Adult Health Assessment ( Clinical)

NURS 212

CHAPTER 1

Introduction to Health
Assessment
Dr. Faroq Alshameri
 Case Study 1
• You walk into Mrs. Sarah room for the first time. She is
sitting on the edge of the bed crying and has not changed into
a hospital gown. You introduce yourself and say, “You seem
very upset.” Mrs. Sarah tells you that she is concerned about
her husband being left at home alone while she is in the
hospital for colon surgery.
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 Case study 2
• You make a follow-up visit to a new mother, Rebecca Brown, and her 3-day-old son. You

arrive at the address provided to you and find Mrs. Brown and newborn living in a worn-

down trailer. She appears very tired. When asked about this, she says that she has been

unable to rest because of several visitors. “I don’t mind the attention, but I’m sorta

worried that my baby is gonna get sick because a lot of the people that have been coming

over are sick with colds.” Mrs. Brown also tells you that she has had trouble breast-

feeding. You see the newborn in a crib and notice that his breathing is labored.
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 Assessment
• is the collection of data about the individual's health state.
✓ subjective data (i.e., what the person says about himself or
herself during history taking)
✓ objective data (i.e., what you as the health professional observe
by inspecting, percussing, palpating, and auscultating during the
physical examination).
➢ Together with the patient's record and laboratory studies,
these elements form the database.

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Assessment: Step One of
the Nursing Process

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Types of Assessment (Database)

1) Complete (Total Health) Database (Initial or comprehensive)

2) Follow-Up Database ( Ongoing or partial)

3) Focused or Problem-Centered Database

4) Emergency Database

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STEPS OF HEALTH ASSESSMENT

1. Collection of subjective data

2. Collection of objective data

3. Validation of data

4. Documentation of data
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Comparing Subjective and Objective Data

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