needs to achieve

healthy living needs as stated in Maslow's Theory of Hierarchy of Needs was put forward by
Abraham Maslow, a Human Psychologist in 1943 through his book "A Theory of Human
Motivation" in Psychological Studies there 5 needs that need to be met namely physiology,
safety, social, self -esteem, and achievement of self -desire. Both play an important role in
complementing patient care and care as well as in determining an accurate nursing diagnosis, an
authentic evidence-based assessment framework is best practice for healthy.

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PART II (ONLINE CLASS PARCIPITATION )

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 REFERENCES
 Baid, H. (2006). Patient assessment. The process of conducting a physical assessment: a
nursing perspective. British Journal Of Nursing, 15(13), 710-714.
 Bickley, L. S., Szilagyi, P. G., & Bates, B. (2009). Bates' guide to physical examination
and history taking (10th ed.): Philadelphia : Wolters Kluwer Health/Lippincott Williams
& Wilkins, .
 Brocato, C. (2009). A lot of nerve: how to perform a full neurological assessment for
medical & trauma patients. JEMS: Journal of Emergency Medical Services, 34(3), 72-72-
75, 77, 79-82 passim. doi: 10.1016/s0197-2510(09)70074-9
 Susan, S. (2012). Pediatric Physical Examination & Health Assessment: Jones & Bartlett
Learning.
 Jarvis, C., Forbes, H., & Watt, E. (2011). Jarvis's physical examination & health
assessment / Carolyn Jarvis ; Australian adapting editors, Helen Forbes, Elizabeth Watt:
Chatswood, N.S.W. : Elsevier Australia

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