GENERAL PRINCIPLES
• A complete or partial physical examination is conducted
following a careful comprehensive or problem- related
history
• It is conducted in a quiet, well-lit room with consideration
for patient privacy and comfort.
• When possible, begin with the patient in a sitting position
so both the front and back can be examined.
• Conduct the examination systematically from head to foot
so as not to miss observing any system or body part
• While examining each region, consider the underlying
anatomic structures, their function, and possible
abnormalities.
• Because the body is bilaterally symmetric for the most part,
compare findings on one side with those on the other
• Explain all procedures to the patient while examination is
conducted to avoid alarming or worrying the patient and to
encourage cooperation.
OBJECTIVE DATA
•Includes information about the client that the nurse directly
observes during interaction with him, and information
elicited through physical assessment (examination)
techniques.
BASIC KNOWLEDGE
• Types of and operation of equipment needed for the
particular examination (e.g., penlight, sphygmomanometer,
otoscope, tuning fork, stethoscope)
• Preparation of the setting, oneself, and the client for the
physical assessment
• Performance of the four assessment techniques: inspection,
palpation, percussion, and auscultation
EQUIPMENT
• Gloves and Gowns- To protect examiner in any part of the
examination when the examiner may have contact with
blood, body fluids, secretions, excretions, and contaminated
items or when disease causing agents could be transmitted to
or from the client
• When taking Vital signs: Sphygmomanometer,
Thermometer (oral, rectal, tympanic), Watch with Second
hand and Pain rating scale
• For Eye Examination: Penlight, Snellen chart,
Ophthalmoscope, Cover card, and Newspaper
• For abdominal area: Stethoscope, measuring tape, pillows
prior to the examination, collect the necessary equipment
and place it in the area where the examination will be
performed. This promotes organization and prevents the
nurse from leaving the client to search for a piece of
equipment.
PHYSICAL SETTING
• Comfortable, warm room temperature
• Private area free of interruptions from others
• Quiet area free of distractions
• Adequate lighting
• Firm examination table or bed at a height that prevents
stooping
• A bedside table/tray to hold the equipment needed for the
examination
PREPARING ONESELF
General principles to keep in mind while performing a
physical assessment include the ff:
1. Wash your hands before beginning the examination,
immediately after accidental direct contact with blood or
other body fluids, and after completing the physical
examination or after removing gloves. If possible, wash your
hands in the examining room in front of the client. This
assures your client that you are concerned about his or her
safety.
2. Wear gloves if you have an open cut or skin abrasion. If the
client has an open or weeping cut, if you are collecting body
fluids for specimen and if you are handling contaminated
surfaces and when you are performing an examination of the
mouth and an open wound, genitalia, vagina, or rectum
change gloves when moving from a contaminated to a clean
body site and between patients.
3. If a pin or other sharp object is used to assess sensory
perception, discard the pin and use a new one for your next
client.
4. Wear a mask and protective eye goggles if you are
performing an examination in which you are likely to be
splashed with blood or other body fluid droplets. E.g.
performing an oral examination on a client who has a chronic
reproductive cough.
APPROACHING AND PREPARING THE CLIENT
• The nurse–client relationship should be established during
the client interview before the physical examination takes
place.
• At the end of the interview, explain to the client that the
physical assessment will follow and describe what the
examination will involve.
• Respect the client’s desires and requests related to the
physical examination.
• Ultimately, however, whether or not to have the
examination is the client’s decision.
• If a urine specimen is necessary, explain to the client the
purpose of a urine sample and the procedure for giving a
sample; provide him or her with a container to use.
• Begin the examination with the less intrusive procedures
such as measuring the client’s temperature, pulse, blood
pressure, height, and weight. These non-threatening, non-
intrusive procedures will allow the client to feel more
comfortable with you and help ease the client’s anxiety about
the examination. Throughout the examination, continue to
explain what procedure you are performing and why you are
performing it. It is usually helpful to integrate health
teachings and health promotions during the examination.
• Approach the client from the right-hand side of the
examination table or bed because most examination
techniques are performed with the examiner’s right hand.
You may ask the client to change positions frequently
depending on the part of the examination being performed.
Prepare the client for these changes at the beginning of the
examination by explaining that these position changes are
necessary to ensure thorough examination of each body part
and system.
PHYSICAL EXAMINATION TECHNIQUES PERCUSSION
• IPPA- Inspection, Palpation, Percussion, and Auscultation Percussion involves tapping body parts to produce sound
• IAPP- Assessing the bowel - Inspection, Auscultation, waves. These sound waves or vibrations enable the examiner
Percussion and Palpation to assess underlying structures.
Percussion has several different assessment uses, including
INSPECTION • Eliciting pain – percussion helps detect inflamed underlying
• Inspection involves using the senses of vision, smell, and structure. If an inflamed area is percusses, the client’s
hearing to observe and detect any normal or abnormal physical response may indicate or the client will report that
findings. This technique is used from the moment that you the are feels tender sore or painful.
meet the client and continues throughout the examination.
• Determining location, size, and shape – percussion no
Inspection precedes palpation, precaution, and auscultation
changes between borders of an organ and its neighboring
because the latter techniques can potentially alter the
organs can elicit information about location, size and shape.
appearance of what is being inspected.
• Determining density – percussion helps determine whether
Use the following guidelines as you practice the technique of
an underlying structure is filled with air or fluid or is a solid
inspection:
structure.
• Make sure the room is a comfortable temperature. A too
•Detecting abnormal masses – percussion vibrations
cold or too-hot room can alter the normal behavior of the
penetrate approximately 5cm deep. Deep masses do not
client and the appearance of the client’s skin. produce any change in the normal percussion vibrations.
• Use good lighting, preferably sunlight. Fluorescent lights
•Eliciting reflexes – deep tendon reflexes are elicited using
can alter the true color of the skin. In addition, abnormalities
the percussion hammer
may be overlooked with dim lighting.
• Look and observe before touching. Touch can alter 3 Types of Percussion
appearance and distract you from a complete, focused 1. Direct percussion – is a direct tapping of a body part with
observation. one or more fingertips to elicit possible tenderness.
• Completely expose the body part you are inspecting while 2. Blunt percussion – is used to detect tenderness over organs
draping the rest of the client as appropriate. by placing one hand flat on the body surface and using the
Note the following characteristics while inspecting the client: fist of the other hand to strike the back of the flat hand on
color, patterns, size, location, consistency, symmetry, the body surface.
movement, behavior, odors, or sounds. 3. Indirect or mediate percussion – is the most commonly
• Compare the appearance of symmetric body parts (e.g., used method of percussion. The tapping done with this type
eyes, ears, arms, hands) or both sides of any individual body of percussion produces a sound or tone that varies with the
part. density of underlying structure. As density increases, the
sound of tone becomes quieter. Solid tissues produce a soft
PALPATION
tone, fluid produces a louder tone and the air produces an
• Palpation consists of using parts of the hand to touch and
even louder tone.
feel for the following characteristics: texture (rough/smooth),
temperature (warm/cold), moisture (dry/wet), mobility The following techniques help to develop proficiency in the
(fixed/movable/vibrating), consistency (soft/hard/fluid-filled), technique of indirect percussion:
strength of pulses (strong/weak/thready/bounding), • Place the middle finger of your nondominant hand on the
size (small/medium/large), shape (well-defined/irregular), body part you are going to percuss.
and degree of tenderness. • Keep your other fingers off the body part being percussed
• Three different parts of the hand—the finger pads, because they will damp the tone you elicit.
ulnar/palmar surface, and dorsal surface—are used during • Use the pad of your middle finger of the other hand (ensure
palpation. Each part of the hand is particularly sensitive to that this fingernail is short) to strike the middle finger of your
certain characteristics nondominant hand that is placed on the body part.
• Withdraw your finger immediately to avoid damping the
4 Types of Palpation
tone.
1. Light palpation: To perform light palpation, place your
• Deliver two quick taps and listen carefully to the tone.
dominant hand lightly on the surface of the structure. There
• Use quick, sharp taps by quickly flexing your wrist, not your
should be very little or no depression (less than 1 cm). Feel forearm.
the surface structure using a circular motion. Use this
technique to feel for pulses, tenderness, surface skin texture,
temperature, and moisture.
2. 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.
Note the size, consistency, and mobility of structures you
palpate.
3. Deep palpation: Place your dominant hand on the skin
surface and your nondominant hand on top of your dominant
hand to apply pressure. This should result in a surface
depression between 2.5 and 5 cm (1 and 2 inches). This
allows you to feel very deep organs or structures that are
covered by thick muscle.
4. Bimanual palpation: Use two hands, placing one on each
side of the body part (e.g., uterus, breasts, spleen) being
palpated.
• Use one hand to apply pressure and the other hand to feel the structure.
Note the size, shape, consistency, and mobility of the structures you palpate.
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. The sounds
detected using auscultation are classified according to the
intensity (loud or soft), pitch (high or low), duration (length),
and quality (musical, crackling, raspy) of the sound.
The following guidelines should be followed as you practice
the technique of auscultation:
• Eliminate distracting or competing noises from the
environment (e.g., radio, television, machinery).
• Expose the body part you are going to auscultate. Do not
auscultate through the client’s clothing or gown. Rubbing
against the clothing obscures the body sounds.
• Use the diaphragm of the stethoscope to listen for high
pitched sounds, such as normal heart sounds, breath sounds,
and bowel sounds, and press the diaphragm firmly on the
body part being auscultated.
• Use the bell of the stethoscope to listen for low-pitched
sounds such as abnormal heart sounds and bruits (abnormal
loud, blowing, or murmuring sounds heard during
auscultation). Hold the bell lightly on the body part being
auscultated.
POSITIONING THE CLIENT
Sitting Position: The client should sit upright on the side of
the examination table. In the home or office setting, the
client can sit on the edge of a chair or bed. This position is
good for evaluating the head, neck, lungs, chest, back,
breasts, axillae, heart, vital signs, and upper extremities. This
position is also useful because it permits full expansion of the
lungs, and it allows the examiner to assess symmetry of
upper body parts.
Supine Position: Ask the client to lie down with the legs
together on the examination table (or bed if in a home
setting). A small pillow may be placed under the head to
promote comfort. If the client has trouble breathing, the
head of the bed may need to be raised. This position allows
the abdominal muscles to relax and provides easy access to
peripheral pulse sites. Areas assessed with the client in this
position may include head, neck, chest, breasts, axillae,
abdomen, heart, lungs, and all extremities.
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. This position
may be more comfortable than the supine position for clients
with pain in the back or abdomen. Areas that may be
assessed with the client in this position include head, neck,
chest, axillae, lungs, heart, extremities, breasts, and
peripheral pulses. The abdomen should not be assessed
because the abdominal muscles are contracted in this
position.
SIMS’ Position: The client lies on his or her right or left side
with the lower arm placed behind the body and the upper
arm flexed at the shoulder and elbow. The lower leg is slightly
flexed at the knee while the upper leg is flexed at a sharper
angle and pulled forward. This position is useful for assessing
the rectal and vaginal areas. The client may need some
assistance getting into this position. Clients with joint
problems and elderly clients may have some difficulty
assuming and maintaining this position.
Standing Position: The client stands still in a normal,
comfortable, resting posture. This position allows the
examiner to assess posture, balance, and gait. This position is
also used for examining the male genitalia.
Prone Position: The client lies down on his or her abdomen
with the head to the side. The prone position is used
primarily to assess the hip joint. The back can also be
assessed with the client in this position. Clients with cardiac
and respiratory problems cannot tolerate this position.
Knee–Chest Position: The client kneels on the examination
table with the weight of the body supported by the chest and
knees. A 90- degree angle should exist between the body and
the hips. The arms are placed above the head, with the head
turned to one side. A small pillow may be used to provide
comfort. The knee–chest position is useful for examining the
rectum. This position may be embarrassing and
uncomfortable for the client, and, therefore, the client should
be kept in the position for as limited a time as possible.
Elderly clients and clients with respiratory and cardiac
problems may be unable to tolerate this position.
Lithotomy Position: The client lies on his or her back with the
hips at the edge of the examination table and the feet
supported by stirrups. The lithotomy position is used to
examine the female genitalia, reproductive tracts, and the
rectum. The client may require assistance getting into this
position. It is an exposed position, and clients may feel
embarrassed. In addition, elderly clients may not be able to
assume this position for very long or at all. Therefore, it is
best to keep the client well draped during the examination
and to perform the examination as quickly as possible.
GENERAL CONSIDERATIONS FOR EXAMINING OLDER
ADULTS
- Some positions may be very difficult or impossible for the
older client to assume or maintain because of decreased joint
mobility and flexibility. Therefore, try to perform the
examination in a manner that minimizes position changes.
- It is a good idea to allow rest periods for the older adult, if
needed.
- Some older clients may process information at a slower rate.
Therefore, explain the procedure and integrate teaching in a
clear and slow manner
Collecting objective data is essential for a complete nursing
assessment. The nurse must have knowledge of and skill in
three basic areas to become proficient in collecting objective
data which are the necessary equipment and how to use it,
preparing the setting oneself and the client for the
examination and lastly, on how to perform the four basic
assessment techniques. Collecting objective data requires a
great deal of practice to become a proficient nurse.
Proficiency is needed because how the data collected can
affect the accuracy of the information listed.
Subjective data consists of:
✓Sensation or symptoms
✓Feelings
✓Perception
✓Desires
✓Preferences
✓Beliefs
✓Ideas
✓Values
✓Personal information
Collecting subjective data is an integral part of interviewing
the client to obtain a nursing health history.
Collecting subjective data is an integral part of interviewing
the client to obtain a nursing health history.
These types of data can be elicited and verified only by the
client.
The information is obtained through interviewing.
Phases of Interview
1. Pre-introductory - The nurse reviews the medical record
before meeting with the client.
2. Introductory - 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.
3. Working - 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. The nurse then listens, observes cues, and uses critical
thinking skills to interpret and validate information received
from the client.
4. Summary/Closing phases - 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
Non-Verbal Communication
1. Appearance - Wear comfortable, neat clothes and a
laboratory coat or a uniform. Be sure that your nametag,
including credentials, is clearly visible.
2. Demeanor - When you enter a room to interview a client,
display poise. Social distance between you and client during
interview.
3. Facial Expression - smile
4. Attitude - One of the most important nonverbal skills to
develop as a health care professional is a nonjudgmental
attitude.
5. Silence – Periods of silence allow you and the client to
reflect and organize thoughts, which facilitates more accurate
reporting and data collection.
6. Listening - To listen effectively, you need to maintain good
eye contact, smile or display an open, appropriate facial
expression, maintain an open body position.
Verbal Communications
1. 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.”
2. 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.”
3. Laundry list - Another way to ask questions is to provide
the client with a list of words to choose from in describing
symptoms, conditions, or feelings. For example, “Is the pain
severe, dull, sharp, mild, cutting or piercing?” “Does the pain
occur once every year, day, month, or hour?”
4. Rephrasing - This technique helps you to clarify information
the client has stated.
5. Well-placed phrases - Listen closely to the client during his
or her description and use phrases such as “um-hum,” “yes,”
or “I agree” to encourage the client to continue.
6. Inferring - Inferring information from what the client tells
you and what you observe in the client’s behavior may elicit
more data or verify existing data.
7. Providing information - Another important thing to do
throughout the interview is to provide the client with
information as questions and concerns arise. Make sure that
you answer every question as thoroughly as you can. If you
do not know the answer, explain that you will find out for the
client.
Special Considerations During the Interview
Three variations in communication must be reconsidered as
you interview clients:
✓ Gerontologic
✓ Cultural
✓ Emotional
These variations affect the nonverbal and verbal techniques
you use during the interview.
Gerontologic Variations in communication
✓ Age affects and commonly slows all body systems to
varying degrees.
However, normal aspects of aging do not necessarily equate
with a health problem, so it is important not to approach an
interview with an elderly client assuming that there is a
health problem.
Cultural Variations in Communication
Ethnic/cultural variations in communication and self-
disclosure styles may significantly affect the information
obtained.
✓ Frequently noted variations in communication styles
1. Reluctance to reveal personal information to strangers.
2. Variations in willingness to openly express emotional
distress or pain.
3. Variation in ability to receive information (listen).
4. Variation in meaning conveyed by language.
5. Variation in use and meaning of non-verbal,
communication: eye contact, stance, gestures, demeanor
6. Variation in disease/illness perception: culture specific
syndromes or disorders
7. Variation in past, present or future time orientation.
8. Variation in the family’s role in the decision-making process
Emotional Variations in Communication
✓ Clients emotions vary for a number of reasons
✓ Anxious, scared, angry, depressed
COLLECTION OF SUBJECTIVE DATA Past Health History (PHH)

The health history has eight sections:
- Biographic data
- Reasons for seeking health care
- Personal health history
- Family health history
- Review of body systems (ROS) for current health problems
- Lifestyle and health practices profile
- Developmental level
Biographic Data
Biographic data usually include information that identifies the client,
such as name, address, phone number, gender, type of insurance.
And who provided the information – the client or significant others.
The client’s birth date, Social Security number, medical record
number, or similar identifying data may be included in the
biographic data section.
- includes the client’s habits & lifestyle patterns
• Provides a holistic view of a patient’s health care experiences and
current health habits.
• Assess whether a patient has ever been hospitalized or injured or
has had surgery. (Include herbal and over-the-counter (OTC) drug).
• Description of Allergies, includes allergic reactions to food, latex,
drugs, or contact agents (ex. Soap)
• Ask patient if they have problems with medications or food.
• If the patient has an allergy, note the specific reaction and
treatment on the assessment form and special armband provided.
Family Health History (FHH)
• Includes data about immediate and blood relatives.
Objective: To determine whether a patient is at risk for illness of a
genetic or familial nature and to identify areas of health promotion
and illness prevention.

Reason for Seeking Health Care REVIEW OF SYSTEM (ROS)

• Is the information you gather when you initially set an agenda
during a patient-centered interview.
• The nurse may ask why he or she is seeking health care.
• Exploring patient’s reason for seeking health care, you will learn
the chronological and sequential history of his or her health
problems.
Chief Complaint (C/C)
• is often type on the patient's admission sheet.
• is the medical term used to describe the primary problem of the
patient that led the patient to seek medical attention and of which
they are most concerned.
History of Present Health
During the review of body systems, document the client’s
descriptions of her health status for each body system and note the
client’s denial of signs, symptoms, diseases, or problems that the
nurse asks about but are not experienced by the client.
The questions about problems and signs or symptoms of disorders
should be asked in terms that the client understands, but findings
may be recorded in standard me
Skin, hair and nails
Head and neck
Eyes
Ears
Mouth, throat, nose and sinuses

• Collect of essential and relevant data about the symptoms and Thorax and lungs
their effects on the patient’s health. Breast and regional lymphatics
• Apply critical thinking intellectual standards. Heart and neck vessels
• Use the acronym PQRST or COLDSPA to guide an assessment. Peripheral vascular
Abdomen
PQRST Guide
P – Provokes (precipitating and relieving factors) Male genitalia
what causes the symptoms, what makes it Female genitalia
better or worse Anus
Q – Quality Musculoskeletal
what does the symptoms feel like (sharp, Neurologic
burning etc.)
R – Radiate Lifestyle and Health Practices Profile
where is the symptom located (is it in one Data to gather:
place, does is occur anywhere else?) 1. Description of a typical day (AM to PM)
S – Severity 2. Nutrition and weight management
how intense is the pain Rate scale of 1 to 10. 3. 24-hour dietary intake (foods and fluids)
T – Time 4. Who purchases and prepares meals
when did it start, come, and go, how often/long 5. Activities on a typical day
COLDSPA Guide 6. Exercise habits and patterns
C – CHARACTER 7. Sleep and rest habits and patterns
O – ONSET 8. Use of medications and other substances (caffeine, nicotine,
L – LOCATION alcohol, recreational drugs).
D – DURATION 9. Self-concept
S - SEVERITY 10. Self-care responsibilities
P – PATTERN 11. Social activities contributing to society
A - ASSOCIATED FACTORS 12. Relationships with family, significant others, and pets
13. Values, religious affiliation, spirituality
14. Past, current, and future plans for education
15. Type of work, level of job satisfaction, work stressors
16. Finances
17. Stressors in life, coping strategies used
18. Residency, types of environment, neighborhood, environmental
risks

Developmental Level

1. Sigmund Freud's Stages of Psychosexual Development

2. Erik Erickson’s Stages of Psychosocial Development
3. Jean Piaget’s Stages of Cognitive Development
4. Lawrence Kohlberg’s Stages of Moral Development
Nursing (ANA) HEALTH ASSESSMENT
as the promotion and optimization of health and abilities,
➢ “the protection, promotion, and optimization of health
prevention of illness and injury, alleviation of suffering
and abilities, prevention of illness and injury, alleviation of
through the diagnosis and treatment of human responses and
advocacy in the care of individuals, families, communities, suffering through the diagnosis and treatment of human
responses and advocacy in the care of individuals, families,
and populations.
communities, and populations.”
Nursing process - health assessment involves a thorough dynamic action using
• is a series of organized steps designed for nurses to provide the phases of nursing process, by these nursing process, we
excellent care. Flexible. can help to improve the client’s condition.
• is one of the foundations of practice. It offers a framework ➢ “The registered nurse collects comprehensive data
for thinking through problems and provides some pertinent to the patient’s health or situation”
organization to a nurse's critical thinking skills. ➢ The nurse:
OVERVIEW OF NURSING PROCESS ✓ Collects data in a systematic and ongoing process
✓ Involves the patient, family, other health care
Phase Title providers and environment, as appropriate , in a holistic data
I Assessment collection
II Diagnosis - constantly observing the situations to collect information to
III Planning make nursing judgement.
IV Implementation ➢ Prioritizes data collection activities based on the patient’s
V Evaluation immediate condition, or anticipated needs of the patient or
Assessing situation
● Collecting Data – collect subjective and objective ➢ Uses appropriate evidence-based assessment techniques
information. Subjective info/data – referring to client’s and instruments in collecting pertinent data
perception. Objective info/data – our own observation - synthesizing available data that we gather and also other
● Organize Data – to come up w/ a solution information or knowledge relevant to the situation to identify
● Validate Data – by asking questions and reassessing data patterns and variances. Document these data. Have
● Document Data brainstorming involves the other healthcare team.

Diagnosing ASSESSMENT
● Analyze Data
Description
● Identify health problems, risk, and strengths
● Collecting, organizing, validating, and documenting client
● Formulate diagnostic statements
data
- collaborative problem of referral to healthcare team.
Purpose
E.g. doctor, physiotherapy, depends on client’s condition
● To establish a database about the client's response to
Planning health concerns or illness and the ability to manage health
● Prioritize problems/diagnosis care needs
● Formulate goals/desired outcomes Activities
● Select Nursing intervention ● Establish a Data base
● Write nursing interventions 1. Obtain health history or previous medical condition
- nursing care plan: your actions so the client’s condition will 2. Conduct physical assessments
improve ● Update data as needed.
● Organize data.
Implementing ● Validate data.
● Reassess the client – to know if your action or plan is ● Communicate/document data.
effective or not
● Determine the nurse's need for assistance Critical Thinking Activities
● Implement the nursing interventions – reassess and ● Making reliable observations
reassess to know if it’s good to the client or not ● Distinguishing relevant from irrelevant data
● Supervise delegated care ● Distinguishing important from unimportant data
● Document nursing activities ● Validating data
● Organizing data
Evaluating ● Categorizing data according to a framework
● Collect data related to outcomes ● Recognizing assumptions
● Compare data with outcomes ● Identifying gaps in the data
● Relate nursing actions to client goals/outcomes
● Draw conclusions about problem status
● Continue, modify, or terminate the client's care plan
- revise nursing care plan if necessary especially when those
actions are not good enough for our clients
- evaluate every now end then if our goals are achieved or
not
- if the client’s condition is solved, we need to terminate that
plan and reassess again to identify another health problems
of our client and come up again with another plan
HEALTH ASSESSMENT IN NURSING PRACTICE
As a nurse, you must have a systematic and continuous
collection of data. You need to organize, validate, and
document important information or data pertaining to your
client. Assessment varies to the purpose, timing, availability,
and also the client’s status. Remember that assessment
should include client’s perceived needs, health problems,
related experience, health practices, values and lifestyle.
Five Basic Type of Assessment
1. Initial Comprehensive Assessment (ICA)
2. Ongoing or Partial Assessment (OPA)
3. Focused or problem-oriented Assessment (FPOA)
4. Emergency Assessment (EA)
5. Time-Lapsed Assessment (TLA)
Initial Comprehensive Assessment
● Performed within specified time after admission to a health
care agency
Purpose:
● to establish a complete database for problem identification,
reference and future comparison
- involves the collection of subjective data about the client’s
perception of his health, past health history, family history,
lifestyle and health practices. As well as objective data
gathered during a step by step process.
Ongoing or Partial Assessment
● Performed whenever and wherever the nurse or another
health care professional has an encounter with the client in
any setting
Purpose:
● To determine any changes from the baseline data
(deterioration or improvement)
Focused or Problem-oriented Assessment
● Performed when a comprehensive database exists for a
client with a specific health concern.
Purpose:
● a thorough assessment of a particular client problem.
- e.g. neurologic or cardiac
Emergency Assessment
● During a physiologic or psychologic crisis of the client
● A very rapid assessment performed in life threatening
situations for prompt treatment or intervention.
Example:
Choking, cardiac arrest, drowning.
Purpose:
● to identify life-threatening problems
● to identify new or overlooked problems
- could involve physiologic or psychologic crisis on your client
Time-lapsed Reassessment
● Several months after initial assessment
Purpose:
● to compare the client's current status to baseline data
previously obtained
- tract client’s condition upon admission up to present
NURSE’S ROLE IN HEALTH ASSESSMENT
Late 1800s – Early 1900s
➢ Nurses relied of their natural senses, the client’s face and
body would be observed for “change in color, temperature,
muscle strength, use of limbs, body output, and degrees of
nutrition and hydration.
1930 – 1949
➢The American Journal of Public Health documents routine
client and home inspection by public health nurse in 1030s
1950 – 1969
➢ Nurses were hired to conduct pre-employment health
histories and physical examination for major companies such
as NY telephone from 1953-1960.
1970 – 1989
➢Conducts health histories and physical and psychological
assessments.
➢assessment which individualized plans of care were
established.
1990 – Present
➢ Downsizing budget cuts, and restructuring were the
priorities of the 1990’s. In turn, there was the demand for
documentation of client assessments by all health care
provides to justify, health care services.
➢ 1990’s critical pathways or care maps guided the client’s
progression, with each stage guided by each protocols that
the nurse was responsible for assessing and validating.
• Acute Care Nurse - performs a focused assessment and
relays findings with the multidisciplinary team to develop a
comprehensive care plan.
- doctors, pharmacists, dietitian/nutritionist, therapists,
laboratory
• Critical Care Outreach Nurses - safely assess critically ill
clients who are outside the structured intensive care
environment.
- home setting
• Ambulatory Care Nurses - assess and screen clients to
determine the need for physician referrals.
• Home Health Nurses - make independent nursing diagnoses
and referrals
• Public Health Nurse - is the practice of promoting and
protecting the health of populations using knowledge from
nursing, social, and public health sciences.
• School Nurses - a specialized practice of public health
nursing, protects and promotes student health, facilitates
normal development, and advances academic success.
• Hospice Nurses - is a specialist in the nursing field who is
trained to work closely with terminally ill patients. While
nurses who work in hospice settings are licensed as a
registered nurse, they play a special role as a case manager
and advocate for patients who are nearing the end of their
life and their families.