Introduction to

Health Assessment
Setting the Mood

• What are the common practices of the family in

assessing the condition of a sick member?

• What is/are the reason(s) why your family is

practicing such way(s) of assessing the sick?

• Do you think such practice(s) is/are helpful?

Why or why not?
Health

• a state of complete physical, mental, and social well being

and not merely the absence of disease of infirmity (WHO)*

• an individual is viewed as a total person interacting with

others

• the individual functions within his/her physical,

psychological, and social fields**
Models of Health*
• a process and a state of being and becoming whole and
integrated in a way that reflects the persona and
environment mutuality (Roy and Andrews, 1999)

• the state of a person as characterized by soundness or

wholeness of developed human structures and mental
bodily functioning that requires therapeutic self-care (Orem,
1971)

• a culturally defined, valued, and practiced state of well

being reflective of the ability to perform role activities
(Leininger, 1991)

• the state of well being and the use of every power the
person possesses to the full extent (Nightingale, 1860)
Models of Health*

• the ecologic model developed by Leavell and Clark

(1965) examines the interaction of agent, host, and
environment*

• clinical model defines health as the absence of

disease or injury**

• eudaemonistic model views health as the actualization

of a person’s potential***

• health promotion model defines health as the

actualization of inherent and acquired human potential*
Health Assessment

• the plan of care the identifies the specific needs of a

patient and how those needs can be addressed by a
healthcare system or nursing facility*

• a systematic method of collecting data about a

patient for the purpose of determining his/her current
and ongoing health status, predicting risks of health
and identifying health-promoting activities**
Health Assessment

• includes interview, physical assessment,

documentation, and interpretation of findings

• scope of focus is more than the problems presented

by the patient

• nurse needs a variety of sources to gather data,

knowledge of the natural and social sciences,
effective communication techniques, and use of
critical thinking skills*
Why do we conduct
Health Assessment?

• to gather subjective and objective data to determine a

patient’s over-all level of functioning for nurses to
make a professional clinical judgement

• to collect physiological, psychological, sociocultural,

developmental, and spiritual data about the patient
 Health Assessment
and the Nursing Process
Overview

• assessment is the first and most critical phase of the

nursing process

• every healthcare professional performs assessment

to make professional judgements related to the
patient

• accuracy of the assessment data affects all other

phases of the nursing process

• health assessment is performed by conducting

interview and physical examination
The Nursing Process

• a systematic problem-solving process that guides all

nursing actions

• serves as the organizational framework for the

practice of nursing

• assists the nurse to provide goal-directed and client-

centered care

• composed of five (5) dynamic and interrelated phases

(ADPIE): assessment, diagnosis, planning,
implementation, and evaluation
The Five Phases
of the Nursing Process
• Assessment: collect subjective and objective data

• Diagnosis: analyze the gathered data to make a

professional nursing judgment

• Planning: determine the outcome criteria and

develop a plan

• Implementation/Intervention: carry out the plan

• Evaluation: measure and assess if the outcome

criteria have been met; make necessary revisions if
the goals are not met
Types of Nursing Assessment

• Initial Comprehensive Assessment:

admission assessment; collection of
subjective and objective data; includes
gathering of detailed history, physical
examination, and examination of
patient’s over-all health status

• Ongoing or Partial Assessment:

collection of data after comprehensive
database is established; mini-overview
of the patient’s body systems and
holistic health as a follow-up on health
status
 Types of Nursing Assessment

• Focused or Problem-Oriented
Assessment: consists of a thorough
assessment of a particular patient’s
problem*

• Emergency Assessment:
rapid assessment performed in life-
threatening situations; immediate
diagnosis is needed; focuses on few
essential health patterns and are not
comprehensive
 Types of Nursing Assessment
Type Time Performed Purpose Example
Performed within the To establish a complete Nursing admission assessment
specified time after database for problem
Initial Assessment admission identification, reference, and
future comparison

Ongoing One or several hours; or To compare the client’s Reassessment of a client's functional health
Assessment/ Time- may be weeks or current status to the baseline patterns in a home care or outpatient setting
lapsed months* data previously obtained or in a hospital at shift change
Reassessment
The stage in which the To diagnose and treat Assessment of data collected on a specific
Problem-oriented problem is exposed and patient in order to stabilize problem; examination is limited to a specific
Assessment managed his/her condition problem or complaint**

During any physiologic or To identify life-threatening Rapid assessment of a patient’s airway,

Emergency psychologic crisis of the problems breathing status and circulation during a
Assessment patient cardiac arrest; assessment of suicidal
tendencies or potential for violence
Complete and Reflect!

• “Health Assessment is important because…”

• “The data gathered…”

• “I used to think that…”

• “Now, I learned that…”

Parts of Health
Assessment
Parts of Health Assessment
Parts of Health Assessment

• Collection of subjective (covert) data

• the verbal statements provided
by the patient
• sensations or symptoms, feelings,
perceptions, desires, preferences,
beliefs, ideas, values and personal
information

• Collection of objective (overt) data

• directly observed by the examiner
• detectable by an observer or can be
measured or tested against an
accepted standard
Parts of Health Assessment

• Validation of Data
• serves to ensure that the
assessment process is not ended
before all relevant data have been
collected
• helps to prevent documentation of
inaccurate data*

• Documentation of data
• forms the database for the entire
nursing process and provides data
for all other members of the health
care team
 Subjective VS Objective
Area Subjective Objective
Data directly or indirectly observed through
Description Data elicited and verified by the patient
measurement

Observations and physical assessment

findings of the nurse and other health care
Patient, family, significant others,
professionals; documentation of assessment
Sources patient’s record and other health care
findings made in the patient’s record;
professionals
observations made by the patient’s family or
significant others

Methods Patient interview Observation and physical examination

Interview and therapeutic

Inspection, palpation, percussion and
Skills communication skills; caring, empathy
auscultation
and listening skills
Subjective VS Objective
Area Subjective
Example(s) “I am in pain”
“It frightens me”
“I have a fever”
“I feel sick to my stomach”
“I cannot breathe well”
Objective
RR of 23 cpm
BP of 150/100 mmHg
Apical pulse of 120 bpm, irregular
Xray film reveals fractured pelvis
Body temperature of 38 degrees Celsius,
heart rate of 105 beats per minute, skin
warm to touch
Vomited 100 mL of green tinged fluid,
abdomen is firm and slightly distended,
active bowel sounds in all 4 quadrants
Respiration of 28 cpm, shallow; diminished
lung sound at the right lower lobe
The Interview

• gathers subjective data during health history

taking and focused interview

• primary and secondary sources*

• subjective data
• information that the patient experiences and
communicates to the nurse
• covert (hidden) or symptom
 The Health History

• the purpose is to obtain information about the

patient’s health in his of her own words and
based on his/her own perceptions

• biographical data, perceptions about health,

past and present history of illness and injury,
family history, a review of systems and health
patterns and practices

• provides cues regarding the patient’s health

and guides further data collection
 The Focused Interview

• enables the nurse to clarify points, to obtain

missing information and to follow up on verbal
and nonverbal cues identified in the health
history

• provides means and opportunity to expand the

subjective database regarding specific
strengths, weaknesses, problems or concerns
expressed by the patient
 Physical Assessment

• hands-on examination of the patient

• gathers objective data which are observed or

measured by the nurse; also known as overt
data or sign*

• both subjective and objective can be

categorized as constant or variable
• constant data: information that does not
change over time such as race, sex or blood
type
• variable data: may change within minutes,
hours or days; ex. BP, PR, and age
 Documentation
• creates a patient record or becomes an
addition to an existing health record

• patient record is a legal document used to plan

care, to communicate information between
and among healthcare providers and to
monitor the quality of care*

• documentation must be accurate, confidential,

appropriate, complete and detailed**

• in documenting, the nurse must use standard

and accepted abbreviations, symbols, and
terminologies and must reflect professional
and organizational standards
Interpretation of Findings

• making determinations about all of the data

collected in health assessment process

• the nurse must determine if findings fall within

normal or expected ranges in relation to the
patient’s age, gender and race and then the
significance of the findings in relation to the
patient’s health status and immediate and
long-range health-related needs

• influenced by the ability to obtain, recall, and

apply knowledge; to communicate effectively;
and to use a holistic approach
Complete and Reflect!

• “In interviewing a patient, I…”

• “Subjective data are…”

• “The data that I gathered…”

• “In conducting physical assessment…”

• “The patient’s health history…”

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