Assessment is the first and most critical phase of the nursing process.

Assessment is a Collecting subjective and objective data.

Diagnosis Analyzing subjective and objective data to make a professional nursing judgment (nursing
diagnosis, collaborative problem, or referral)
Planning Determining outcome criteria and developing a plan
Implementation Carrying out the plan
Evaluation Assessing whether outcome criteria have been met and revising the plan as necessary

WRITING A NURSING DIAGNOSIS STATEMENT

P- Activity intolerance
E- Related to imbalance between oxygen supply and demand
S-verbal reports of fatigue exertional dyspnea and dysrythmia

FOCUS OF HEALTH ASSESSMENT IN NURSING

Virtually every health care professional performs assessments to make professional judgments
related to clients. A comprehensive health assessment consists of both a health history and physical
examination. However, the purpose of a nursing health history and physical examination differs
greatly from that of a medical or other type of health care examination (e.g., dietary assessment or
examination for physical therapy). The purpose of a nursing health assessment is to collect holistic
subjective and objective data to determine a client’s overall level of functioning in order to make a
professional clinical judgment. The nurse collects physiologic, psychological, sociocultural,
developmental, and spiritual data about the client. Thus the nurse performs holistic data collection.

FRAMEWORK FOR HEALTH ASSESSMENT IN NURSING

The framework used to collect nursing health assessment data differs from those used by other
professionals. A nursing framework helps to organize information and promotes the collection of
holistic data. This, in turn, provides clues that help to determine human responses.

USING EVIDENCE TO PROMOTE HEALTH AND PREVENT DISEASE

In order to participate in health promotion and disease prevention, the nurse needs knowledge of
physiology as well as factors affecting a client’s risk of developing a disease and factors affecting client
behavior.

The Health Belief Model is based on three concepts: the existence of sufficient motivation; the belief
that one is susceptible or vulnerable to a serious problem; and the belief that change following a
health recommendation would be beneficial to the individual at a level of acceptable cost.

The focus of the model is on likelihood of behavior as it is affected by demographic variables, which
affect cues to action, susceptibility, and severity of the condition, as well as benefits or costs of the
action.

TYPES OF HEALTH ASSESSMENT

The four basic types of assessment are
• Initial comprehensive assessment- involves collection of subjective data about the client’s
perception of his or her health of all body parts or systems, past health history, family history, and
lifestyle and health practices (which includes information related to the client’s overall function) as
well as objective data gathered during a step-by-step physical examination. For example, in a hospital
setting the physician usually performs a total physical examination when the client is admitted (if this
was not previously done in the physician’s office). In this setting, the nurse continues to assess the
client as needed to monitor progress and client outcomes.
• Ongoing or partial assessment- consists of data collection that occurs after the comprehensive
database is established. This consists of a mini-overview of the client’s body systems and holistic
health patterns as a follow-up on health status. For example, a client admitted to the hospital with
lung cancer requires frequent assessment of lung sounds. A total assessment of skin would be
performed less frequently, with the nurse focusing on the color and temperature of the extremities to
determine level of oxygenation.
• Focused or problem-oriented assessment- It is performed when a comprehensive database exists
for a client who comes to the health care agency with a specific health concern. A focused assessment
consists of a thorough assessment of a particular client problem and does not cover areas not related
to the problem. For example, if your client, John P., tells you that he has pain you would ask him
questions about the character and location of pain, onset, relieving and aggravating factors, and
associated symptoms.
• Emergency assessment- performed in life-threatening situations. For example, do not assume that a
30-year-old female client who happens to be a nurse knows everything regarding hospital routine and
medical care or that a 60-year old male client with diabetes mellitus needs client teaching regarding
diet. Validate information with the client and be prepared to collect additional data.

COLLECTING SUBJECTIVE DATA

Subjective data are sensations or symptoms (e.g., pain, hunger), feelings (e.g., happiness, sadness),
perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited
and verified only by the client (Fig. 1-7). To elicit accurate subjective data, learn to use effective inter-
viewing skills with a variety of clients in different settings. The major areas of subjective data include:

• Biographical information (name, age, religion, occupation)

• History of present health concern: Physical symptoms related to each body part or system (e.g.,
eyes and ears, abdomen)
• Personal health history
• Family history
• Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity,
relationships, cultural beliefs or practices, family structure and function, community environment)

COLLECTING OBJECTIVE DATA

The examiner directly observes objective data (Fig. 1-8). These data include:
• Physical characteristics (e.g., skin color, posture)
• Body functions (e.g., heart rate, respiratory rate)
• Appearance (e.g., dress and hygiene)
• Behavior (e.g., mood, affect)
• Measurements (e.g., blood pressure, temperature, height, weight)
• Results of laboratory testing (e.g., platelet count, x-ray
findings)

This type of data is obtained by general observation and by using the four physical examination
techniques: inspection, palpation, percussion, and auscultation. Another source of objective data is
the client’s medical/health record, which is the document that contains information about what other
health care professionals therapists, dietitians, social workers) observed about the client. Objective
data may also be observations noted by the family or significant others about the client.

Validation of assessment data is a crucial part of assessment that often occurs along with collection of
subjective and objective data. It serves to ensure that the assessment process is not ended before all
relevant data have been collected, and helps to prevent documentation of inaccurate data.

DOCUMENTING DATA
Documentation of assessment data is an important step of
assessment because it forms the database for the entire nursing professionals.
Collecting subjective data is an integral part of interviewing
the client to obtain a nursing health history. Subjective data
consist of:
*SENSATIONS OR SYMPTOMS
*FEELINGS
*PERCEPTIONS
*DESIRES
*PREFERENCES
*"BELIEFS
*IDEAS
*VALUES
*PERSONAL INFORMATION

These types of data can be elicited and verified only by the client. Subjective data provide clues to
possible physiologic, psychological, and sociologic problems. They also provide the nurse with
information that may reveal a client’s risk for a problem as well as areas of strengths for
the client. The information is obtained through interviewing. Therefore, effective interviewing skills
are vital for accurate and thorough collection of subjective data.

Interviewing
Obtaining a valid nursing health history requires professional, interpersonal, and interviewing skills.
The nursing interview is a communication process that has two focuses:

1. Establishing rapport and a trusting relationship with the client to elicit accurate and meaningful
information

2. Gathering information on the client’s developmental, psychological, physiologic, sociocultural, and

spiritual statuses to identify deviations that can be treated with nursing and collaborative
interventions or strengths that can be enhanced through nurse–client collaboration.

PHASES OF THE INTERVIEW

Pre introductory Phase The nurse reviews the medical record before meeting with the client . This
information may assist the nurse with conducting the interview by knowing some of the client’s
biographical information that is already documented. For example, the record may indicate that the
client has difficulty hearing in one ear. This information will guide the nurse as to which side of the
client would be best to conduct the interview.

Introductory Phase
After introducing himself to the client, the nurse explains the purpose of the interview, discusses the
types of questions that will be asked, explains the reason for taking notes, and assures the client that
confidential information will remain confidential. It is important to understand the HIPAA (Health
Insurance Portability and Accountability Act) guidelines enacted by the U.S. Department of Health and
Human Services (USDHHS, n.d.) to ensure confidentiality of patient information.
Working Phase
During this phase, the nurse elicits the client’s comments about major biographic data, reasons for
seeking care, history of present health concern, past health history, family history, review of body
systems for current health problems, lifestyle and health practices, and developmental level.

Summary and Closing Phase

During the summary and closing, the nurse summarizes information obtained during the working
phase and validates problems and goals with the client.

COMMUNICATION DURING THE INTERVIEW

Nonverbal Communication
Nonverbal communication is as important as verbal communication. Your appearance, demeanor,
posture, facial expressions, and attitude strongly influence how the client perceives the questions you
ask.

Verbal Communication
Effective verbal communication is essential to a client interview. The goal of the interview process is
to elicit as much data about the client’s health status as possible.

Open-Ended Questions
Open-ended questions are used to elicit the client’s feelings and perceptions. They typically begin
with the words “how” or “what.” An example of this type of question is: “How have you been feeling
lately?” These types of questions are important because they require more than a one-word response
from the client and, therefore, encourage description.

Closed-Ended Questions
Use closed-ended questions to obtain facts and to focus on specific information. The client can
respond with one or two words. The questions typically begin with the words “when” or
“did.” An example of this type of question is: “When did your headache start?” Closed-ended
questions are useful in keeping the interview on course. They can also be used to clarify or obtain
more accurate information about issues disclosed in response to open-ended questions. For example,
in response to the open-ended question “How have you been feeling lately?” the client says, “Well,
I’ve been feeling really sick to my stomach and I don’t feel like eating because of it.” You may be able
to follow up and learn more about the client’s symptom with a closed-ended question such as “When
did the nausea start?”

PROCESS OF COMMUNICATION
Sending- is done through verbal and non verbal communication, is through spoken or written words,
vocalization.
Receiving- words and gestures must be interpreted in a specific context to have meaning

INTERNAL FACTORS
*liking others
*empathy
*ability to listen
EXTERNAL FACTORS- physically setting of interview
*ensure privacy *tape and video recording
*refuse interruptions
*physically environment
*dress
*note taking
SPECIAL CONSIDERATIONS DURING THE INTERVIEW
Three variations in communication must be considered as you interview clients: gerontologic, cultural,
and emotional. These variations affect the nonverbal and verbal techniques you use during the
interview.

BIOGRAPHIC DATA
BIOGRAPHIC DATA USUALLY INCLUDE INFORMATION THAT IDENTIlES THE client, such as name,
address, phone number, gender, and who provided the information—the client or significant others.

REASON(S) FOR SEEKING HEALTH CARE

This category includes two questions: “What is your major health problem or concerns at this time?”
and “How do you feel about having to seek health care?” The first question assists the client in
focusing on the most significant health concern and answers the nurse’s question, “Why are you
here?” or (HOW CAN) HELP YOU PHYSICIANS CALL THIS THE CLIENTS CHIEF complaint (CC), but a more
holistic approach for phrasing the question may draw out concerns that reach beyond a physical
complaint and may address stress or lifestyle changes.
HISTORY OF PRESENT HEALTH CONCERN
This section of the health history takes into account several aspects of the health problem and asks
questions whose answers can provide a detailed description of the concern.

PERSONAL HEALTH HISTORY

This portion of the health history focuses on questions related to the client’s personal history, from
the earliest beginnings to the present. Ask the client about any childhood illnesses and immunizations
to date.

FAMILY HEALTH HISTORY

As researchers discover an increasing number of health problems that seem to run in families and
that are genetically based, the family health history assumes greater importance. In addition to
genetic predisposition, it is also helpful to be aware of other health problems that may have affected
the client by virtue of having grown up in the family and being exposed to these problems.

REVIEW OF SYSTEMS (ROS) FOR CURRENT HEALTH PROBLEMS

In the review of systems (or review of body systems), each body system is addressed and the client is
asked specific questions to draw out current health problems or problems from the recent past that
may still affect the client or that are recurring.

LIFESTYLE AND HEALTH PRACTICES PROFILE

This is a very important section of the health history because it deals with the client’s human
responses, which include nutritional habits, activity and exercise patterns, sleep and rest patterns,
self-concept and self-care activities, social and community activities, relationships, values and beliefs
system, education and work, stress level and coping style, and environment.

Preparing for the Examination

How well you prepare the physical setting, yourself, and the client can affect the quality of the data
you elicit. As an examiner, you must make sure that you have prepared for all three aspects before
beginning an examination. Practicing with a friend, relative, or classmate will help you to achieve
proficiency in all three aspects of preparation.

PREPARING THE PHYSICAL SETTING

The physical examination may take place in a variety of settings such as a hospital room, outpatient
clinic, physician’s office, school health office, employee health office, or a client’s home. It is
important that the nurse strive to ensure that the examination setting meets the following conditions:
• Comfortable, warm room temperature: Provide a warm blanket if the room temperature cannot be
adjusted.
• Private area free of interruptions from others: Close the door or pull the curtains if possible.
• Quiet area free of distractions: Turn off the radio, television, or other noisy equipment.

PREPARING ONESELF
As a beginning examiner, it is helpful to assess your own feelings and anxieties before examining the
client. Anxiety is easily conveyed to the client, who may already feel uneasy and self-conscious about
the examination.

APPROACHING AND PREPARING THE CLIENT

Establish the nurse–client relationship during the client interview before the physical examination
takes place. This is important because it helps to alleviate any tension or anxiety that the client is
experiencing.

PHYSICAL EXAMINATION TECHNIQUES

Four basic techniques must be mastered before you can perform a thorough and complete
assessment of the client. These techniques are inspection, palpation, percussion, and auscultation.
SITTING POSITION
The client should sit upright on the side of the examination table.

SUPINE POSITION
Ask the client to lie down with the legs together on the examination table.

DORSAL RECUMBENT POSITION

The client lies down on the examination table or bed with the knees bent, the legs separated, and the
feet flat on the table or bed.

SIMS’ POSITION
The client lies on the right or left side with the lower arm placed behind the body and the upper arm
flexed at the shoulder and elbow.

STANDING POSITION
The client stands still in a normal, comfortable, resting posture.

PRONE POSITION
The client lies down on the abdomen with the head to the side.

KNEE–CHEST POSITION
The client kneels on the examination table with the weight of the body supported by the
chest and knees.

LITHOTOMY POSITION
The client lies on the back with the hips at the edge of the examination table and the feet supported
by stirrups.

Inspection
Inspection involves using the senses of vision, smell, and hearing to observe and detect any normal or
abnormal findings. This technique is used from the moment that you meet the client and continues
throughout the examination. Inspection precedes palpation, percussion, and auscultation because the
latter techniques can potentially alter the appearance of what is being inspected.

Palpation
Palpation consists of using parts of the hand to touch and feel for the following characteristics:
• Texture (rough/smooth)
• Temperature (warm/cold)
• Moisture (dry/wet)
• Mobility (fixed/movable/still/vibrating)
• Consistency (soft/hard/fluid filled)
• Strength of pulses (strong/weak/thready/bounding)
• Size (small/medium/large)
• Shape (well defined/irregular)
• Degree of tenderness

Light palpation: place your dominant hand lightly on the surface of the structure.
Moderate palpation: Depress the skin surface 1 to 2 cm (0.5 to 0.75 inch) with your dominant hand,
and use a circular motion to feel for easily palpable body organs and masses.
Deep palpation: Place your dominant hand on the skin surface and your nondominant hand on top of
your dominant
Bimanual palpation: Use two hands, placing one on each side of the body part.

Percussion
Percussion involves tapping body parts to produce sound waves. These sound waves or vibrations
enable the examiner to assess underlying structures. Percussion has several different assessment uses,
including:
*Eliciting pain:
*Determining location, size, and shape:
*Determining density:
*Detecting abnormal masses:
*Eliciting reflexes:

Auscultation
Auscultation is a type of assessment technique that requires the use of a stethoscope to listen for
heart sounds, movement of blood through the cardiovascular system, movement of the bowel, and
movement of air through the respiratory tract. A stethoscope is used because these body sounds are
not audible to the human ear.