HEALTH ASSESSMENT LECTURE
1ST SEMESTER
LESSON 1 & 2
NURSE’S ROLE IN HEALTH ASSESSMENT
INITIAL COMPREHENSIVE ASSESSMENT
ASSESSMENT
DIAGNOSIS
PLANNING
IMPLEMENTATION
EVALUATION
ONGOING OR PARTIAL ASSESSMENT
FOCUS OF HEALTH ASSESSMENT IN
NURSING
• A comprehensive health assessment
consists of both a health history and
physical examination
• PURPOSE -> 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
FRAMEWORK FOR HEALTH ASSESSMENT
IN NURSING
4 TYPES OF HEALTH ASSESSMENT
Initial comprehensive assessment
Ongoing or partial assessment
Focused or problem-oriented assessment
Emergency assessment
• An 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.
• An ongoing or partial assessment of the
client 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. Any
problems that were initially detected in the
client’s body system or holistic health
patterns are reassessed to determine any
changes (deterioration or improvement)
from the baseline data.
FOCUSED OR PROBLEM- ORIENTED
ASSESSMENT
• A focused or problem-oriented assessment
does not replace the comprehensive health
assessment. It is performed when a
comprehensive database exists for a client
who comes to the health care agency with a
specific health concern.
EMERGENCY ASSESSMENT
• An emergency assessment is a very rapid
assessment performed in life-threatening
situations
• In such situations (choking, cardiac arrest,
drowning), an immediate assessment is
needed to provide prompt treatment. The
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major and only concern during this type of FOUR PHYSICAL EXAMINATION
assessment is to determine the status of the TECHNIQUES
client’s life- sustaining physical functions.
INSPECTION
STEPS OF HEALTH ASSESSMENT PALPATION
1. COLLECTION OF SUBJECTIVE DATA PERCUSSION
2. COLLECTION OF OBJECTIVE DATA AUSCULTATION
3. VALIDATION OF DATA VALIDATING ASSESSMENT DATA
4. DOCUMENTATION OF DATA
• Validation of assessment data is a crucial
COLLECTION OF SUBJECTIVE DATA part of assessment that often occurs along
• Subjective data are sensations or symptoms with collection of subjective and objective
(e.g., pain, hunger), feelings (e.g., data. What types of assessment data
happiness, sadness), perceptions, desires, should be validated, the different ways to
preferences, beliefs, ideas, values, and validate data, and identifying areas where
personal information that can be elicited and data are missing are all parts of the
verified only by the client process.

AREAS OF SUBJECTIVE DATA

• 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 ANALYSIS OF ASSESSMENT DATA
practices, family structure and function,
community environment) • Often called nursing diagnosis
• This must be done in order to arrive with a
COLLECTING OBJECTIVE DATA (DIRECT conclusion about your client’s health
OBSERVATION) • Based on your data: is this a nursing
concern?
• Physical characteristics (e.g., skin color, • If not -> collaborative concern (help of
posture) physicians etc.)
• Body functions (e.g., heart rate, respiratory
rate) PROCESS OF DATA ANALYSIS
• Appearance (e.g., dress and hygiene)
• Behavior (e.g., mood, affect) 1. Identify abnormal data and strengths.
2. Cluster the data.
• Measurements (e.g., blood pressure,
3. Draw inferences and identify problems.
temperature, height,
4. Propose possible nursing diagnoses.
• weight)
5. Check for defining characteristics of those
• Results of laboratory testing (e.g., platelet
diagnoses.
count, xray findings)
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6. Confirm or rule out nursing diagnoses. NON-VERBAL COMMUNICATION

7. Document conclusions.
APPEARANCE
DOCUMENTING DATA DEMEANOR
FACIAL EXPRESSION
• Documentation of assessment data is an ATTITUDE
important step of assessment because it SILENCE
forms the database for the entire nursing LISTENING
professionals.
WHAT TO AVOID……
COLLECTION OF SUBJECTIVE DATA
EXCESSIVE OR INSUFFICIENT EYE
1. Biographic Data CONTACT
2. Reasons for Seeking Health Care DISTRACTION OR DISTANCE
3. Chief Complaint STANDING
4. History of:
o Present Illness VERBAL COMMUNICATION
o Past Health History
o Family Health History OPEN-ENDED QUESTIONS
o Current Medications CLOSED-ENDED QUESTIONS:
o Lifestyle o “When did your headache start?”
o Developmental Level LAUNDRY LIST
o “Is the pain dull, cutting, sharp,
INTERVIEWING throbbing, aching, piercing?”
o “Does the pain occur every hour,
TWO FOCUSES OF AN INTERVIEW every day, every month, every
year?”
• Establishing rapport and a trusting
REPHRASING
relationship with the client to elicit accurate
WELL-PHASED PHRASES
and meaningful information
INTERFERRING
• Gathering information on the client’s
PROVIDING INFORMATION
developmental, psychological, physiologic,
sociocultural, and spiritual statuses to SPECIAL CONSIDERATIONS DURING THE
identify deviations that can be treated with INTERVIEW
nursing and collaborative interventions or
strengths that can be enhanced through Gerontologic
nurse–client collaboration. Cultural
Emotional
PHASES OF THE INTERVIEW
EIGHT SECTIONS OF HEALTH HISTORY
Preintroductory Phase
Introductory Phase Biographic data
Working Phase Reasons for seeking health
Summary and Closing Phase Care History of Present health Concern
Personal Health history
COMMUNICATION DURING THE Family health History
INTERVIEW Review of Systems
Lifestyle and Health Practices
NON-VERBAL
Developmental Level
VERBAL
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1. BIOGRAPHIC DATA
INCLUDES: client, such as name, address, phone
number, gender, 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.
2. REASONS FOR SEEKING HEALTH
CARE
• This category includes two questions:
“What is your major health problem or
concerns at this time?”
“How do you feel about having to seek
health care?”
LESSON 3
3. HISTORY OF PRESENT ILLNESS
• First, encourage the client to explain the
health problem or symptom in as much
detail as possible by focusing on the onset,
progression, and duration of the problem;
signs and symptoms and related problems;
and what the client perceives as causing the
problem.
• You may also ask the client to evaluate what
makes the problem worse, what makes it
better, which treatments have been tried,
what effect the problem has had on daily life
or lifestyle, what expectations are held
regarding recovery, and what is the client’s
ability to provide self-care.
HISTORY OF PRESENT ILLNESS
Mnemonic used is “COLDSPA.”
• C: Character
• O: Onset
• L: Location
• D: Duration
• S: Severity
• P: Pattern
• A: Associated Factors
PAST HEALTH HISTORY/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.
• Adult illnesses (physical, emotional, and
mental) 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, other) and use of prescription and
over-the-counter (OTC) medications.
• Information covered in this section includes
questions about birth, growth, development,
childhood diseases, immu- nizations,
allergies, medication use, previous health
problems, hospitalizations, surgeries,
pregnancies, births, previous acci- dents,
injuries, pain experiences, and emotional or
psychiatric problems
FAMILY HEALTH HISTORY
• The family history should include as many
genetic relatives as the client can recall.
Include maternal and paternal grand-
parents, aunts and uncles on both sides,
parents, siblings, and the client’s children.
REVIEW OF SYSTEMS
• 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.
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• SKIN, HAIR, AND NAILS: Skin color,
temperature, condition, excessive sweating,
rashes, lesions, balding, dandruff, con-
dition of nails
• HEAD AND NECK: Headache, swelling,
stiffness of neck, diffi- culty swallowing, sore
throat, enlarged lymph nodes
• EYES: around lights, blurring, loss of side
vision, moving black spots/specks in visual
fields, flashing lights, double vision, and eye
pain
• EARS: Hearing, ringing or buzzing,
earaches, drainage from ears, dizziness,
exposure to loud noises
• MOUTH, THROAT, NOSE, AND
SINUSES: Condition of teeth and gums;
sore throats; mouth lesions; hoarseness;
rhinorrhea; nasal obstruction; frequent
colds; sneezing or itching of eyes, ears,
nose, or throat; nose bleeds; snoring
• THORAX AND LUNGS: - ness of breath
during routine activity, orthopnea, cough or
sputum, hemoptysis, respiratory infections
• BREASTS AND REGIONAL
LYMPHATICS: Lumps or discharge from
nip- ples, dimpling or changes in breast
size, swollen or tender lymph nodes in axilla
• HEART AND NECK VESSELS: Last
blood pressure, ECG tracing or findings,
chest pain or pressure, palpitations, edema
• PERIPHERAL VASCULAR: Swelling, or
edema, of legs and feet; pain; cramping;
sores on legs; color or texture changes on
the legs or feet
• ABDOMEN: Indigestion, difficulty
swallowing, nausea, vomit- ing, abdominal
pain, gas, jaundice, hernias
• MALE GENITALIA: Excessive or painful
urination, frequency or difficulty starting and
maintaining urinary stream, leaking of urine,
blood noted in urine, sexual problems,
perineal lesions, penile drainage, pain or
swelling in scrotum, dif- ficulty achieving an
erection and/or difficulty ejaculating,
exposure to sexually transmitted infections
(STIs)
• FEMALE GENITALIA: Sexual problems;
STIs; voiding problems (e.g., dribbling,
incontinence); reproductive data such as
age at menarche, menstruation (length and
regularity of cycle), pregnancies, and type of
or problems with delivery, abor- tions, pelvic
pain, birth control, menopause (date or year
of last menstrual period), and use of
hormone replacement therapy (HRT)
• ANUS, RECTUM, AND PROSTATE: -
defecation, hemorrhoids, blood in stool,
constipation, diarrhea
• MUSCULOSKELETAL: Swelling,
redness, pain, stiffness of joints,
• NEUROLOGIC: General mood, behavior,
depression, anger, concussions,
headaches, loss of strength or sensation,
coor- dination, difficulty speaking, memory
problems, strange thoughts and/or actions,
difficulty learning.
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 sys- tem,
education and work, stress level and coping
style, and environment.
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✓ Description of Typical Day FREUD’S STAGES OF SEXUAL

✓ Nutrition and Weight Management DEVELOPMENT
✓ Activity Level and Exercise
✓ Sleep and Rest
✓ Substance Use
✓ Self-Concept and Self-Care Responsibilities
✓ Social Activities
✓ Relationships
✓ Values and Belief System
✓ Education and Work
✓ Stress Levels and Coping Styles
✓ Environment

FREUD’S THEORY OF PSYCHOSEXUAL

DEVELOPMENT

• The first level, consciousness, refers to

whatever a person is sensing, thinking
about, or experiencing at any given
moment. Freud considered this level to be
limited, since only a small amount of such
thought exists at one time.
• The second level, preconsciousness,
involves all of a person’s memories and
stored knowledge that can be recalled and
brought to the conscious level.
• Freud declared the third level,
unconsciousness, as the largest and most
influential.
REVISED – THREE BASIC STRUCTURES
IN THE ANATOMY OF PERSONALITY
LESSON 4 & 5
COLLECTING OBJECTIVE DATA
• A complete nursing assessment includes
both the collection of subjective data and
the 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
(examination) techniques.
• To become proficient with physical
assessment skills, the nurse must have
basic knowledge in three areas:
o Types and operation needed for the
particular examination (e.g.,
penlight, sphygmomanometer,
otoscope, tuning fork, stethoscope)
o Preparation of the setting, oneself,
and the client for the physical
assessment
o Performance of the four assessment
techniques: inspection, palpation,
percussion, and auscultation

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EQUIPMENT

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PREPARING FOR THE EXAMINATION
PREPARING THE PHYSICAL SETTING
• It is important that the nurse strive to ensure
that the examination setting meets the
following conditions:
o Comfortable, warm
temperature
o Private area free of interruptions
from others
o Quiet area free of distractions
o Adequate lighting
o Firm examination table or bed at a
height that prevents stooping
o A bedside table/tray to hold the
equipment needed for
examination
PREPARING ONESELF
• 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.
• Always wear gloves if there is a chance that you
will come in direct contact with blood or other
body fluids.
• 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.
• 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
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.
• 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.
room PHYSICAL EXAMINATION TECHNIQUES
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
FOWLER'S POSITION
• This is the most common position for patient
the
resting comfortably, whether inpatient or in
the emergency department, with knees
either straight or slightly bent and the head
of the bed between 45 and 60 degrees.
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• 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 comfort-
able 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
SUPINE POSITION peripheral pulses. The abdomen should not
be assessed because the abdominal
• Ask the client to lie down with the legs muscles are contracted in this position.
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, SIMS’ POSITION
neck, chest, breasts, axillae, abdo- men,
heart, lungs, and all extremities. • 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. 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
DORSAL RECUMBENT POSITION
and maintaining this 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 STANDING POSITION
assessed because the abdomInal muscles
are contracted in this position. • The client stands still in a normal,
comfortable, resting posture. This position

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allows the examiner to assess posture,

balance, and gait. This position is also used
for examining the male genitalia.

LITHOTOMY POSITION

• The client lies on the back with the hips at

PRONE POSITION
• The client lies down on the 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 posi- tion. Clients with cardiac and
respiratory problems cannot tolerate this
position.
the edge of the exami- nation 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.

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 INSPECTION
head turned to one side. A small pillow may
• Inspection involves using the senses of
be used to provide comfort. The knee–chest
vision, smell, and hearing to observe and
position is useful for examining the rectum.
detect any normal or abnormal findings.
This position may be embarrassing and
This technique is used from the moment
uncomfortable for the client; therefore, the
that you meet the client and continues
client should be kept in the position for as
throughout the examination.
limited a time as possible. Elderly clients
• Although most of the inspection involves the
and clients with respiratory and cardiac
use of the senses only, a few body systems
problems may be unable to tolerate this
require the use of special equipment (e.g.,
position.
ophthalmoscope for the eye inspection,
otoscope for the ear inspection).

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GENERAL CONSIDERATIONS FOR • Mobility(fixed/movable/still/vibrating)

EXAMINING OLDER ADULTS • Consistency (soft/hard/fluid filled)
• Strength of pulses
• Some positions may be very difficult or (strong/weak/thready/bounding)
impossible for the older client to assume or • Size(small/medium/large)
maintain because of decreased joint • Shape (well defined/irregular)
mobility and flexibility. Therefore, try to • Degree of tenderness
perform the examination in a manner that
minimizes position changes. PARTS OF HAND TO USE WHEN
• It is a good idea to allow rest periods for the PALPATING
older adult, if needed.
• Some older clients may process information HAND PART SENSITIVE TO
at a slower rate. Therefore, explain the Finger pads Fine discriminations:
procedure and integrate teaching in a clear pulses, texture, size,
and slow manner. consistency, shape,
crepitus
INSPECTION Ulnar or palmar Vibrations, thrills,
surface fremitus
• Make sure the room is a comfortable Dorsal (back) surface Temperature
temperature. A toocold or too-hot room can
alter the normal behavior of the client and
LIGHT PALPATION
the appearance of the client’s skin.
• Use good lighting, preferably sunlight. • To perform light palpation, place your
Fluorescent lights can alter the true color of dominant hand lightly on the surface of the
the skin. In addition, abnormali- ties may be structure. There should be very little or no
overlooked with dim lighting. depression (less than 1 cm). Feel the
• Look and observe before touching. Touch surface structure using a circular motion.
can alter appearance and distract you from Use this technique to feel for pulses,
a complete, focused observation. tenderness, surface skin texture,
• Completely expose the body part you are temperature, and moisture.
inspecting while draping the rest of the
client as appropriate. MODERATE PALPATION
• Note the following characteristics while
• Depress the skin surface 1 to 2 cm (0.5 to
inspecting the client: color, patterns, size,
0.75 inch) with your dominant hand, and
location, consistency, symmetry, movement,
use a circular motion to feel for easily
behavior, odors, or sounds.
palpable body organs and masses. Note the
• Compare the appearance of symmetric
size, consistency, and mobility of structures
body parts (e.g., eyes, ears, arms, hands)
you palpate.
or both sides of any individual body part.
DEEP PALPATION
PALPATION
• Place your dominant hand on the skin sur-
Palpation consists of using parts of the hand to
face and your nondominant hand on top of
touch and feel for the following characteristics:
your dominant hand to apply pressure. This
• Texture(rough/smooth) should result in a surface depression
• Temperature(warm/cold) between 2.5 and 5 cm (1 and 2 inches).
• Moisture(dry/wet)

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This allows you to feel very deep organs or o ELICITING REFLEXES: Deep
structures that are covered by thick muscle. tendon reflexes are elicited using the
percussion hammer.
BIMANUAL PALPATION
THREE TYPES OF PERCUSSION
• Use two hands, placing one on each side of the
body part (e.g., uterus, breasts, spleen) being • DIRECT - is the direct tapping of a body
palpated. Use one hand to apply pressure and part with one or two fingertips to elicit
the other hand to feel the structure. Note the possible tenderness
size, shape, consistency, and mobility of the • BLUNT - is used to detect tenderness over
structures you palpate. organs (e.g., kidneys) by plac- ing one hand
flat on the body surface and using the fist of
PERCUSSION
the other hand to strike the back of the hand
• Percussion involves tapping body parts to flat on the body surface.
produce sound waves. These sound waves • INDIRECT - mediate percussion is the
or vibrations enable the examiner to assess most commonly used method of percussion.
underlying structures. Percussion has The tapping done with this type of
several different assessments uses, percussion produces a sound or tone that
including: varies with the density of underlying
o ELICITING PAIN: Percussion structures. As density increases, the sound
helps to detect inflamed underlying of the tone becomes quieter. Solid tissue
structures. If an inflamed area is produces a soft tone, fluid produces a
percussed, the client’s physical louder tone, and air produces an even
response may indicate or the client louder tone. These tones are referred to as
will report that the area feels tender, percussion notes and are classified
sore, or painful. according to origin, quality, intensity, and
o DETERMINING LOCATION, pitch.
SIZE, AND SHAPE: Percussion
note changes between borders of an
organ and its neighboring organ can
elicit information about location, size,
and shape.
o DETERMINING DENSITY:
Percussion helps to determine
whether an underlying structure is
Direct percussion of sinuses
filled with air or fluid or is a solid
structure.
o DETECTING ABNORMAL
MASSES: Percussion can detect
superficial abnormal structures or
masses. Percussion vibrations
penetrate approximately 5 cm deep.
Deep masses do not produce any
change in the normal percussion
Blunt percussion of kidneys
vibrations.

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Indirect or mediate percussion of

lungs

THE FOLLOWING TECHNIQUES HELP TO

DEVELOP PROFICIENCY IN THE
AUSCULTATION
TECHNIQUE OF INDIRECT PERCUSSION:

• Place the middle finger of your nondominant • Auscultation is a type of assessment

technique that requires the use of a
hand on the body part you are going to
percuss. stethoscope to listen for heart sounds,
movement of blood through the
• Keep your other fingers off the body part
cardiovascular system, movement of the
being percussed because they will damp
bowel, and movement of air through the
the tone you elicit.
respiratory tract.
• Use the pad of your middle finger of the
• A stethoscope is used because these body
other hand (ensure that this fingernail is
sounds are not audible to the human ear.
short) to strike the middle finger of your
The sounds detected using auscultation are
nondominant hand that is placed on the
classified according to the intensity (loud or
body part.
soft), pitch (high or low), duration (length),
• Withdraw your finger immediately to avoid
and quality (musical, crackling, raspy) of the
damping the tone.
sound.
• Deliver two quick taps and listen carefully to
the tone. HOW TO USE THE STETHOSCOPE
• Use quick, sharp taps by quickly flexing
your wrist, not your forearm.

• Practice percussing by tapping your thigh to

elicit a flat tone and by tapping your puffed-
out cheek to elicit a tympanic tone. A good
way to detect changes in tone is to fill a
carton halfway with fluid and practice
percussing on it. The tone will change from
resonance over air to a duller tone over the
fluid.

SOUNDS ELICITED IN PERCUSSION THESE GUIDELINES SHOULD BE

FOLLOWED AS YOU PRACTICE THE
TECHNIQUE OF AUSCULTATION:

ELIMINATE Eliminate distracting or competing

noises from the environment (e.g.,
radio, television, machinery).

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EXPOSE 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 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 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). Hold the bell
lightly on the body part being
auscultated.
SUMMARY
• 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: necessary
equipment and how to use it; preparing the
setting, oneself, and the client for the
examination; and how to perform the four
basic assessment techniques.
• Collecting objective data requires a great
deal of practice to become proficient.
Proficiency is needed because how the data
are collected can affect the accuracy of the
information elicited.
VALIDATING AND DOCUMENTING DATA
PURPOSE OF VALIDATION
• Validation of data is the process of
confirming or verifying that the subjective
and objective data you have collected are
reliable and accurate.
• The steps of validation include deciding
whether the data require validation,
determining ways to vali- date the data, and
identifying areas for which data are missing.
• Failure to validate data may result in
premature closure of the assessment or
collection of inaccurate data. Errors during
assessment cause the nurse’s judgments to
be made on unreliable data, which results in
diagnostic errors during the second part of
the nursing process—analysis of data
(determining nursing diagnoses,
collaborative problems, and referrals). Thus,
validation of the data collected during
assessment of the client is crucial to the first
step of the nursing process.
DATA REQUIRING VALIDATION
• Conditions that require data to be
rechecked and validated include:
o Discrepancies or gaps between
subjective and objective data.
Example: A patient claims to be very
happy despite just finding out he has
terminal cancer.
o Discrepancies or gaps between what
the client says at one time versus
another time. For example, your
female client says that she has
never had surgery but later in the
interview she mentions that her
appendix was removed at a military
hospital when she was in the Navy.
o Inconsistent findings. For example,
the following are inconsistent with
each other: the client has a
temperature of 104°F, is resting
comfortably, and her skin is warm to
the touch and not flushed.
METHODS OF VALIDATION
• Recheck your own data. Example, take the
client’s temperature again with a different
thermometer.
• Clarify data by asking additional questions.
For example, if a client is holding his
abdomen the nurse may assume he is
having abdominal pain, when actually the
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client is very upset about his diagnosis and
is feeling nauseated.
• Validate data with another health care
professional. For example, ask a more
experienced nurse to listen to the abnormal
heart sounds you think you have just heard.
• Compare your objective findings with your
subjective findings to uncover
discrepancies. For example, if the client
states that she “never gets any time in the
sun,” yet has dark, wrinkled, suntanned
skin, you need to validate the client’s
perception of never getting any time in the
sun by asking exactly how much time is
spent working, sitting, or doing other
activities outdoors. Also, ask what the client
wears when engaging in outdoor activities.
IDENTIFICATION OF AREAS FOR WHICH
DATA ARE MISSING
• Once you establish an initial database, you
can identify areas for which more data are
needed. You may have overlooked certain
questions. In addition, as data are examined
in a grouped format, you may realize that
additional information is needed. For
example, if an adult client weighs only 98
pounds, you would explore further to see if
the client recently lost weight or this has
been the usual weight for an extended time.
If a cli- ent tells you that he lives alone, you
may need to identify the existence of a
support system, his degree of social
involvement with others, and his ability to
function independently.
DOCUMENTING DATA
• In addition to validation, documentation of
assessment data is another crucial part of
the first step in the nursing process. The
significance of this aspect of assessment is
addressed specifically by various state
nurse practice acts, accreditation - care,
Medicaid), professional organizations (local,
state, and national), and institutional
agencies (acute, transitional, long- that
address documentation for assessments.
PURPOSE OF DOCUMENTATION
• The primary reason for documentation of
assessment data is to promote effective
communication among multidisciplinary
health team members to facilitate safe and
efficient client care.
INFORMATION REQUIRING DOCUMENTATION
• Most data collection starts with subjective
data and ends with objective data.
• Subjective data typically consist of
biographic data, present health concern(s)
and symptoms (or the client’s reason for
seeking care), personal health history,
family history, and life- style and health
practices information
• Objective Data
o Make notes as you perform
assessments, document as
concisely as possible
o Avoid using non measurable terms
like normal, abnormal, good, fair,
satisfactory, poor
o Use measurable terms like (3 inches
in diameter, red excoriated edges,
with purulent discharge)
GUIDELINES FOR DOCUMENTATION
• Keep confidential all documented
information in the client record.
• Document legibly or print neatly in
nonerasable ink
• Use correct grammar and spelling.
• Use phrases instead of sentences to record
data.
• Record data findings, not how they were
obtained.
• Write entries objectively without making
premature judgments or diagnoses.
• Record the client’s understanding and
perception of problems.
• Avoid recording the word “normal” for
normal findings.
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• Record complete information and details for
all client symptoms or experiences.
• Include additional assessment content when
applicable.
• Support objective data with specific
observations obtained during the physical
examination.
INITIAL ASSESSMENT FORM
• An initial assessment form is called a
nursing admission or admission database.
• Four types of frequently used initial
assessment documentation forms are
known as open-ended, cued or checklist,
integrated cued checklist, and nursing
minimum data set.
• Cued or checklist admission documentation
form used in an acute care setting.
FREQUENT OR ONGOING ASSESSMENT
FORM
• Various institutions have created flow charts
that help staff to record and retrieve data for
frequent reassessments.
• Examples of two types of flow charts are the
frequent vital signs sheet, which allows for
vital signs to be recorded in a graphic
format that promotes easy visualization of
abnormalities, and the assessment flow
chart, which allows for rapid comparison of
recorded assessment data from one time
period to the next.
FOCUSED OR SPECIALTY AREA
ASSESSMENT FORM
• Some institutions may use assessment
forms that are focused on one major area of
the body for clients who have a particular
problem.
• Examples include cardiovascular or
neurologic assessment documentation
forms. In addition, forms may be
customized.
• For example, a form may be used as a
screening tool to assess specific concerns
or risks such as falling or skin problems.
These forms are usually abbreviated
versions of admission data sheets, with
specific assessment data related to the
purpose of the assessment.
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VERBAL COMMUNICATION OF DATA SUMMARY

• Nurses are often in situations in which they • Validation, documentation, and verbal
are required to verbally share their communication of data are three crucial
subjective and objective assessment aspects of nursing health assessment.
findings. Nurses need to concentrate on learning how
• They must be able to report assessment to perform these three skills steps of
findings verbally. assessment thoroughly and accurately.
• This occurs anytime one health care
provider is transferring client care
responsibilities for the client’s care to
another health care provider. This is referred
to as a “handoff.” This handoff may occur
when the agency shift changes, nurses
leave the unit for a break or meal, a client is
transferred to another unit or facility, and
when a client leaves their unit for a test or
procedure.

IN ORDER TO PREVENT DATA

COMMUNICATION ERRORS:

• Use standardized method. (SBAR)

• Communicate face to face with good eye-
contact.
• Allow time for the receiver to ask questions.
• Provide documentation of the data you are
sharing.
• Validate what the receiver heard by asking
them to summarize your report.
• When reporting over a telephone ask the
receiver to read back what she heard you
report.

SBAR

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