CHRISTIAN COLLEGE OF NURSING NEYYOR

ASSIGNMENT
ON

HEALTH ASSESSMENT

GUIDED BY SUBMITTED BY
Dr. Sasi Sulochana, Rajalakshmi D,
Associate professor Msc (N) 1st year

SUBMITTED ON
29-11-23
 HEALTH ASSESSMENT
INTRODUCTION
It provides the basis to gather a health history and asses the functioning of
individuals through the proper use of physical examination techniques,
Psychological and cultural assessment is included. The emphasis is on recognition
and identification of normal things.
DEFINITION OF HEALTH
Health is "a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity."
-(According to WHO)
DEFINITION OF ASSESSMENT
Assessment is the deliberate and systematic collection of data to determine a
client current and past health status, functional status and coping strategies.
DEFINITION OF HEALTH ASSESMENT
A health assessment is a plan of care that identifies the specific needs will be
addressed by the health care system or skill nursing facility.
Health assessment is the evaluation of health status by performing a physical
exam after taking a health history.
NURSING ASSESSMENT
DEFINITION
Nursing assessment is the gathering of information about a patient's
physiological, psychological, sociological, and spiritual status by licensed register
nurse..
Nursing assessment is the first step in the nursing process. Here the nurse
collects physiological, psychological, socio cultural, developmental and spiritual
data about the client.
Nursing assessment includes two steps:-
Collection and verification of data from a primary source(client)and secondary
source(family, health professional and medical record) Analysis of all the data as a
basis for developing nursing diagnosis and an individual nursing care plan for the
client.
PURPOSES OF ASSESSMENT
To establish a data base (all the information about the client)
 Nursing health history.
 Physical assessment.
 The physicians history and physical examination.
 Result of laboratory and diagnosis tests.
 Material from other health personnel.
TYPES OF ASSESSMENT
1. Initial comprehensive assessment
 An Initial assessment also called as admission assessment, is performed
when the client enters a health care from a health care agency.
 The purpose is to evaluate the clients health status, to identify functional
health patterns that are problematic, and to provide an in depth
comprehensive data base, which is critical for evaluating changes in the
client health status in subsequent assessments.

2. Problem focused assessment

 A problem focused assessment collects about a problem that has already
been identified.
 This type of assessment has narrower scope and a shorter time frame than
the initial assessment.
 In focused assessment nurse determine whether the problems still exist
and whether the status. of the problem has changed (1.e improved,
worsened, or resolved). This assessment also includes the appraisal of
any new, over looked or misdiagnosed problems. intensive care unit may
perform focus assessment every few minutes.
3.Emergency assessment
 Emergency assessment takes place in life-threatening situations in which the
preservation of life is the top priority. Time is of the essence in rapid
identification of and intervention for the client's health problems.
 Often the client difficulties involve airway, breathing and circulatory
problems. Abrupt changes in self concept (suicidal thoughts) or roles or
relationships (social conflict leading to violent acts) can also initiate an
 emergency. Emergency assessment focuses on few essential health patterns
and is not comprehensive.
4.Time-lapsed assessment or ongoing assessment
Time lapsed assessment, another type of assessment, takes place after the initial
assessment to evaluate any changes in the client's functional health. Nurse
performs time-lapsed assessment when substantial periods of time have elapsed
between assessments (e.g, periodic output patient clinic visit, home health visit,
and health and development screening).
STEP OF ASSESSMENT
A. Collection of data.
 Subjective data collection.
 Objective data collection.
B. Validation of data.
C. Organization of data.
D. Recording/documentation of data.
A. COLLECTION OF DATA
 Gathering of information about the client.
 Include physical, psychological, emotion, social cultural, spiritual factors
that may affect client health status.
 Includes past health history of client (allergies, past surgeries, chronic
diseases, use of folk
 healing methods). Includes current/present problems of client (pain, nausea,
sleep pattern, religious practices, medication or treatment the client is taking
now).
Types of data
a. Subjective data.
 Also referred to as symptoms or sensations.
 Information from the client's point of view is described by the person
experiencing it.
 Information supplied by family members, significant others; other health
 professionals are considered subjective data.
 Ex Pain, dizziness, ringing of ears/ tinnitus.
b) Objective data
  Also referred to as sign.
 Those that can be detected observed or measure/tested using accepted
 standard or norm.
 Mainly collected by general observation and by using the four physical
examination techniques: inspection, percussion, palpation and auscultation.
Source of data
A. Primary source
Data directly gathered from the client using interview and physical
examination.
B. Secondary source
Data gathered from client's family members, significant others, client medical
records/chart, other members of health team and related care literature/journals.

Methods of data collection

INTERVIEW
It is an organized conversation with the client to obtain history and current
illness.
Phase of interview are:
Orientation: In which the nurses introduce self and the purpose of Interview. This
helps to develop trusting relation in client.
Working phase: Actual gathering of information takes place.
Termination phase: Nurse concludes the Interview and summarizes the data cross-
check with client for accuracy. It should be terminated in a positive and friendly
manner.
OBSERVATION
It used to gather data by using the five senses and instruments.
PHYSICAL EXAMINATION
Systematic detailed examinations of all systems are carried out.
ASSESSMENT SEQUENCING
a. Cephalocaudal approach-Head to toe Assessment.
➤ General

 General health status

 Vital sign and weight
 Nutritional status
➤ Mobility and self care
 Observe posture
 Assess gait and balance
 Evaluate mobility
 Activities of daily living
➤ Head face and neck
 Evaluate cognition Level of consciousness
 Orientation
 Mood
 Language and memory
 Sensory function
 Test vision
 Inspect and examine ears
 Test hearing
 Cranial nerves
 Inspect lymph nodes
 Inspect neck veins
➤Skin, hair and nails
 Inspect scalp, hair and nails
 Evaluate skin turgor
 Observe skin lesion
 Assess wounds
➤ Chest
 Inspect and palpate breast
 Inspect and auscultate lungs.
➤ Abdomen
 Auscultate heart
 Inspect, auscultate, palpate four quadrant
  Bowel elimination
 Palpate and percuss liver, stomach, bladder
 Urinary elimination
➤ Genitalia
 Inspect female client
 Inspect male client
> Extremities
 Palpate arterial pulses
 Observe capillary refill
 Evaluate edema
 Assess joint mobility
 Measure strength
 Assess sensory function
 Assess circulation, movement and sensation
 Deep tendon reflexes
 Inspect skin and nail
b. Body system approach-examine all the body system
Review of system
General presentation of symptoms: Fever, chills, malaise, pain, sleep patterns,
fatigability.
Diet: Appetite likes and dislikes, restrictions, written diary of food Intake.
Skin, hair and nails: Rash or eruption, itching, color or texture change, excessive
sweating, abnormal nail or hair growth.
Musculoskeletal: Joint stiffness, pain, restricted motion, swelling, redness, heat,
deformity.
Eyes: Visual acuity, blurring, diplopia, photophobia, pain, Recent change in vision.
Ears: Hearing loss, pain discharge, tinnitus, vertigo.
Nose: sense of smell, frequency of cold, obstruction, epitasis, Sinus pain or post
nasal discharge.
Throat and mouth: Hoarseness or change in voice, frequent sore-throat, bleeding
or swelling of gum, recent tooth abscess or extraction, soreness of tongue or
mucosa.
Endocrine and genital reproductive: Thyroid enlargement or tenderness, heat or
cold Intolerance unexplained weight change, polyuria, polydipsia, change in
distribution of facial hair; males puberty onset, difficulty with erection, testicular
pain, libido, infertility; females: menses (onset, regularity,, duration and
amount)dysmenorrhea, last menstrual period, frequency of intercourse age at
menopause, pregnancies (number, miscarriage, abortions) type of delivery,
complications, use of contraceptives, breast (pain, discharge, tenderness, Jumps).
Chest and lungs: Pain related to respiration, dyspnea, cyanosis, wheezing, cough,
sputum, exposure to tuberculosis, last chest x-ray.
Heart and blood vessel: chest pain or distress precipitating cause, timing and
duration, relieving factor, dyspnea, orthopnea, edema, hypertension, exercise
tolerance.
Gastro intestinal: Appetite, digestion, food intolerance dysphagia, heart burn,
nausea or vomiting, bowel regularity, change in stool color, constipation or
diarrhea, flatulence or hemorrhoids.
Genitourinary: Dysuria, flank pain or suprapubic pain, urgency, frequency,
nocturia, hematuria, polyuria, hesitancy, loss in force of stream, edema, sexually
transmitted disease.
Neurological: Syncope, seizure, weakness or paralysis, abnormality of sensation or
coordination, tremors, loss of memory.
Psychiatric: Depression, mood change difficulty concentrating nervousness,
tension, suicidal thought, Irritability.
Pediatric: Along with systematic approach in case of pediatrics, measure
anthropometric measurement and neuromuscular assessment.
c. Review of system approach-Examine only particular area affected.
d)INSPECTION: Inspection is the visual examination of the client.
Guidelines for effective inspection
 Be systematic
 Fully expose the area to be inspected; cover other body parts to respect the
 clients modesty.
 Use good light, preferably natural light.
 Maintain comfortable room temperature.
 Observe color, shape, size, symmetry, position, and movement. Compare
bilateral structures for similarities and differences.
e) PALPATION
 Palpation uses the sense of touch to assess various parts of the body and
helps. to confirm findings that are noted on inspection.
 The hands, especially the finger tips, are used to assess skin temperature,
check pulses, texture, moisture, masses, tenderness, or pain.
 Ask the client for permission first and explain to your client what to intend
to examine. Establish client trust with being professional. Please remember
to use warm hands.
 Any tender area should be palpated last.
Types of palpation
a) Light palpation to check muscle tone and assess for tenderness
b) Deep palpation-to identify abdominal organs and abdominal masses.
f) PERCUSSION
Percussion is the striking of the body surface with short sharp strokes in order to
produce palpable vibration and characteristic sounds. It uses to determine the
location. size, shape, and density of underlying structures; to detect the presence of
air or fluid in body space; and to client tenderness.
Types of percussion:
I. Direct percussion: Percussion in which one hand is used and the striking
finger of the examiner touches the surface being percussed.
II. Indirect percussion: Percussion in which two hands are used and the
plexor strikes the finger of the examiners other hand, which is in contact
with the body surface being percussed.
III. Blunt percussion - Percussion with the ulnar surface of the hand or fist is
used in place of the fingers to strike the body surface, either directly or
indirectly.
Percussion sounds:
 Resonance: A hollow sound
 Hyper resonance: A booming sound
 Tympany: A musical sound or drum sound like that produced by the
stomach.
 Dullness: Thud sound produced by dense structures such as the liver, and
enlarged spleen, or a full of bladder
 Flatness: An extreamly dull sound like that produced by very dense
structures such as muscle or bone.
g) AUSCULTATION
Auscultation is listening to sounds produced inside the body. These include
breath sound, heart sound, vascular sound, and bowel sounds. It is used to detect
the presence of normal and abnormal sounds and to assess them in terms of
loudness' pitch quality, frequency and duration.
VALIDATION OF DATA
 The act of "double-checking "or verifying data to confirm that it is accurate
and complete. Validation of data is the process of confirming or verifying
that the subjective and objective data collected are reliable and accurate.
 The steps of validation Include deciding whether the data require validation,
determining ways to validate the data, and identifying areas where data are
missing.
 Failure to validate data may result in premature closure of the assessment or
collection of Inaccurate data.
Purposes of data validation
 Ensure that data collection is complete.
 Ensure that objective and subjective data agree.
 Obtain additional data that may have been overlooked.
 Avoid jumping to conclusion.
 Differentiate cues and Inferences
data requiring validation
Not every piece of data you collect must be verified. For ex: You would not
need to verify or repeat the client pulse, temperature, or blood pressure unless
certain condition exists. Conditions that require data to be rechecked and validate
include:
 Discrepancies or gaps between the subjective and objective data. Ex- A male
client tell you that he is very happy despite learning that he has terminal
cancer.
 Discrepancies or gap between what the client says at one time and then
another time. Ex Your female patient says she has never hard surgery, but
later in the interview she mentions that her appendix was removed at a
military hospital. When she was in the navy.
 Findings those are very abnormal and inconsistent with other findings. EX-
The client has a temperature of 104f.the client is resting comfortably. The
client's skin is warm to touch and not flushed.
Method of validation
There are several ways to validate your data:
 Recheck your own data through a repeat assessment. For ex, take the client
temperature again with a different thermometer.
 Clarify data with the client by asking additional question for example: If a
client is holding his abdomen, the nurse may assume he is having abdominal
pain, when actually the client is very upset about his diagnosis and is feeling
upset.
 Verify the data with another health care professiona. Ex-Asked a more
 experienced nurse to listen to the abdominal heart sounds you think you
have just heard.
 Compare you objective findings with your subjective findings to uncover
discrepancies. Ex-If the client states that she 'never get any time in the sun
"yet has dark wrinkled, suntanned skin; you need to validate the client
perception of never getting any time in the sun.
ORGANIZATION OF DATA
Uses a written or computerized format that organizes assessment data
systematically.
ORGANIZATION OF DATA GATHERING
Assessment data must be descriptive, concise, and complete. Open ended
question will allow the client to tell in detail and help the nurse to focus on the
client priority quickly.
DATA VALIDATION AND INTERPRETATION
Interpretation of data helps to summarize, cluster and to make meaningful
conclusions.
DOCUMENTATION OF DATA
This is the last part of assessment. A through, accurate, clear, concise record is
made using appropriate technology. Systematic and detailed physical examination
is carried out diagnostic and lab investigation result is studied and abnormal
variations are identified. Anything heard, felt, seen and smelled must be recorded
objective information from client should be in quotation marks.
SUMMARY
So for we discussed about health assessment and its definition, purposes,
approaches, types, steps, source, methods of assessment, sequencing of data,
organization of data of health assessment.

CONCLUSION

From this assignment we discussed about Health assessment, which is important

for everyone. It is an evaluation in which we detect a disease in the person who
look and feel well by taking a physical exam and by this assessment we detect
disease early followed by the treatment and lower the risk of serious complications.
BIBLIOGRAPHY
BT Basavanthappa (2013) ‘Fundamentals of nursing’,4 th edition, New Delhi,
Jaypee publications, Page No:58-71.
Potter, Perry (2017), ‘Fundamental of nursing’,2nd edition, New Delhi, Elsevier
Publication, Page No: 201-217
Spring house (2015) ‘Fundamentals of Nursing’,7 th edition, New York, Wolter
Kluwer Publishers, Page no:112-121
P.Basheer Shebeer and Khan s. Yaseen.2012.A concise Text Book of Advance
Nursing practice.1" (ed). EMMESS Medical publisher, Pp504-510.
Webliography
 https://Google.com
 http://slideshare.in
 http://scribd.com