A.

Health Assessment in Nursing Practice

The purpose of a nursing 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 judgement. The nurse
collects physiologic, psychological, sociocultural, developmental, and spiritual data about the client.
Thus, the nurse performs holistic data collection.

Types of Health Assessment

•It 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 as
well as objective data gathered during a step-by-step physical examination
Initial Comprehensive
Assessment

•It consists of data collection that occurs after the comprehensive database is established.
This consist of a minioverview of the client’s body systems and holistic health patterns as a
follow up on health status
On-going or Partial
Assessment

•A focused assessment consists of a thorough assessment of a particular client problem and

Focused or Problem- does not address areas not related to the problem
oriented Assessment

•An emergency assessment is a very rapid assessment performed in a life threatening

situations.
•The major and only concern during this type of assessment is to determine the status of the
Emergency client’s life-sustaining physical functions.
assessment

Nurse’s Role in Health Assessment

The nurse’s role in health assessment has changed significantly over the years. The rapidly evolving
roles of nursing require extensive focused assessment and the development of related nursing
diagnosis. The future will see increased specialization and diversity of assessment skills for nurses.
While client acuity increases technology advances, bedside nurses are challenged to make in-depth
physiologic and psychosocial assessment while correlating clinical data from multiple technical
monitoring devices.

1.Acute Care Nurse – performs a focused assessment, and then incorporates

assessment findings with a multidisciplinary team to develop a comprehensive plan
of care

2.Critical care outreach nurses – need enhanced assessment skills to safely assess
critically ill clients who are outside the structured intensive care environment
 3.Ambulatory care nurses – asses and screen clients to determine the need
for physician referrals

4.home health nurses – make independent nursing diagnoses and referrals for
collaborative problem as needed

5.Public health nurses – assess the needs of communities

6.School nurses – monitor the growth and health of children

7. hospice nurses - assess the needs of the terminally ill clients and their families

STEPS OF HEALTH ASSESSMENT:

Preparing for the Assessment:

Awareness of the
Knowing the Knowing the
client’s previous
client’s medical client’s basic
and current
record biographical data
health status

Obtain and organize Educate yourself

Take a minute to
material that you will about the client’s
reflect on your
need medical
own feelings.
diagnosis.

COLLECTING SUBJECTIVE DATA: THE INTERVIEW AND HEALTH HISTORY

Learning Objectives

1. Discuss the 4 phases of a client interview

2. Explain types of communication to avoid during interview
3. Identify the major categories of a complete client health history
4. Describe how to use a genogram
5. Describe the process of performing a review of system

Collection of Subjective data

Subjective data are sensations or symptoms (pain, hunger), feelings (happiness, sadness),
perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be
elicited and verified only by the client.

INTERVIEWING
Obtaining a valid nursing health history requires professional, interpersonal, and interviewing
skills. The nursing interview is a communication process that has two focuses.
• Establishing rapport and a trusting relationship with the client to elicit accurate and
meaningful information
o Gathering information on the client’s developmental, psychological,
physiologic, sociocultural, and spiritual status

Phases of the Interview

The nursing interview has 4 basic phases:
 Pre-Introductory Phase

Introductory Phase

Working Phase

Summary and Closing Phase

Communication During the Interview

The client interview involves two types of communication: verbal and non-verbal. Several
special techniques and certain general considerations will improve both types of communication
as well as promote an effective and productive interview.

Communication to Avoid
A. Nonverbal Communication
Excessive or insufficient eye contact
Distraction and distance
Standing

B. Verbal Communication
Biased or Leading questions

Rushing through the Interview

Reading the questions

Interacting with clients with various emotional Status

1. When interacting a. Provide with simple, organized information in a
with an anxious structured format
client b. Explain who you are, along with your role and
purpose
c. Ask simple, concise questions
d. Avoid becoming anxious also
e. Do not hurry, and decrease any external stimuli

2. When interacting a. Approach the client in a calm, reassuring, in-control

with an angry client manner
b. Allow the client to ventilate feelings. However,
when the client is out of control, do not argue with
or touch the client
 c. Obtain help from other health care professionals as
needed.
d. Avoid arguing and facilitate personal space so that
the client does not feel threatened
e. Never allow the client to position him or herself
between you and the door

3. When interacting a. Express interest in and understanding of the client

with a depressed and respond in a natural manner
client b. Do not try to communicate in an upbeat,
encouraging manner.

4. When interacting a. Provide structure and set limits

with a manipulative b. Differentiate between manipulation and a
client reasonable request
c. If you are not sure whether you are being
manipulated, obtain an objective opinion from
other nursing colleague

5. When interacting a. Set firm limits on evert sexual client behavior and
with seductive client avoid responding to subtle seductive behavior
b. Encourage client to use more appropriate methods
of coping in relating to others
c. If the overt sexually continues, do not interact
without a witness
d. Report inappropriate behavior to a supervisor

6. When discussing a. First, be aware of your own thoughts and feelings

sensitive issues regarding dying, spirituality, and sexuality; then
recognize that these factors may affect the client’s
health and may need to be discussed with someone
b. Ask simple questions in a nonjudgmental manner
c. Allow time for ventilation of client’s feelings as
needed.
d. If you do not feel comfortable or competent
discussing personal, sensitive topics, you make
referrals as appropriate.

COMPLETE HEALTH HISTORY

When the client is having a complete, head-to-toe physical assessment, collection of
subjective data usually requires that the nurse take a complete health history. The health history
is modified or shortened when necessary.
Major areas of subjective data 1. Biographical Data

Biographical data usually include information that identifies the client, such as name, address,
phone number, gender, and who provided the information – the client or significant others.
 2. Reasons for seeking health care and Chief Complaint

This category includes two questions: “What is your major health problems or concern 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 I help you!”

3. History of:
•
a. Present Illness
The client’s answer to the questions provides the nurse with a great deal of
information about the client’s problem and especially how it affects lifestyle and activities of daily
living (ADLs). This helps the nurse to evaluate the client’s insight into the problem and the client’s
plans for managing it. The nurse can also begin to postulate nursing diagnoses from this initial
information.

b. Past Health History

Ask the client about any childhood illnesses and immunizations to date. Adult illnesses
(physical, mental and emotional) are then explored. Ask the client to recall past surgeries or
accidents. Ask the client to describe any prolonged episodes of pain or pain patterns he or she has
experienced. Inquire about any allergies (food, medicine, pollens and use of prescription and OTC
medications.

c. Family Health History

It is 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.

d. Review of System
In ROS, each body system is addressed and the client is asked specific questions to
elicit further details of current health problems from the recent past that may still affect the client.
In this section, only the client’s subjective information and not the examiner’s observation are
noted. The questions about problems and signs and symptoms of disorders should be asked in
terms that client understands, but findings should be recorded in standard medical terminology.

e. Lifestyle
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 pattern, sleep and rest
patterns, self-concept and self-care activities, relationships, values and belief system, education
and work, tress level and coping style, and environment.

f. Developmental Level and Psychosocial History

A developmental and social history is an important part of an assessment for the
diagnosis of learning disabilities. It is the collection of background information on a student.
 MODULE 3 COLLECTING OBJECTIVE DATA: THE PHYSICAL EXAMINATION

Learning Objectives

1. Explain how to prepare oneself, the environment, and the client for a physical examination
2. Explain the uses of equipment needed for physical examination
3. Describe and demonstrate various client positions used for different physical examination
4. Demonstrate correct IPPA techniques

Collection of Objective data

Objective data include information about the client that the nurse directly observes during
interaction with the client and information elicited through physical assessment techniques. To
become proficient with physical assessment skills, the nurse must have basic knowledge in three
areas:
a. Types and operation of equipment needed for the particular examination
b. Preparation of the setting, oneself, and the client for the physical assessment
c. Performance of the four assessment techniques: inspection, palpation, percussion and
auscultation

1. Physical Examination
Each part of the physical examination requires specific pieces of equipment. Prior to the
examination, collect the necessary equipment and place it in 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.

2. Preparation
As an examiner, you must make sure that you have prepared or all three aspects before beginning an
examination.
a. Preparing the physical setting
b. Preparing oneself
c. Approaching and preparing the client

3. Positioning – different position during physical examination

4. Techniques – four basic techniques must be mastered before you can perform
a thorough and complete assessment of the client.

a. Inspection – involves using the senses of vision, smell, and hearing

to observe and detect any normal or abnormal findings. Note the
following characteristics while inspecting the client; color, patterns,
size, location, consistency, symmetry, movement, behavior, odors
or sounds

b. Palpation – it consists of using body parts of the hands to touch and feel
 b.1 light palpation – to perform light palpation, place your
dominant hand lightly on the surface of the structure. There
should be very little or no depression (less than 1cm). feel
the surface structure using a circular motion.
b.2 moderate palpation – depress the skin surface 1 to 2 cm 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.

b.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
allows you to feel very deep organs or structure covered with thick muscle

b.4 bimanual palpation – use two hands, placing one on each side
of the body part being palpated (uterus, breast, spleen). Use one hand to apply
pressure and the other hand to feel the structure.

c. Percussion – involves tapping body parts to produce sound waves. Uses of percussion
includes: eliciting pain, determining location, size and shape, determining density,
detecting abnormal masses, eliciting reflexes.

c.1 Direct percussion – is the direct tapping of a body with one or two
fingertips to elicit possible tenderness

c.2 Blunt percussion – used to detect tenderness over organs (eg kidneys)
by placing one hand flat on the body surface and using the fist of the other
hand to strike the back of the hand flat on the body surface.

c.3 Indirect or mediate percussion – It produces sound or tone that varies

with the density of underlying structures. As density increases, the sound of
tone becomes quieter

d. Auscultation – A stethoscope is used because these

body sounds are not audible to the human ear. The sounds detected are
classified according to the intensity (loud or soft), pitch (high or low),
duration (length), and quality (musical, crackling or raspy) of the sounds.