Nursing

Health Assessment
NCM 101J

M A R G A J A NE C U E VA S C I R C U L A D O, R N
FINALS
1/3 Recitation,Activities,Reflection,Attendance
2/3 Quizes
1/3 Class standing
1/3 MIDTERMS FINAL GRADE
1/3 FINAL EXAMINATION
The Nursing Process and the Assessment Process

Nursing is the diagnosis and treatment of human

responses to actual or potential health problems.
Diagnosis and treatment are achieved through a
process, called the nursing process, that guides
nursing practice.
Definition
Nursing process :
systematic rational method of planning and
providing nursing care
cyclical, that its components follow a logical
sequence, but not more than one components may
be involved at one time
Purpose of nursing process
To identify a client’s status and actual or potential
health care problems or needs
To establish plans to meet the identified needs,
To deliver specific nursing interventions to meet
those needs
Characteristics of the Nursing Process
Dynamic and cyclic
■ Patient centered
■ Goal directed
■ Flexible
■ Problem oriented
Characteristics of the Nursing Process

■ Cognitive
■ Action oriented
■ Interpersonal
■ Holistic
■ Systematic
Nursing process
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation
Communication
Communication is a process of sharing information
and meaning, of sending and receiving messages. The
messages we communicate are both verbal and non-
verbal.
Nonverbal Messages

Nonverbal behavior is an important source of data.

message being sent is more accurate than the verbal
one.
NON-VERBAL
Nonverbal behavior includes vocal cues or paralinguistics,
action cues orkinetics, object cues, personal space, and
touch. For example, a patient who tells you he is having
“crushingpain”should look like he is having “crushing chest
pain.”His nonverbal behavior should be consistent with he is
telling you. So you would expect the tone inhis voice to
convey “crushing pain”as he is clutching his chest.
Verbal
Vocal cues describe the quality of your voice and its
inflections, tone, intensity, and speed when speaking.
These voice characteristics usually reflect underlying
FEELINGS.
You are doing blood pressure screening at a health center.
You take the blood pressure of a middle-aged man. Your
reading is 170/100.
You are working in the emergency department
(ED) when a father comes in with his 9-year-old daughter. He states that she fell
off her bike and hit her head but did not lose consciousness. But she has a
terrible headache and feels sick.
You are making a postpartum follow-up visit to the home of a young mother
who had her first baby 2 days ago.
Assessment
Systematic and continuous data collection,
organization, validation and documentation of
data(information) as compared to what is standard
norm.
It is a continuous process
All phases of nursing process depend on the
accurate and complete collection of date
Purpose of assessment
Establish a data base
Identify health promoting behaviors
Identify actual and/ potential health problems
Types of Assessment

Initial assessment
Problem focused assessment
Emergency assessment
Time lapsed assessment
Initial Assessment
It is done within specified time after admission to hospital
Purpose: To establish a complete data base for problem
identification, reference and future comparison
Eg. Admission assessment
Problem Focused Assessment
Ongoing process integrated with nursing care
Purpose:
To determine the status of specific problem
identified in an earlier assessment
Eg: Assessment of clients fluid intake and urinary
output in an ICU
Emergency assessment
During any physiologic and psychologic crisis of the
client
Purpose:
To identify the threatening problem and to identify
new and overlooked problem
Eg: Rapid assessment of person’s airway and
breathing status and circulation during a cardiac
arrest
Time Lapsed Reassessment
Several months after initial assessment
Purpose:
To compare the clients current status to baseline data
previously obtained
Collection of data
Is the process of gathering information about client’s
health status. It includes the health history, physical
examination, results of laboratory and diagnostic
tests, and material contributed by other health
personnel.
Type of data

1. Subjective data referred to as symptoms or covert

data, are clear only to the person affected and can be
described only by that person.
Eg: itching, pain and feeling of worry
Type of data

2. Objective data referred to as signs or overt data,

are detectable by an observer or can be measured or
tested against an acceptable standard. They can be
seen, heard , felt or smelled and they are obtained by
observation or physical examination.
Eg: discoloration of the skin or a blood pressure
reading
Sources of data
1. Primary : it is the direct source of information. The
client is the primary source of data.
2. Secondary: it is the direct source of information.
all sources other than the client are considered
secondary sources. Family members, health
professionals, records and reports, laboratory and
diagnostic results are secondary sources.
Methods of Data Collection

The methods used to collect data are observation,

interview and examination.
Observation: it is gathering by using the senses.
Vision, smell, and hearing are used.
Interview : An interview is planned communication
or a conversation with a purpose.
Two approaches to interview
Directive interview is highly structured and directly
ask questions. The nurse controls the interview.
Non Directive interview or rapport building interview
and the nurse allows the client to control the
interview.
Stages of interview
An interview has three major stages:
1. The opening or introduction
2. The body or development
3. The Closing
Examination
The physical examination is a systematic data collection
method to detect health problems. To conduct the
examination, the nurse uses techniques of:
 Inspection
 Palpation
 Percussion
Auscultation
Validating Organizing and Prioritizing Data

Organization of data
The nurse uses a format that organizes the
assessment data systematically. This is often referred
to as nursing health history or nursing assessment
form.
Validation of data
The information gathered during the assessment is
“double-checked” or verified to confirm that it is
accurate and complete.
Documentation of data
To complete the assessment phase, the nurse records
client data. Accurate documentation is essential and
should include all data collected about the client’s
health status.
Nursing Diagnosis
Is the second stage of nursing process. In this
phase, nurses use critical thinking skills to interpret
assessment data to identify clients problem.
North American Diagnosis Association (Nanda)
define or refine nursing diagnosis.
Definition
Nursing Diagnosis:
A clinical judgement concerning a human response to
health conditions/life processes or a vulnerability for
that response , by an individual, family, group or
community”
Status of nursing diagnosis
The status of nursing diagnosis are actual health
promotion and risk
1. An Actual diagnosis is a client problem that is
present at the time of the nursing assessment.
2. A health promotion diagnosis relates to client’s
preparedness to improve their health condition.
Characteristics of the Nursing Process

A risk nursing diagnosis is a clinical judgement that a

problem does not not exist, but the presence of risk
factors indicates that problem may develop if
adequate care is not given.
 Component of NANDA Nursing Diagnosis
1. The problem and its definition
2. The etiology
3. The defining characteristic
Component of NANDA Nursing Diagnosis
1. The problem statement describes the client’s
health problem.
2. The etiology component of a nursing diagnosis
identifies causes of the health problem.
3. Defining characteristics are the cluster of signs and
symptoms that indicate the Presence of health
problem.
Formulating Diagnostic Statement
The basic three part nursing diagnosis statement is
called the PES format and includes the following:
1. Problem(P) : statement of the client’s health
problem
2. Etiology (E): causes of the health problem
3. Signs and symptoms (S): defining characteristics
manifested by the client.
Nursing Diagnosis Medical diagnosis

Statement of nursing judgement Is made by a physician.

that made by nurse, by their
education, experience and
expertise are licensed to treat.

Describe the human response to Refers to disease process.

an illness or a health problem.
May change as the client’s Remains the same for as long as
responses change. the disease is present.
Nursing Diagnosis Medical diagnosis

Ineffective breathing pattern Asthma

Activity intolerance Cerebrovascular accident
Acute pain
Appendicitis
Disturbed body image Amputation
Planning
Involves decision making
It is the process of formulating goals and designing
the nursing intervention required to prevent, reduce
or eliminate the client’s health problems.
Types of planning
1. Initial planning- done after the initial assessment
2. Ongoing planning-continuous planning
3. Discharge planning-needs after discharge
Setting priorities
The nurse begin planning by deciding which nursing
diagnosis requires attention first, which second and
so on.
Nurses frequently use Maslow’s hierarchy of needs
when setting priorities.
Establishing desired outcomes/client
goals
After ,establishing priorities, the nurse set goals for
each nursing diagnosis. Goals may be short term or
long term.
Nursing intervention
A nursing intervention is any treatment, that a nurse
performs to improve patient’s health.
Types of Nursing Intervention

1. independent interventions are those activities that

nurses are licensed to initiate on the basis of their
knowledge and skills.
2. dependent interventions are activities carried out
under the orders or supervision of a licensed
physician.
3. Collaborative interventions are action the nurse
carries out in collaboration with other health team
members.
 Writing individualized Nursing
Interventions
After choosing the appropriate nursing
interventions, the nurse writes them on the care
plan.
Nursing care plan is a written or computerized
information about the client’s care
Implementation

Consist of doing and documenting the activities.

The process of implementation includes:
Implementing the nursing interventions
Documenting the nursing activities
Evaluation
Is a planned ,ongoing purposeful activity in which he
nurse determines
1. Client’s progress toward achievement of
goals/outcomes and
2. Effectiveness of the nursing care plan
Evaluation includes:
Comparing the data with desired outcomes
Continuing, modifying or terminating the nursing
care plan
Health History

Is the collection of data regarding client’s health in

chronological order.
Purpose and Types of Health History

Provide subjective database.

Identify patient strengths.
Identify patient’s health problems., both actual and
potential. Identify supports.
Identify teaching needs.
Identify referral needs.
Medical VS Nursing History

Physicians diagnose and treat illness.

Nurses diagnose and treat the patient’s response to
a health problem.
Setting the Scene and Components of Health History

Key points to remember when obtaining health history

1. Listen to what your patient is telling you both verbally and non
verbally.
2. Don’t rush. Allow enough time to obtain the data.
3. Ensure confidentiality
4.Provide a private, quite comfortable environment.
5. Avoid interruptions.
6. Tell your patient how long the interview will tke and why you need
to ask these questions.
7. Donot be so concerned about completing forms
that you neglect the patient.
8.Start with what the patient perceives as the
problem
9.Use an open ended question to elicit the patient's
perspective
10. attend to any acute problems, such as pain,
before obtaining a detailed history.
11. Remember that quality is more important than
the quantity of information obtained.
Component of health history
1. Biographic data
2.Reason for seeking health care
3. Present/current Health ‘history
4.Past health history
5. Family history
7.Review of system
8.Socio economic history
Biographical data
Patient’s name, address, phone number, contact
person, age/birth date, place of birth, gender, race,
religion, marital status, educational level, occupation,
and social security number/health insurance.
Current Health Status
Patient is Maria dele Cruz, age 42,married, mother of
three, full-time teacher. Usual state of health good.
Has yearly physical with pelvic examination and
dental examination. Last eye examination 1 year ago.
Expresses concern regarding family history of
hypertension and ovarian cancer.
Current Health Status
■ Usual state of health.
■ Any major health problems.
■ Usual patterns of healthcare.
■ Any health concerns.
Helpful
Perform a symptom analysis for any positive symptom that your
patient reports.
PQRST provides key questions that will give you a good overview of
any symptom.
Additional questions to ask to provide a thorough analysis of any
presenting symptom:
■ Precipitating/Palliative Factors:
Ask:What were you doing when the problem started?
Does anything make it better,such as medications or certain
positions? Does anything make it worse, such as movement
or breathing?
■ Quality/Quantity
Ask: Can you describe the symptom? What does it feel like,
look like, or sound like? How often are you experiencing it?
To what degree does this problem affect your ability to
perform your usual daily activities?
■ Region/Radiation/Related Symptoms

Ask: Can you point to where the problem is? Does it occur
or spread anywhere else? (Take care not to lead your
patient.) Do you have any other symptoms?(Depending on
the chief complaint, ask about related symptoms. For
example, if the patient has chest pain, ask if she or he has
breathing problems or nausea.)
Severity

Ask: Is the symptom mild, moderate, or severe?

Grade it on a scale of 0 to 10, with 0 being no symptom
and 10 being the most severe. (Grading on a scale helps
objectify the symptom.)
■ Timing
Ask: When did the symptom start? How often does it occur?
How long does it last?
Past Health History

The past health history assesses:

childhood illnesses, Hospitalizations, surgeries, serious
injuries adult medical problems (including serious or chronic
illnesses), immunizations, allergies, medications, recent
travel, and military service.
The purpose
to identify any health factors from the past that may have
a direct relationship to your patient’s current health status.
For example, a history of rheumatic fever as a child may
explain mitral valve disease as an adult.
Past Health History
Data Significant/Consideration

Childhood Positive history of mumps, chickenpox,

Illnesses rubella, frequent ear infections, frequent
streptococcal infections or sore throats,
rheumatic fever, scarlet fever, pertussis,
or asthma may have a direct link to current
health problem (e.g., history of
chickenpox explains current shingles).
Past Health History

Data Significant/Consideration

Hospitalizations Previous hospitalizations may have a

direct link to current problem or provide
clues to preexisting problems. Knowing
name of hospital and dates facilitates
record retrieval. Ask about
hospitalizations for both physical and
psychological
problems.
Surgeries Knowing past surgical procedures may rule
out certain problems or explain others.
For example, a patient with right lower
quadrant pain cannot have appendicitis
if his or her appendix has been removed,
but pain may be caused by adhesions.
Serious History of serious injuries (fractures, head
Injuries injuries with loss of consciousness,
motor vehicle accidents, burns, or lacerations)
may relate to current promusculoskeletal
problems or scars.
blem or explain findings during physical
examination. For example, past motor vehicle
accident (MVA) may cause lingering
Lack of immunization may explain current problem. Consider patient’s
age:Ask if children have had the following immunizations: measles,
mumps,rubella, chickenpox, hepatitis B, diphtheria, tetanus, polio, and
Haemophilusinfluenzae B (HIB). Ask older adults if they have had a
pneumococcal vaccine(Pneumovax) and influenza (flu shot). If not
vaccinated against tuberculosis (TB),ask about last purified protein
derivative (PPD) test. Consider where patient lives:
In the United States, people are not routinely immunized against TB, but
in othercountries where incidence of TB is high, bacille Calmette-Guérin
(BCG) vaccinemay be used.
Medications Medications may be causing current problem. For example,
over-the-counter (OTC)
medication may be interacting with a prescribed medication,
causing adverse effects
or negating desired effects. Allows you to assess patient’s
understanding of her or his
medications, which may identify teaching needs. Ask about
prescribed and OTC
medications, including vitamins, supplements, and herbs.
Obtain name of medication,
dose, frequency, and last time taken.
Recent May identify exposure to health hazards and
Travel explain presenting symptoms (e.g., traveler’s
Diarrhea,covid).
Military Recent or past military service may identify
Service exposure to health hazards. For example,
exposure to Agent Orange during Vietnam
War is risk factor for cancer, and exposure
to chemical toxins during Operation Desert
Storm is risk factor for later health
problems.
Family History
Provides clues to genetically linked or familial diseases that may be
risk factors for your patient.
Ask about the health status and ages of your patient’s family
members. Family members include the patient, spouse, children,
parents, siblings, aunts and uncles, and grandparents. Ask about
genetically linked or common diaseases, such as heart disease, high
blood pressure, stroke, diabetes, cancer, obesity, bleeding disorders,
tuberculosis, renal disease, seizures, or mental disease. If the
patient’s family members are deceased, record the age and cause of
death.
Family History by Listing Family Members
Patient: Age 37, alive and well
Spouse: Age 40, divorced, alcoholism
Daughter: Age 12, alive and well
Son: Age 8, alive and well
Brother: Age 32, alive and well
Sister: Age 30, alive and well
Family History by Listing Family Members
Father: Age 66, hypertension (HTN)
Mother: Age 60, mitral valve prolapse (MVP)
Paternal Aunt: Age 65, breast cancer
Maternal Uncle: Age 62, HTN
Maternal Uncle: Deceased age 28, tuberculosis (TB)
Maternal Aunt: Age 64, MVP
Maternal Aunt: Age 58, HTN
Maternal Aunt: Deceased age 9, ruptured appendix
Family History by Listing Family Members

Paternal Grandfather: Deceased age 68, cancer

Paternal Grandmother: Age 80, HTN
Maternal Grandmother: Age 77, HTN, breast cancer
Maternal Grandfather: Deceased age 70, cardiovascular
disease (CVD)
Second meetings

Nursing
Health Assessment
Review of Systems
used to obtain the current and past health status of each
system and to identify health problems that your patient
may have failed to previously
 if patient has an acute problem in one area, every other
body system will be affected, so look for correlations as you
proceed with the ROS.
Then perform a symptom analysis for every positive
finding and determine the effect of and the patient’s
response to the symptom.
 ROS
 Provides clues to health promotion activities for each
particular system.
Identify health promotion activities and provide
instruction as needed.
REVIEW OF SYSTEM
To obtain the current and past health status of each system
To identify health problems that your patient may have failed to
mention previously. Remember, if your patient has an acute problem
in one area, every other body system will be affected, so look for
correlations as you proceed with the ROS.
Perform a symptom analysis for every positive finding and
determine the effect of and the patient’s response to, this symptom.
Provides clues to health promotion activities for each particular
system. Identify health promotion activities and provide instruction
as needed
As you proceed with the ROS, consider any prescribed or over-the-
counter medications your patient is taking and how they affect every
system. This may help explain some of your findings.
Review of Systems
Area/system Ask about
General Health Survey Unusual problems or symptoms, fatigue, exercise intolerance, unexplained
fever, night sweats, weakness, difficulty doing activities of daily living (ADLs),
number of colds or illnesses per year.
Integumentary Skin diseases, such as psoriasis, itching, rashes, scars, sores, ulcers, warts, and
moles;
changes in skin lesions; skin reaction to hot and cold. Changes in hair texture,
baldness, usual patterns of hair care (e.g., shampooing, coloring, permanents).
Changes in nails (e.g., color, texture, splitting, cracking, breaking); usual
patterns
of nail care (e.g., use of polish, acrylic nails).
Head and Neck Headaches; lumps; scars; recent head trauma, injury, or surgery; history of
concussion or loss of consciousness; dizzy spells; fainting; stiff neck; pain with
movement of head and neck; swollen glands, nodes, or masses.
Eyes Wearing glasses or contact lenses, visual deficit, last eye examination, last
glaucoma check, eye injury, itching, tearing, drainage, pain, floaters, halos, loss of
vision or parts of fields, blurred vision, double vision, colored lights, flashing
lights, light sensitivity, twitching, cataracts or glaucoma, eye surgery, retinal
detachment, strabismus, or amblyopia.
Ears Last hearing test, difficulty hearing, sensitivity to sounds, ear pain, drainage,
vertigo, ear infections, ringing, fullness in ears, ear wax problems, use of hearing
aids, ear-care habits, such as use of cotton-tipped swabs.
Nose and Sinuses Nosebleeds, broken nose, deviated septum, snoring, postnasal drip, runny nose,
sneezing, allergies, use of recreational drugs, difficulty breathing through nose,
problem with ability to smell, pain over sinuses, sinus infections.
Mouth and Throat Sore throats, streptococcal infections, mouth sores, oral herpes, bleeding gums,
hoarseness, changes in voice quality, difficulty chewing or swallowing, changes
in sense of taste, dentures and bridges, description of dental health, dental
surgery, last dental examination, dental hygiene patterns.

Respiratory Breathing problems; cough; sputum (color and amount); bloody sputum;
shortness
of breath (SOB) with activity; noisy respirations such as wheezing (as is seen with
asthma); pneumonia; bronchitis; tuberculosis (TB); last chest x-ray and results;
purified protein derivative (PPD) and results; history of smoking.

Cardiovascular Chest pain; palpitations; murmurs; skipped beats; hypertension (HTN);

awakening at
night with SOB; dizzy spells; cold or numb hands and feet; color changes in
hands
and feet; pain in legs while walking; swelling of extremities; hair loss on legs;
sores
that do not heal; results of electrocardiogram, if ever done.
Breasts Breast masses, lumps; pain, discharge, swelling; changes in breast or nipples;
cystic
breast disease; breast cancer; breast surgery, reduction, enhancements; breast
self-examination (BSE) (when and how); date of last clinical breast examination;
date of last mammogram, if ever done.

Gastrointestinal Loss of appetite; indigestion; heartburn; gastroesophageal reflux disease (GERD);

nausea; vomiting; vomiting blood; liver or gallbladder disease; jaundice;
abdominal swelling; regular bowel patterns; changes in bowel patterns; color of
stool; diarrhea; constipation; hemorrhoids; weight changes; use of laxatives and
antacids; date and results of last fecal occult blood test, if ever done.

Genitourinary Pain on urination; burning; frequency; urgency; dribbling; incontinence;

hesitancy;
changes in urine stream, color of urine; history of urinary tract infections, kidney
infections, kidney disease, kidney stones, frequent nighttime urination.
Female Reproductive Menarche; description of cycle; last menstrual period; painful menstruation;
excessive bleeding; irregular menses; bleeding between periods; last Pap test
and
results; satisfaction with sexual performance; painful intercourse; use of
contraceptives; history of sexually transmitted disease (STD); knowledge of
prevention of STDs including human immunodeficiency virus (HIV); infertility
problems; obstetrical history including pregnancies, live births, miscarriages,
abortions.

Male Reproductive Lesions; discharge; pain on urination; painful intercourse; prostate or scrotal
problems; history of STDs, infertility problems, impotence, or sterility;
satisfaction with sexual performance; knowledge of prevention of STDs
including

HIV; use of contraceptives; frequency and technique for testicular self-

examination, if ever done; date and results of last prostate examination, if ever

done.
Musculoskeletal Fractures, sprains, muscle cramps, pain, weakness, joint swelling, redness,
limited
range of motion, joint deformity, noise with movement, spinal deformities,
low
back pain, loss of height, osteoporosis, degenerative joint disease, or
rheumatoid
arthritis; impact on ability to do ADLs; use of calcium supplements.
Neurological Loss of consciousness; fainting; seizures; head injury; changes in cognition or
memory; hallucinations; disorientation; speech problems; sensory
disturbances
such as numbness, tingling, or loss of sensations; motor problems; problems
with
gait, balance, or coordination; and impact on ability to do ADLs.
Endocrine Endocrine disorders such as thyroid disease or diabetes; unexplained
changes in
weight or height; increased thirst, hunger, or urination; heat and cold
intolerance; goiter; weakness; hormone therapy; changes in hair or skin.
Immune/Hem Anemia, bleeding disorders; recurrent
atologic infections; cancers; HIV; fatigue;
bloodtransfusion; bruising; allergies;
unexplained swollen glands.
Immune/Hem Anemia, bleeding disorders; recurrent
atologic infections; cancers; HIV; fatigue;
bloodtransfusion; bruising; allergies;
unexplained swollen glands.
Thank you for listening and participation