ST.

PAUL UNIVERSITY PHILIPPINES

School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

Nurse’s Role in Health Assessment: 3. Keep an open mind

• Collecting and
• Analyzing Data
COLLECTING DATA
THE PHILIPPINE PROFESSIONAL NURSING PRACTICE
STANDARDS (PPNPS)
▪ The Standards of Professional Nursing Practice are
authoritative statements of the duties that all
registered nurses, regardless of role, population or
specialty are expected to
perform competently (ANA, 2010, p.2)
HEALTH ASSESSMENT AS PPNPS COMPETENCY
4. Avoid premature judgements
5. Obtain and organize materials
ANALYZING DATA
Analysis of Assessment Data/ Nursing
Diagnosis
• Analysis of data (often called nursing diagnosis) is
the second phase of the nursing process.
• A NURSING DIAGNOSIS is defined by the North
American Nursing Diagnosis Association (NANDA,
2012–2014) as “a clinical judgment 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.”

Health Care Team in Health Assessment

• The nurse acts as a collaborator
• The definition of “team-based care” for all care
settings that is most widely accepted and consistent
with the World Health Organization principles of
primary health care.
Nursing Process
• The nursing process is a systematic, rational method of
HOLISTIC 1
planning and providing individualized nursing care.
(Berman, Snyder,
HOLISTIC - describes things related to the idea that the
& Frandsen, 2016) PHASES:
whole is more than the sum of its parts.
ADPIE
Holistic patient assessment is used in nursing to inform the
1. ASSESSMENT
nursing process and provide the foundations of patient care.
- first step of the Nursing Process - most
A holistic approach acknowledges and addresses the
critical phase 4 Major Steps:
physiological, psychological, sociological, developmental,
1. Collection of Subjective Data spiritual and cultural needs of the patient.
2. Collection of Objective Data
3. Validation of Data WHY ASSESS?
4. Documentation of data Assessing a client’s health status is a major component of
TYPES OF DATA: nursing care and has two aspects:
• Subjective Data - Symptoms/covert a) the nursing health history
• Objective Data - Signs/overt b) the physical examination
These are some of the purposes of the physical examination:
SOURCES OF DATA: To obtain baseline data about the client’s functional
- Primary abilities.
- Secondary To supplement, confirm, or refute data obtained in
the nursing history.
DATA COLLECTION METHOD To obtain data that will help establish nursing
- Observation diagnoses and plan of care.
- Interviewing To evaluate the physiological outcomes of health
- Examining care and thus the progress of a client’s health
problem.
TYPES OF HEALTH ASSESSMENT To make clinical judgments about a client’s health
status.
4 BASIC TYPES: To identify areas for health promotion and disease
1) Initial Comprehensive Assessment prevention.
2) Ongoing or partial Assessment
3) Focused or problem-oriented assessment ASSESSMENT AREAS
4) Emergency Assessment
• General status and vital signs
PREPARING FOR THE ASSESSMENT • Mental status
• Children and Adolescent Adults
1. Review client's medical records, if available • Psychosocial, Cognitive and Moral Development
2. Know basic biographical data • Pain
• Violence
dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

• Culture and Ethnicity Weight

• Spirituality and Religious Practices o Normal: The weight appears within normal range for
• Nutritional Status height and body build; body fat distribution is even
o Abnormal: Cachectic, emaciated; simple obesity,
PERFORMANCE with even fat distribution; centripetal (truncal) obesity
Symmetry
1. Prior to performing the procedure, introduce self and o Normal: Body parts look equal bilaterally and are in
verify the client’s identity using agency protocol. relative proportion to each other.
2. Explain to the client what you are going to do, why it o Abnormal: Unilateral atrophy or hypertrophy;
is necessary, and how he or she can participate. asymmetric location of a body part.
3. Discuss how the results will be used in planning Posture
further care or treatments. o Normal: The person stands comfortably erect as
4. Perform hand hygiene and observe other appropriate for age; note the normal “plumb line”
appropriate infection prevention procedures. o Abnormal: Rigid spine and neck; moves as one unit;
5. Provide for client privacy. stiff and tense, ready to spring from chair, fidgety
movements; shoulders slumped, looks deflated.
GENERAL SURVEY AND MENTAL STATUS
Position
General Survey o Normal: the person sits comfortably in a chair or on
The study of the whole person, covering the general health the
state and any obvious physical characteristics. o bed or examination table, arms relaxed at sides,
head turned to examiner § Abnormal: Tripod; sitting
Areas of Assessment straight up and resists lying down; curled up in fetal
✓ Physical Appearance position
✓ Mobility
✓ Body Structure Body build, contour-proportions
✓ Behavior o Normal: Arm span equals height; body length from
crown to pubis roughly equal to length from pubis to
PHYSICAL APPEARANCE sole.
o Abnormal: Elongated arm span, arm span greater
Age than height; missing extremities or digits webbed
o Normal: the person appears his/her stated age. digits; shortened limb.
o Abnormal: Appears older than stated age
MOBILITY
Gait
Sex
o Normal: The base is as wide as the shoulder width;
o Normal: sexual development is appropriate for
o foot placement is accurate; the walk is smooth, even,
gender and age
o well-balanced; and associated movements such as
o Abnormal: Delayed or precocious puberty.
o symmetric swing, are present.
o Abnormal: Exceptionally wide base. Staggered
Level of Consciousness
stumbling; shuffling, dragging, nonfunctional leg;
o Normal: The person is alert and oriented, attends to
limping with injury, propulsion (difficulty stopping).
your questions appropriately
o Abnormal: Confused, drowsy, lethargic
Range of Motion
o Normal: Note full mobility for each joint, and that
Skin Color
movements is deliberate, accurate, smooth and
o Normal: Color tone is even, pigmentation varying
coordinated; No involuntary movements
with genetic background, skin is intact with no
o Abnormal: Limited joint range of motion; paralysis;
obvious lesions
jerky, uncoordinated movement; ticks, tremors,
o Abnormal: Pallor, cyanosis, jaundice, erythema, any
seizures.
lesions.
Facial Features
o Normal: Facial features are symmetric with
movement; no signs of acute distress are present
o Abnormal: immobile, masklike, asymmetric
drooping; respiratory signs, objective data for pain.

BODY STRUCTURE

Stature
o Normal: The height appears within normal range for
age, genetic heritage.
o Abnormal: Excessively short or tall

dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

BEHAVIOR SIGMUND FREUD STAGES OF PSYCHOSEXUAL

DEVLOPMENT
Facial expression
o Normal: The person maintains eye contact, STAGE APPROXIMATE PSYCHOSEXUAL
expressions are appropriate to the situation AGE DEVELOPMENT
o Abnormal: Flat depressed, angry, sad, anxious. Oral 0 - 1.5 years Pleasure derived from the
Mood and Affect mouth such as sucking,
o Normal: The person is comfortable and cooperative eating, chewing, biting,
with the and vocalizing - serve to
o examiner and interacts pleasantly reduce the infant’s tension.
o Abnormal: Hostile, distrustful, suspicions, crying. The ID controls this stage.
Speech Anal 1.5 - 3 years Pleasure involves the
o Normal: Articulation is clear and understandable; the elimination of feces. As the
stream of talking is fluent, with an even pace; ego develops, the child
conveys ideas clearly; word choice is appropriate to decides to expel or retain
culture and education; the bowel movement.
o Abnormal: Dysarthria and dysphagia; speech defect; Phallic 3 - 6 years Pleasure is derived from
monotone, garbled speech; extremes of few words the genital region. This can
or constant talking. involve exploring and
Personal Hygiene manipulating the genitals
o Normal: The person appears clean and groomed of self and others. A child
appropriately for his/her age, occupation, and can express curiosity
socioeconomic group; hair is groomed, brushed; about how a baby is
make-up is appropriate for age and culture “made” and born. The
o Abnormal: In a previously carefully groomed woman, superego emerges from
unkempt hair and absent make-up may indicate interactions with parents.
malaise or illness. Parents insists the child
control biologic impulses.
VITAL SIGNS Oedipal (males), Electra
(females)
The traditional vital signs are: Latency 6 - 11 years Abeyance of sexual urges
✓ Body temperature (T) occurs as the child
✓ Pulse (PR)/Cardiac rate (CR) develops more intellectual
✓ Respirations (RR) and social skills. It is the
✓ Blood pressure (BP) time of school activities,
✓ Pain hobbies, sports, and for
✓ Oxygen Saturation developing friendships
with members of the same
Vital signs, which should be looked at in total, are checked to sex. The superego
monitor the functions of the body. continues to develop.
Vital signs are often considered to be the baseline indicators Defense mechanisms
of a patient’s health status. appear.
To obtain baseline data Genital Adolescence Puberty allows sexual
When a client has a change in health status or reports impulses to reappear.
symptoms Once conflicts with parents
Before and after surgery or an invasive procedure are resolved and if no
Before and/or after the administration of a medication Before major functions have
and after any nursing intervention that could affect the vital occurred, the individual will
signs. develop heterosexual
attachments outside the
HOLISTIC 2 family. Romantic love can
lead to successful
FREUD marriage and parenting.

Freud (1935) postulated that the psychological nature of

human beings is determined by the result
of conflict between biologic drives (instincts) and social
expectations.

Mental Qualities - 3 levels of awareness

➢ Consciousness
➢ Preconsciousness
➢ Unconsciousness

dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

TODDLER
CENTRAL TASK FOCAL NEGATIVE POSITIVE
RELATIONSHIP RESOLUTION RESOLUTION
Autonomy vs. Parents Doubts Self-
shame and primary, abilities, confidence
doubt caregivers, feel and
toilet training, ashamed willpower.
bodily for not
functions, trying
experimenting
with “holding
on and letting
go” having
control without
loss of self-
esteem.

PRESCHOOLER
CENTRAL FOCAL RELATIONSHIP NEGATIV POSITIVE
TASK E RESOLUTION
RESOLUT
ION
Initiative Family, play, May fear Direction and
Vs. Guilt exploring and disappro purpose.
discovering, learning val of
how much own
assertiveness powers.
influences others and
the environment,
developing a sense of
moral responsibility.

SCHOOL-AGER
CENTRAL TASK FOCAL NEGATIVE POSITIVE
RELATIONSHIP RESOLUTION RESOLUTION
Industry vs. School, May feel Method and
inferiority teachers, sense of competence.
friends, failure.
ERIK ERIKSON experiencing
physical
Psychosocial Theory independence
Erikson proposed that each stage (or achievement level) has from parents,
a central developmental task corresponding to both neighborhood,
biophysical maturity and societal expectations. wishing to
accomplish,
ERIK ERIKSON STAGES OF PYSCHOSOCIAL learning to
DEVELOPMENT create and
produce,
INFANT accepting
CENTRAL FOCAL NEGATIVE POSITIVE when to stop
TASK RELATIONSHIP RESOLUTION RESOLUTION
working on a
Basic Mother, primary Suspicious Drive project,
Trust vs. caregivers, Fearful Hope learning to
Basic feeding “feeling complete a
Mistrust and being project,
comforted” learning to
sleeping teething, cooperate,
“taking in” trusting developing an
self, others and
attitude
environment. toward work.

dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

acceptance of
ADOLESCENCE worth of other,
CENTRAL FOCAL NEGATIVE POSITIVE acceptance of
TASK RELATIONSHIP RESOLUTION RESOLUTION
death as an
Identity Peers and Confused, Devotion entity.
vs. role groups, non- fidelity
confusion experiencing focused
emotional
independence
from parents,
seeking to be the
same as others
yet unique,
planning to
actualize
abilities and
goals, fusing
several activities
into one.
PIAGET
YOUNG ADULTS Piaget (1970) as cited by Weber (2014) postulated that a
CENTRAL FOCAL NEGATIVE POSITIVE person may progress through four major stages of
TASK RELATIONSHIP RESOLUTION RESOLUTION intellectual development.
Intimacy Friends, love, Loneliness Affiliation
vs. spouses, Poor love
isolation community, work relationships
connections
(networking),
committing to
work
relationships,
committing to
social
relationships,
committing to
intimate
relationships

MIDDLE ADULT
CENTRAL FOCAL NEGATIVE POSITIVE
TASK RELATIONSHIP RESOLUTION RESOLUTIO
N
Generativit Younger Shallow Production
y vs. generation, involvement and care.
stagnation often children with the
(whether one’s world in
own or those general
of others) selfish, little
helping to care psychosoci
for others, al growth.
discovering
new
abilities/talents
, continuing to
create, “giving
back”

OLDER ADULT
CENTRAL FOCAL NEGATIVE POSITIVE
TASK RELATIONSHIP RESOLUTION RESOLUTION
Ego All mankind, Regret, Renunciation
integrity reviewing one’s discontent, wisdom.
vs. life, acceptance pessimism
despair of self self
uniqueness,

dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

HOLISTIC 3
The International Association for the Study of Pain (IASP)
has defined pain as “an unpleasant sensory and emotional
experience, which we primarily associate with tissue damage
or describe in terms of such damage” as cited by Weber
(2014).

McCaffery and Pasero (1999)

“pain is whatever the person says it is”

PHYSIOLOGY OF PAIN (NOCICEPTION)

KOHLBERG
Kohlberg (Colby, Kohlberg, Gibbs, & Lieberman, 1983) as
cited by Weber (2014) proposed three levels of moral Transduction Transmission Perception
development, best recognized as encompassing six stages.

TRANSDUCTION

Transduction of pain begins when a mechanical, thermal, or

chemical stimulus results in tissue injury or damage
stimulating the nociceptors, which are the primary afferent
nerves for receiving painful stimuli.

TRANSMISSION

The transmission process is initiated by the inflammatory

process, resulting in the conduction of an impulse in the
primary afferent neurons to the dorsal horn of the spinal cord.
PERCEPTION

The hypothalamus and limbic system are responsible for the

emotional aspect of pain perception while the frontal cortex
is responsible for the rational interpretation and response to
pain.

MODULATION

Modulation changes or inhibits the pain message relay in the

spinal cord. The descending modularly pain pathways either
increase (excite) or inhibit pain transmission.

dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

ACCORDING TO DURATION AND ETIOLOGY

CULTURAL PAIN EXPRESSION/BELIEFS
Acute GROUP
Chronic nonmalignant
Cancer Pain Asian and • pain is natural.
Asian • use mind over body; positive
ACCORDING TO ORIGIN Americans thinking.
• pain may be cased by past
cutaneous transgressions and helps to atone
deep somatic achieve higher spirituality.
visceral • Stigma against narcotic use may
result in underreporting of pain.
ACCORDING TO LOCATION
African • pain is challenge to be fought.
radiating American • pain is inevitable and is to be
referred endured.
intractable • pain is stigmatized, resulting in
neuropathic inhibition n expressing pain or
phantom seeking help.
• pain may be a punishment from
Concepts Associated with Pain God.
• god and prayer will help more
PAIN THRESHOLD than medicine.
o least amount of stimulation a person requires in Hindu • pain must be endured as a part of
order to feel pain.
preparing for the next life in the
cycle of reincarnation.
PAIN TOLERANCE
• must remain unconscious when
nearing death to experience the
o maximum amount and duration of pain that an
events of dying and perhaps
individual is willing to endure. rebirth.
PAIN REACTION Native • pain is to be endured.
• may not ask for medicine due to
o includes the ANS and behavioral responses to the American respect for caregivers who should
stimuli.
know their needs.
• metaphors and images from
PAIN PERCEPTION
nature are used to describe pain.
(Kaegi, 2004)
o the point in which the person becomes aware of the
pain.
Hispanic • pain response is often very
expressive though pain must be
DIMENSIONS OF PAIN (SILKMAN)
endured to perform gender role
duties.
• Physiologic
• pain is natural, but may be result
• Spiritual of sinful or immoral behavior.
• Sensory
• Behavioral Jewish • Pain is expressed openly with
• Sociocultural much complaining.
• Cognitive • pain must be recognized, shared,
• Affective and validated by others so that the
experience is affirmed. (Sttefel,
FACTORS INFLUENCING THE PAIN EXPERIENCE 2001)

Ethnic and cultural values Guidelines when Assessing Pain

Developmental stage - young vs. old
environmental and support systems Prepare the environment – quiet, calm, comfortable (not too
past pain experiences warm or cold), free from any distractions or interruptions.
meaning of pain PRIVACY is observed and maintained
anxiety and stress
Prepare the equipment – tools to be used

dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

Prepare the patient

PAIN ASSESSMENT TOOLS
• proper positioning
• psychological preparation – explanation

Special considerations

• age
• cultural and religious beliefs.

ASSESSING PAIN (COLDSPA)

✓ Characteristics
✓ Onset
✓ Location
✓ Duration
✓ Severity
✓ Pattern
✓ Associated Factors

Affective Responses

Observation of Behavioral and

Physiologic Responses Use of the tools:

Daily Pain Diary
o Time or onset of pain
o Activity before pain
o Pain-related positions or behaviors
o Pain intensity level • Use of analgesics or other relief
measures
o Duration of Pain
o Time spent in relief activities
PAIN ASSESMENT
Collection of SUBJECTIVE data (cont...)
a) History of Past Pain Experience – when, how and
what
b) Family History – who, what, how
c) How does pain affect the family?
d) Lifestyle and health practices – how does pain affect
and interfere with the following:
- general activity, physical activity and work
- concentration, mood and emotions
- sleep
- appetite
- relationships with others
- enjoyment of life, leisure
e) Use of PAIN ASSESSMENT TOOLS – these are
standard guides that help the nurse quantify the
patient’s experience of pain, make use of
descriptive and visual, as well as numerical
subjective measurement of pain
e.g.
✓ Verbal Descriptive Scale (VDS)
✓ Wong baker faces scale (FACES)
✓ Numeric Rating Scale (NRS)
✓ Visual Analog Scale (VAS)
Present the tool – explain its use and ask the patient to
choose the corresponding parameter (number, picture or
description) which he/she thinks best quantifies his/her pain.
Make sure that the patient fully understands how the tool is
used.
The same tool must be used to assess the patient’s pain level
frequently.
Collection of OBJECTIVE data – these are the nurse’s
observations of the patient in pain
❖ vital signs – increase in temp., RR, HR and BP
❖ behavioral reactions – crying, grimacing, anger,
hostility, irritability, guarding behavior
❖ physiologic signs associated with pain – sweating,
pallor, flushed appearance, etc…
Documentation of Findings
❖ correlate subjective and objective data obtained
❖ use of the tools.
NURSING DIAGNOSES RELATED TO PAIN
▪ Acute pain
▪ Chronic pain
▪ Fear/anxiety
▪ Impaired breathing pattern
▪ Impaired physical mobility
▪ Activity intolerance
▪ Bathing/Self-care deficit
▪ Fatigue
▪ Ineffective stress-coping pattern
▪ Risk for activity intolerance
▪ Risk for impaired physical mobility

dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

▪ Risk for constipation

▪ Risk for physical injury

HOLISTIC 4
VIOLENCE
Family violence can be defined as “a situation in
which one family member causes physical or
emotional harm to another family member (Weber
and Kelly, 2014).

PREPARING YOURSELF FOR THE EXAMINATION

Before you can begin to effectively assess for the presence

of family violence, you must first examine your feelings,
beliefs, and biases regarding violence.

Be aware of “red flags” that may indicate the presence of

family violence; these red flags.

CULTURE

Culture affects so many aspects of life including health and

health practices.

COLLECTING SUBJECTIVE DATA

✓ Create safe and confidential environment

✓ >3y/o, secure and private setting, no other else in the
room
✓ Do not screen if there are any safety concerns for
you or the client.
✓ Allow the client to answer completely. Do not
interrupt the client.
✓ Convey a concerned and nonjudgmental attitude.

COLLECTING OBJECTIVE DATA

General Survey and Vital Signs

Head to Toe Approach

The main purposes of assessing culture in a health
✓ SKIN care setting are:
✓ HEAD AND NECK
▪ To learn about the client’s beliefs and usual
✓ EYES
behaviors associated with health and illness,
✓ EARS
including beliefs about disease causes, caregiving,
✓ ABDOMEN
expected treatments (both Western medicine and
✓ GENITALIA AND RECTAL AREA
folk practices), daily hygiene, food preferences and
✓ MUSCULO SKELETAL SYSTEM
rituals, religious beliefs relative to health care.
✓ NEUROLOGIC SYSTEM
▪ To compare the client’s beliefs and practices to
standard Western health care.
▪ To compare the client’s beliefs and practices with
those of other persons from a similar cultural
background (to avoid stereotyping).
▪ To assess the client’s health relative to diseases
prevalent in the specific cultural group.
dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

• obtained through an interview.

The following may affect interactions between
clients and their health care providers: Purpose of taking a Health

▪ Ethnicity History
▪ Generational status
▪ Educational level • Taking the health history provides
▪ Religion
focus on the patient’s health and illness status
▪ Previous health care experiences
▪ Occupation and income level data from the patient’s perspectives
▪ Beliefs about time and space opportunity to establish rapport with client/s
▪ Communication needs/preferences a direction for physical examination

SPIRITUALITY AND RELIGIOUS PRACTICES Components a Health History

Spirituality and religion are important factors in health and ✓ Biographical (demographic) data
can influence health decisions and outcomes. ✓ Chief complaint
✓ History of present illness
✓ History of past illness
✓ Family history – illnesses in the family
✓ Lifestyle
✓ Social support system
✓ Psychological data
✓ Values and beliefs

BIOGRAPHICAL DATA
information to be obtained include
• name (initials would do – to maintain confidentiality)
• age
• sex
• marital status – married, single, divorced, widowed,
widower
• educational attainment
• occupation – specify trade or profession religion

CHIEF COMPLAINT
• specifies the reason/s which prompted the client to
seek medical advice or
• admission
SPIRITUAL ASSESSMENT • better recorded in the client’s own words
example:
Approach: There is no absolute in the timing - difficulty of breathing
of a spiritual assessment. - severe abdominal pain
Techniques: Spirituality is multidimensional. - dry cough for 2 weeks
It is also unique to individuals. (Formal –Spirituality
- burning sensation on urination.
Assessment Tool/Non-Formal – SPIRIT Acronym)
- headache
NUTRITIONAL STATUS
HISTORY of PRESENT ILLNESS
Information gathered during the nutritional • specifies and elaborates the chief complaint/s
assessment provides insight into the client’s overall • time when symptoms started or were experienced
health status. Nutritional assessment identifies risk
• onset of symptoms – sudden or gradual
factors for obesity and is also used to guide health
promotion. • frequency of the problem
• exact location of the distress or complaint
• character of the complaint – intensity, duration,
TAKING A HEALTH HISTORY etc…
HEALTH HISTORY • activity or event that triggered the problem
• a collection of client-centered data or information which • factors that aggravate or alleviate the problem
provides a comprehensive picture of a person’s health • also called PAST MEDICAL-SURGICAL
status
• serves as the basis for identifying a client’s health
strengths, needs and problems
dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

HISTORY VALUES and BELIEFS

• provides a quick look at a client’s previous health • these refer to the client’s principles, morals and
status and illness experiences o this include philosophy that are held dearly
• childhood illnesses • those interpretations or conclusions that the client
• childhood immunizations accepts as true
• allergies – to drugs, food, environmental agents, • these include the belief in God, goodness, honesty,
animal dander integrity, health, etc…
• accidents and injuries – what, where, when and how;
treatment received INTERVIEW and TAKING HEALTH HISTORY in
• hospitalization – dates and length of admission; ACTION
course of treatment Sample Questions and Rationale
• medications – over-the-counter or maintenance

FAMILY HISTORY
• to screen, detect and ascertain risk factors for diseases
information include
• age and health status of parents, siblings,
• grandparents, relatives who have diseases such as:
✓ heart disease
✓ allergies
✓ cancer
✓ obesity
✓ diabetes
✓ mental health disorders
✓ hypertension
✓ bleeding

LIFESTYLE
• refers to the values and behaviors adapted by a
person in daily life which could make him/her
healthy or ill, this include
✓ personal habits
✓ diet
✓ sleep-rest patterns
✓ activities of daily living (ADLs) – also include
exercise and engagement in sports
✓ recreation or hobbies

DEVELOPMENTAL LEVEL
• assessment is focused on the person’s
• developmental milestones
• developmental tasks
• based on different theoretical frameworks
✓ Psychosexual (Freud)
✓ Psychosocial (Erikson)
✓ Cognitive (Jean Piaget)
✓ Moral (Kohlberg)
✓
PSYCHOSOCIAL HISTORY
• these pertain to the client’s coping and stress
management these include
✓ major stressors and client’s perceptions of them
✓ usual coping pattern
✓ communication styles

dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

GORDON’S FUNCTIONAL
HEALTH
GORDON’S FUNCTIONAL HEALTH PATTERNS
• is a holistic model for the assessment of an individual
(or family)
• assessment data is based on 11 headings

GORDON’S FUNCTIONAL HEALTH PATTERNS

1. Health Perception Management
2. Nutritional-Metabolic
3. Elimination
4. Activity-Exercise
5. Cognitive-Perceptual
6. Sleep-Rest
7. Self-perception or Self-concept
8. Role-Relationship
9. Sexuality Reproductive
10. Coping-Stress Tolerance
11. Value-Belief

HEALTH-PERCEPTION MANAGEMENT
• it refers to the client’s perceived pattern of health and
well-being
• how healthy one feels
• gives an idea how health is managed

NUTRITIONAL-METABOLIC
• it refers to the pattern of food and fluid consumption
• relative to metabolic needs and patterns, indicators
of local nutrient supply

ELIMINATION
• it refers to the patterns of excretory function (bowel,
bladder ans skin)
• it includes client’s perception of “normal” function

dfpv
 ST. PAUL UNIVERSITY PHILIPPINES
School of Nursing and Health Allied
NCM 101 - HEALTH ASSESSMENT (LECTURE)

• includes description of frequency, characteristics, Points to Remember:

discomfort, etc... regarding urination and defecation.
ACTIVITY-EXERCISE
• describes the client’s pattern of daily activities, forms
of exercise, leisure and recreation.
COGNITIVE-PERCEPTUAL
• describes the client’s sensory capacities, pain
perceptions
• also pertains to the language, memory and
decision-making capacities of the individual.
valid, truthful data are needed in order to properly
categorize patient needs and areas of concern
assessment of functional health patterns can direct
the nurse to immediately focus on problematic areas,
areas of risks and areas needing education
organization of data will lead into a systematic
analysis of client problems
the functional health assessment INDIVIDUALIZES
care

SLEEP-REST PATTERN
• describes the client’s usual or normal sleep and
wake up patterns, rest and leisure activities
• also include to the rituals or activities done (if any) to
induce sleep and quality of sleep.
SELF-PERCEPTION/SELFCONCEPT
• describes the client’s view of his/her self in terms of
what he can do and what he can be
• include views on body image, comfort with
gender/sex, attitudes about one’s self and
acceptance of personhood.

ROLE-RELATIONSHIP
• describes the client’s perception of his/her major
roles and responsibilities in the family, work area,
society
• the client can likewise rate his own satisfaction with
his relations with others.

SEXUALITY-REPRODUCTIVE
• describes the client’s patterns of satisfaction and
dissatisfaction with own sexuality and reproductive
capacity
• include number of pregnancies, difficulty with sexual
functioning and satisfaction with sexual
relationships.

COPING/STRESS TOLERANCE
• describes the client’s coping patterns and their
effectiveness in terms of dealing with stress
• include the manner of handling stress, usual stress-
relievers, available support system, ability to control
or manage situations.

VALUE-BELIEF
• describes the client’s values, beliefs (including
spiritual) and goals that guides his/her decisions and
actions
• include what matters in life, values and beliefs
related to health, special religious practices.

dfpv