Health Assessment in Nursing

MIDTERMS REVIEWER (First Year, Second Semester) RN in the making!

Padayon!

DEFINITIONS HEALTH ASSESSMENT

HEALTH - The state of complete physical, mental, and
social well-being, and not merely the absence of disease or
infirmity.
ASSESSMENT - A deliberate and systematic collection of
data to determine the client’s past health status (health
history), functional status, and present health status.
Deals with the concepts and principles underlying
assessment of the health status of individuals by;
● Interviewing
A systematic and continuous collection, organization,
validation and documentation of data coupled with a plan of
care with specific needs of a person and how those needs
will be carried out by a healthcare provider.
● Is a plan of care that identifies a person's specific
needs and how the healthcare system or skilled
nursing facility will address those needs.
● Health assessment is the evaluation of the health
status by performing a physical examination after

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● Taking health histories (past & present) taking a health history. It is done to detect diseases
● Physical examination (observation, palpation, early in people that may look and not feel well.
percussion, auscultation) ● Health assessment is the evaluation of the health
● Formulate initial nursing plans using the nursing status of an individual
process. ● The collection of data coupled with a plan of care

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with the specific needs of a person and how a
health care provider will carry out those needs.
STEPS IN NURSING PROCESS
● A systematic and continuous collection,
1. Assessment
organization, validation, and data documentation.
2. Nursing Diagnosis
3. Planning
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4. Implementing/implementation
5. Evaluating/evaluation PURPOSES OF HEALTH ASSESSMENT
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Example of Nursing Process 1. To collect data pertinent to the patient’s health
status, subjective data through interviews and
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objective data through physical examination.

Assessment febrile T- 39.2 2. Helps identify clients’ needs, clinical problems, and
deviation from normal.
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Nursing Increased body temperature 3. Identify the client’s strengths, limitations, and
Diagnosis related to presence of infection coping resources
4. To identify the factors that place the client at risk of
nning After 30 minutes of nursing health problems. (internal and external factors)
intervention temperature of the 5. Building and establishing rapport with the client
patient will decrease from 39.2 to and his family
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37.8 6. Helps to evaluate the responses of the client to

health problems and interventions.
Intervention (Independent Nursing
Management) WHY SHOULD WE ASSESS THE PATIENT?
-Render tepid sponge bath (TSB)
-Apply cold compress over the SUBJECTIVE DATA - Collected through interview. Data
forehead -Encourage to increase verbalized by the client/patient; Data that only the patient
fluid intake : temp rechecked can feel, such as; (pain, headache, nausea, chilly sensation)
38.8 OBJECTIVE DATA - Done through physical examination or
(Dependent Nursing observation. Data that can be seen, felt, and heard from the
Management) patient through physical examination.
-Give paracetamol 500mg p.o. as seen: vomiting, chilling, grimacing face, bleeding
ordered felt: fever, tympanic, presence of mass
heard: a)cardiac rate b) breath sounds
Evaluation After 30 minutes of nursing ➢ NORMAL (adult 60-80 b/min)
intervention, patient's ➢ TACHYCARDIA - fast heart/pulse rate (reg; irreg)
temperature went down from ➢ BRADYCARDIA - slow heart/pulse rate (reg; irreg)
39.2 to 37.6

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Health Assessment in Nursing
MIDTERMS REVIEWER (First Year, Second Semester) RN in the making!
Padayon!

BREATHING SOUNDS
COMPUTATIONS
NORMAL - (adult) 16-20 breaths/minute
TACHYPNEA - Fast breathing
BRADYPNEA - Slow breathing IVF COMPUTATIONS
APNEA - Absence of breathing
RALES - Rattling sounds in the lungs, heard when a person
inhales.
RHONCHI - Sounds that resemble snoring.
STRIDOR - Wheeze-like sound heard when a person
breathes.
WHEEZING - High-pitched sounds produced by narrowed
airway,

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TYPES OF ASSESSMENT

❖ 1 macrodrop = 3-4 microdrops

INITIAL ASSESSMENT - Also known as “admission
assessment,” performed when the client enters the health To get the microdrops, multiply your answer from macrodrop
care facility. computation:

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❖ Purpose: To establish database identification and
future comparison.
FOCUS / ONGOING ASSESSMENT - Ongoing process Macrodrop Answer x 4 (if you used 15 gtts drip factor)
Macrodrop Answer x 3 (if you used 20 gtts drip factor)
integrated with nursing care.
❖ Purpose: To determine a specific problem's status
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and identify new or overlooked problems. Eg. 167 gtts x 3 (x 3 only because our DF was 20) = 501 ugtts
➢ Example: An hourly measurement of
intake and output.
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MACRODRIP TUBING - Delivers 15 to 20 gtts/mL and is
■ INTAKE - Everything that the used to infuse large volumes or to infuse fluids quickly.
client takes in liquid form. MICRODRIP TUBING - Delivers 60 ugtts/mL and is used for
● Orally, NGT, OGT, IV small or exact amounts of fluid, as with neonates or
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Fluids pediatric patients.

■ OUTPUT
● Urine, Watery Stool,
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Vomitus, Secretions
EDEMA - More intake ;
Less output
DEHYDRATION - Less
intake ; more output
EMERGENCY ASSESSMENT - Done during the physiologic
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or psychological crisis of the patient.

❖ Purpose: a) Major purpose is to save the patient’s
life, b) To identify life-threatening problems. CELSIUS TO FAHRENHEIT
➢ Example: A rapid assessment of the ➗
℉ = (℃ x 1.8) + 32 OR ℃ x 9 = (ans) 5 = (ans) + 32 = ℉
patient’s airway, breathing, and circulation FAHRENHEIT TO CELSIUS
(ABCs)
TIMELAPSE ASSESSMENT - Done several days after the
➗ ➗
℃ = (℉ - 32) 1.8 OR ℉ - 32 = (ans) x 5 = (ans) 9 = ℃
last assessment OTHER CONVERSIONS
❖ Purpose: To compare current status to baseline 1cc = 1 ml
data previously obtained. 1 liter = 1000 cc
➢ Example: Reassessment of patient’s 1 pint = 473.176 cc
functional health patterns at home. 1 inch = 2.54 cm
1 foot = 12 inches
1 kilogram (kg) = 1000 grams
1 kilogram (kg) = 2.2 lbs
1 gram = 1000 milligrams (mg)

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Health Assessment in Nursing
MIDTERMS REVIEWER (First Year, Second Semester) RN in the making!
Padayon!

Example: You didn't finish the course of antibiotics the

METHODS OF ASSESSMENT
doctor prescribed, did you? rather than "Did you finish the
course of antibiotics
1. OBSERVING - This is a conscious, deliberate skill
developed only through an organized approach. COLLECTING DATA MUST BE SYSTEMATIC AND
➢ Example: A client’s data is observed CONTINUOUS TO PREVENT THE OMISSION OF
through the four senses; vision, smell, SIGNIFICANT DATA, LIKE:
hearing, and touch.
2. INTERVIEWING - This is a planned communication ● Nursing health history
or conversation with a purpose. ● Physical exam
➢ Example: History taking ● Result of laboratory and diagnostic exam
● Choose a quiet, private, well-lighted interview ● Past illness
setting away from destruction ● Current Illness
● Make sure the patient is comfortable, and you are

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facing the patient 1) BIOGRAPHIC DATA - Start the health history by
● Introduce yourself and give the purpose of your taking the Biographic data of the patient;
interview a) Patient's name:
● Reassure the patient that everything he says will b) Age:
be kept confidential c) Sex:
● Tell the patient how long the interview will last and d) Marital Status:

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what he expects from it e) Address:
● Assess the patient if communication barriers exist f) Religion:
● If your patient has a hearing impairment, make g) Nationality:
sure the venue is well-lit, face him, and speak
slowly and clearly so that he/she can read your
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i) Whom to contact in case of emergency:
lips. 2) BASELINE DATA
● Address the patient by full name. Don’t call him by a) Weight:
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his/her first name unless they allow you to do so. b) Height:
● Listen attentively and make eye contact c) Temperature: Oral, Axilla, Rectal
frequently. d) Respiratory rate: (breaths/minute)
e) Pulse rate/cardiac rate: (beats/minute)
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SILENCE - A moment of silence allows the patient to f) Blood pressure: (mmHg)

continue talking and will allow you to assess his ability to 3) CHIEF COMPLAINT - Try to pinpoint why the client
organize thoughts. is seeking care at this time. Document the
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FACILITATION - Facilitation encourages the client to
continue his story. Using phrases like; “please continue,” ‘go
on,’ or even “uh-huh” show that you are interested in his
report.
CONFIRMATION - Confirmation ensures that you and your
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information exactly as what the patient has said.
What prompted him/her to seek medical attention,
and what were the symptoms noted
4) MEDICAL HISTORY
a) Have you been hospitalized? If so, when
and what for?

patient are in the same tract. “If l am correct, you said….”

REFLECTION - Reflection or repeating what the patient has
said.
CLARIFICATION - Clarification is used to clear up
confusion.
SUMMARIZATION - Summarizing or restating the patient's
information.
CONCLUSION - Signaling to the patient that you are ready
to conclude the interview.
WHEN INTERVIEWING YOU CAN USE:
Closed questions - (when, where, who)
Open-ended questions - one that leads the patient to tell
you more (what, how, why)
Neutral questions - Questions that the patient is not
pressured to answer.
Leading questions - the nurse directs the client's answer.
b) Which childhood illness did you have?
c) Are you having any treatment? If so, what
are they?
d) Have you had any surgery? What for?
5) ALLERGY HISTORY - Any allergy to food, fur,
smoke, dust, pollen, etc.
6) FAMILY HISTORY
a) ·Are your mother or father still living?
Siblings?
b) ·Any familial disease like; asthma,
diabetes, hypertension, heart disease,
glaucoma, kidney problem, or renal
disease?
7) PSYCHOSOCIAL HISTORY
a) ·Lifestyle
b) Coping with stress
c) How close do you live to any Health
Facility, and are they easy to get to?

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Health Assessment in Nursing
MIDTERMS REVIEWER (First Year, Second Semester)
3. EXAMINING - Physical examination is the process
of evaluating objective anatomic findings through
observation, palpation, percussion, and auscultation. The
physical examination, thoughtfully performed, should yield
20% of the data necessary for patient diagnosis and
management. During the physical assessment/examination,
use drapes, exposing only the area to be examined.
Organize your steps to minimize the times the patient needs
to change position.
The four techniques used for physical examination come in
sequence, except for the examination of the abdomen
because palpation and percussion alter the bowel sounds.
INSPECTION – This is a close and careful visualization of the
person and of each body system. The health examiner will
look at, or "inspect" specific areas of the client’s body for
normal color, shape and consistency. Certain findings on
"inspection" may alert the healthcare provider to focus other
parts of or certain areas of the body.
Example: Patient’s legs may be swollen. The healthcare
provider will then pay special attention to the common
things that cause leg swelling, such as extra fluid caused by
the heart, and use this information to help them diagnose.
Common areas that are inspected may include:
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● SKIN - To look for bruising, cuts, moles, or
lumps.
● FACE & EYES - To see if they are even and
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"normal".
● NECK VEINS - To see if these are bulging,
distended (swollen).
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● CHEST & ABDOMEN - To see if there are
any masses, or bulges.
● LEGS - To see if there is any
swelling/edema.
● MUSCLES - To check for good muscle tone
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● ELBOWS, KNEES, & JOINTS - Check for
swelling and inflammation if any
deformities are present.
PALPATION - Palpation requires touching the patient with
different parts of the hands, using varying degrees of
pressure. The health care provider touches and feels the
client’s body to examine the size, consistency, texture,
location, and tenderness of an organ or body part.
3 PARTS OF HANDS USED FOR PALPATION
1. FINGER PADS - Used in pulses, texture, size,
consistency, shape
2. ULNAR / PALMAR - Vibrations, thrills, fremitus
3. DORSAL - Temperature
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THRILL - An abnormal vibration that is felt on the skin
overlying a loud cardiac murmur or an arteriovenous
fistula.
➢ A tingling or shivering sensation of tremulous
excitement as from pain, pleasure, or horror.
FREMITUS - Refers to the assessment of the lungs by either
the vibration intensity felt on the chest wall (tactile
fremitus);
or heard by a stethoscope on the chest wall with certain
spoken words (vocal resonance)
TYPES OF PALPATION
LIGHT PALPATION
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● The nurse applies tactile pressure, slowly, gently
and deliberately.
● This technique is used to feel for surface
abnormalities.
● How: Depress the skin ½ to ¾ inch (about 1 to 2 cm)
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with your finger pads, using the lightest touch
possible. Assess for texture, tenderness,
temperature, moisture, elasticity, pulsations, and
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DEEP PALPATION
● Used to detect abdominal masses.
● Use this technique to feel internal organs and
masses for size, shape, tenderness, symmetry, and
mobility.
● How: Depress the skin 1½ to 2 inches (about 4 to 5
cm) with firm, deep pressure. Use one hand on top
of the other to exert firmer pressure, if needed.
BIMANUAL PALPATION
● It involves using both hands to trap a structure
between them.
● This technique can be used to evaluate kidney,
spleen, breast, uterus and ovary.
● Active hands apply pressure to the sensing hand.
IN PALPATION WE CAN;
● Feel body’s temperature
● Sense the skin and its texture
● Rigidity or spasticity of the muscles
● Crepitation/vibration
PERCUSSION - Involves tapping the examiner’s fingers or
hands quickly and sharply against parts of the patient's
body to help locate organ borders, identify organ shape and
position, and determine if an organ is solid or filled with fluid
or gas.
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Health Assessment in Nursing
MIDTERMS REVIEWER (First Year, Second Semester) RN in the making!
Padayon!

METHODS OF PERCUSSION

DIRECT PERCUSSION AUSCULTATION

● This technique reveals tenderness; it's commonly
used to assess/evaluate an adult's sinuses or an
infant thorax.
● It can be performed by striking the surface directly
with the fingers of the hands
INDIRECT PERCUSSION
● This technique elicits sounds that give clues to the
makeup of the underlying tissue.
● Involves listening for various lung, heart, and bowel
sounds with a stethoscope.
● Best performed in a quiet environment
● Make sure the area to be auscultated is exposed (a
gown or bed linens can interfere with sounds.)
● Warm the stethoscope head in your hand.
● Focus your attention.
● How: Use the diaphragm to pick up high-pitched
sounds. Hold the diaphragm firmly against the
patient's skin, using enough pressure to leave a

● It can be performed by using the finger on one
hand as the plexor (striking finger)and the middle
finger of the other hand as a pleximeter (the finger
being struck). Tap quickly and directly over the
point where your other middle finger touches the
patient's skin.
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slight ring on the skin afterward.
● Listen to and try to identify the characteristics of
one sound at a time.
OLFACTION - While assessing a client, the nurse should be

● Listen to the sounds produced.
● Used mainly to evaluate the abdomen or thorax.
FIST PERCUSSION
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familiar with the nature and source of body odors.
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● Used to evaluate the back or kidneys for

tenderness
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● It involves placing one hand flat against the body
surface and striking the back of the hand with the
clenched fist of the other hand.
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PERCUSSION SOUNDS
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1. FLATNESS – bone or muscle

2. DULLNESS – heart, liver, spleen
3. RESONANCE – air-filled lungs (hollow)
4. HYPERRESONANCE – emphysematous lung
5. TYMPANY – air-filled stomach (drumlike)
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SOUNDS PRODUCED BY PERCUSSION

1. Sound: Tympany
2. Intensity: Loud
3. Pitch: High
4. Duration: Moderate
5. Quality: Drumlike
6. Common location: Air containing space, enclosed
area, gastric air bubble, puffed out cheek

NORMAL LUNGS

1. Sound: resonance
2. Intensity: moderate to loud
3. Pitch: Low
4. Duration: Long
5. Quality: Hollow