CEBU TECHNOLOGICAL UNIVERSITY

In consortium with
CEBU CITY MEDICAL CENTER- COLLEGE OF NURSING

HEALTH ASSESSMENT
MODULE 1 : NURSING PROCESS
 Nursing
 the diagnosis and treatment of human
responses to actual or potential health
problems
 Nursing process
 Diagnosis and treatment are achieved
through a process
 a critical thinking process that
professional nurses use to apply the best
available evidence to caregiving and
promoting human functions and
responses to health and illness
(American Nurses Association, 2010)
 a systematic method of providing care to
clients
 a systematic method of planning and
providing individualized nursing care
 used to identify, prevent, and treat actual
or potential health problems and
promote wellness
 provides a framework in which to
practice nursing
“A Delicious PIE”
A - ASSESSMENT
D - DIAGNOSIS
P - PLANNING
I - IMPLEMENTATION
E - EVALUATION
Purposes of nursing process
▪ To identify a client’s health status and
actual or potential health care problems
or needs.
▪ To establish plans to meet the identified
needs.
▪ To deliver specific nursing interventions
to meet those needs
Characteristics of Nursing Process
▪ Cyclic
▪ Dynamic nature,
▪ Client centeredness
▪ Focus on problem solving and decision
making
▪ Interpersonal and collaborative style
▪ Universal applicability
▪ Use of critical thinking and clinical
reasoning.
 Assessment
→ the systematic and continuous collection,
organization, validation, and
documentation of data (information)
→ process of collecting, validating, and
clustering data.
→ first and most important step in the
nursing process
→ sets the tone for the rest of the process
identifies
→ your patient’s strengths and limitations
and is performed not just once, but
continuously throughout the nursing
process
1. After performing your initial assessment,
you establish your baseline
2. Identify nursing diagnoses, and
3. Develop a plan
4. As you implement your plan, you also
assess your patient’s response.
5. Finally, you assess the effectiveness of
your plan of care for your patient.
Types of assessment
The four different types of assessments are;
1. Initial nursing assessment
2. Problem-focused assessment
3. Emergency assessment
4. Time-lapsed reassessment
1. Initial nursing assessment
→ Performed within specified time after
admission.
→ To establish a complete database for
problem identification.
→ Eg: Nursing admission assessment
2. Problem-focused assessment
→ To determine the status of a specific
problem identified in an earlier
assessment.
→ Eg: hourly checking of vital signs of fever
patient
3. Emergency assessment
→ During emergency situation to identify
any life threatening situation.
→ Eg: Rapid assessment of an individual’s
airway, breathing status, and circulation
during a cardiac arrest.
4. Time-lapsed reassessment
→ Several months after initial assessment.
To compare the client’s current health
status with the data previously obtained.
Collection of data
→ Data collection is the process of gathering
information about a client’s health status.
→ It includes the health history, physical
examination, results of laboratory and
diagnostic tests, and material contributed
by other health personnel.
Types of Data
▪ Two types: subjective data and objective
data.
1. Subjective data
− also referred to as symptoms or covert
data
− are clear only to the person affected and
can be described only by that person.
− covert and not measurable
− reflect what the patient is experiencing
and include thoughts, beliefs, feelings,
sensations, and perceptions
− health history is an example of subjective
data
− Itching, pain, and feelings of worry are
examples of subjective data.
2. Objective data
− also referred to as signs or overt data
− are detectable by an observer or can be
measured or tested against an accepted
standard.
− They can be seen, heard, felt, or smelled,
and they are obtained by observation or
physical examination.
− overt and measurable
− For example, a discoloration of the skin
or a blood pressure reading is objective
data.
− The physical examination and diagnostic
studies are examples of objective data
Sources of Data
▪ Sources of data are primary or secondary.
1. Primary
− It is the direct source of information.
− The client is the primary source of data.
2. Secondary
− It is the indirect source of information.
− All sources other than the client are
considered secondary sources. Family
members, health professionals, records
and reports, laboratory and diagnostic
results are secondary sources
Methods of data collection
• The methods used to collect data are
observation, interview and examination.
 Observation
− It is gathering data by using the senses.
− Vision, Smell and Hearing are used.
− second method of data collection
 Ask yourself:
 Does the patient show signs of
physical or psychological stress?
 Does the patient seem comfortable?
 What is the patient doing?
 What position is she or he assuming?
 Are there any abnormal movements?
 What is the patient’s body language
telling you?
 Is the patient’s verbal language
consistent with his or her nonverbal
language?
 Do you notice any unusual odors?
 Do you hear any unusual sounds?
 Is there anything unusual, unsafe, or
risky in the patient’s environment?
 Look for:
 Facial expression, color changes,
breathing problems
 Grimacing, guarding, diaphoresis
 Eye contact
 Tone of voice and flow of speech
 Position, orthopnea
 Grooming and dress
 Nervousness,restlessness,voluntary
/involuntary movements
 Unusual odors,such as fruity smell
associated with diabetic
ketoacidosis, or foul odors
 Drainage associated with infection
 Unusual sounds, such as grunting,
wheezing, rhonchi, or stridor
associated with respiratory
 problems, or swishing sounds
associated with murmurs
 Interview
− An interview is a planned communication
or a conversation with a purpose
− usually structured communication
intended to obtain subjective data
− most useful when taking the health
history
• There are two approaches to interviewing:
directive and nondirective.
● Directive interview
− is highly structured and directly ask the
questions.
− And the nurse controls the interview
PILONES,RISHELLE MAE M.
− require less time and are very effective
for obtaining factual data
● Nondirective interview
− or rapport building interview and the
nurse allows the
− client to control the interview.
− require more time than directive
interviews but are very effective at
eliciting the patient’s perceptions and
feelings
− help you to identify what is important to
the patient
STAGES OF AN INTERVIEW
An interview has three major stages:
1. The opening or introduction
2. The body or development
3. The closing
 Examination
− The physical examination is a systematic
data collection method to detect health
problems.
− To conduct the examination, the nurse
uses techniques of inspection, palpation,
percussion and auscultation.
 Organization of data
− The nurse uses a format that organizes
the assessment data systematically.
− This is often referred to as nursing health
history or nursing assessment form.
 Validation of data
− The information gathered during the
assessment is “double-checked” or
verified to confirm that it is accurate and
complete.
 Documentation of data
− To complete the assessment phase, the
nurse records client data.
− Accurate documentation is essential and
should include all data collected about
the client’s health status.
 For an interview to be successful
 good interpersonal communication skills
 examine your values and beliefs to
minimize any bias
 use your interpersonal skills in a healing
way to help your patient
 Being empathetic
 Showing empathy, demonstrating
acceptance, and giving recognition
 Maintaining a neutral, nonjudgmental
position and demonstrating acceptance
 Acknowledging the patient’s verbal and
nonverbal communication
 Interviewing Techniques
 Introduce yourself.
 Don’t rush. Allow enough time for the
interview.
 Avoid interruptions.
 Explain that information from the
interview is confidential.
 Actively listen to what your patient is
saying.
 Maintain eye contact.
 Work at the same level as your patient.
Pull up a chair and sit next to her or him.
 Don’t invade your patient’s personal
space. Two to 4 feet away is a
comfortable distance for most patients.
 Explain what you are doing and why.
 Consider your patient’s cultural
background. How does it affect the
interview and your
 interpretation of the data?
 Consider your patient’s developmental
level. How does it affect the interview
and your
 interpretation of the data?
 Don’t become preoccupied with writing.
You may convey to the patient that the
forms you are completing are more
important than he or she is.
 Be nonjudgmental.
 Avoid “why?” questions; they tend to put
patients on the defensive.
 Nonverbal behavior is more accurate
than verbal. Take a look at yours—What
is it telling your patient?
 Take a good look at your patient’s
nonverbal behavior. Is it consistent with
what she or he is telling you?
 Now look at your patient’s nonverbal
behavior another way. Does it indicate
health problems?
 Never pass up an opportunity to teach.
 Present reality. Be honest. Provide
reassurance and encouragement. Be
respectful
 If the patient presents with a problem,
begin by asking questions about that.
 Begin with nonsensitive issues. Leave
more sensitive topics until the end.
 Physical Assessment
− provides the objective database
− helps you assess your patient’s health
status and identify actual or potential
problems
− extent of physical assessment depends on
the patient’s condition and your expertise
PILONES,RISHELLE MAE M.
− Physical assessment skills can be used
with patients at all levels of healthcare
1. During physical assessment
 use your senses to collect data through
the techniques of inspection, palpation,
percussion, and auscultation
a) During inspection
 look at your patient
 compare her or his appearance with
what you know as normal.
 Use your sense of smell to detect any
unusual odor that may warrant
further investigation into a possible
health problem
b) During palpation
 use light touch to
 assess surface characteristics, to put
your patient at ease, and to convey
concern and caring
 Use deep palpation to assess organs
and masses
c) During percussion
 use direct, indirect, and fist
percussion to assess organ size
 and areas of tenderness
d) During auscultation
 listen to your patient directly and
indirectly to hear sounds produced
by the body
 Nursing Diagnoses
→ Analyze data
→ Identify health problems , risks and
strengths
→ Formulate diagnostic statements
→ involves identifying and prioritizing
actual or potential health problems or
responses
→ can be actual, potential, possible, or
collaborative problems as well as
wellness issues
→ second phase of the nursing process
→ In this phase, nurses use critical thinking
skills to interpret assessment data to
identify client problems
→ North American Nursing Diagnosis
Association (NANDA) define or refine
nursing diagnosis
→ “a clinical judgment concerning a human
response to health conditions/life
processes, or a vulnerability for that
response, by an individual, family, group,
or community.”-NANDA
→ Once you collect your data, you need to
analyze them and then identify actual and
potential health problems or responses
to life processes and state them as
nursing diagnoses
→ Actual nursing diagnosis identifies an
occurring health problem for your
patient
→ A potential nursing diagnosis identifies a
high-risk health problem that most likely
will occur unless preventive measures
are taken
→ A possible nursing diagnosis is one that
needs further data to support it.
→ wellness diagnoses focus on promoting
or enhancing a patient’s level of wellness
→ Once you have identified the diagnoses,
you need to prioritize them in order to
develop a plan of care. (See NANDA
Nursing Diagnosis.)
Status of the Nursing Diagnosis
▪ The status of nursing diagnosis are actual,
health promotion and risk.
● An actual diagnosis
− is a client problem that is present at the
time of the nursing assessment.
● Health promotion diagnosis
− relates to clients’ preparedness to
improve their health condition
● risk nursing diagnosis
− is a clinical judgement that a problem
does not exist, but the presence of risk
factors indicates that a problem may
develop if adequate care is not given.
Components of a NANDA Nursing Diagnosis
A nursing diagnosis has three components:
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.
● The problem statement
− describes the client’s health problem.
● The etiology
− component of a nursing diagnosis
identifies causes of the health problem.
● Defining characteristics
− are the cluster of signs and symptoms
that indicate the presence of health
problem.
Formulating Diagnostic Statements
▪ The basic three-part nursing diagnosis
statement is called the PES format and
includes the following:
1. Problem (P)
− statement of the client’s health problem
(NANDA label)
PILONES,RISHELLE MAE M.
2. Etiology (E)
− causes of the health problem
3. Signs and symptoms (S)
− defining characteristics manifested by
the client
EXAMPLE:

 Acute pain related to abdominal surgery

as evidenced by patient discomfort and
pain scale.
NANDA nursing diagnosis

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PILONES,RISHELLE MAE M.
PILONES,RISHELLE MAE M.
  PLANNING
→ involves setting goals and outcomes
→ Once you have prioritized your diagnoses,
you are ready to develop an
individualized plan of care for your
patient
→ Priorities problems/diagnosis
→ Formulate goals/desired outcomes
→ Select nursing interventions
→ Write nursing interventions
→ Planning involves decision making and
problem solving.
→ It is the process of formulating client
goals and designing the nursing
interventions required to prevent, reduce,
or eliminate the client’s health problems.

1. establish goals and determine

measurable outcomes
2. identify nursing interventions
needed to meet the goals and
outcomes
3. communicate your plan to both the
patient and all members involved in
the plan of care to maintain
continuity of care and ensure
success
TYPES OF PLANNING
1. Initial Planning
2. Ongoing Planning
3. Discharge Planning

Differentiating Nursing Diagnosis ● Initial Planning

from Medical Diagnosis
PILONES,RISHELLE MAE M.
− Planning which is done after the initial
assessment.
● Ongoing Planning
− It is a continuous planning.
● Discharge Planning
− Planning for needs after discharge
Planning process
▪ Planning includes;
1. Setting priorities
2. Establishing client goals/desired
outcomes
3. Selecting nursing interventions and
activities
4. Writing individualized nursing
interventions on care plans.
Setting priorities
− The nurse begin planning by deciding
which nursing diagnosis requires
attention first, which second, and so on.
− Nurses frequently use Maslow’s
hierarchy of needs when setting
priorities.
Establishing client goals/desired
outcomes
− After establishing priorities, the nurse set
goals for each nursing diagnosis. Goals
may be short term or long term.
Nursing interventions
− A nursing intervention is any treatment,
that a nurse performs to improve
patient’s health.
TYPES OF NURSING INTERVENTIONS
1. Independent interventions
 are those activities that nurses are
licensed to initiate on the basis of their
knowledge and skills.
2. Dependent interventions
 are activities carried out under the
orders or supervision of a licensed
physician.
3. Collaborative interventions
 are actions the nurse carries out in
collaboration with other health team
members
Writing Individualized Nursing
Interventions
− After choosing the appropriate nursing
interventions, the nurse writes them on
the care plan.
− Nursing care plan is a written or
computerized information about the
client’s care.
 Implementation
→ also called intervention
→ involves carrying out your plan to
achieve goals and outcomes
→ This is the “doing” phase of the nursing
process, in which you actually implement
the nursing interventions in the plan
→ As you implement your plan, you
continue to assess your patient’s
responses and modify the plan as needed.
Be sure to document your care.
→ Implementation consists of doing and
documenting the activities.
The process of implementation includes
• Implementing the nursing interventions
• Documenting nursing activities
 EVALUATION
→ involves determining the effectiveness of
your plan
→ assess your patient’s response based on
the criteria you set for the outcome
 If the goals and outcomes have not been
met, you’ll need to rethink the plan and
work through the process again to
develop a more effective plan of care for
your patient
→ Evaluation is a planned, ongoing,
purposeful activity in which the nurse
determines
(a)the client’s progress toward achievement
of goals/outcomes and
(b)the effectiveness of the nursing care plan.
The evaluation includes
• Comparing the data with desired outcomes
• Continuing, modifying, or terminating the
nursing care plan.
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 Communication
 a process of sharing information and
meaning, of sending and receiving
messages
 both verbal and nonverbal
 Nonverbal Messages
− an important source of data
− more accurate than the verbal one
− Nonverbal behavior includes :
▪ vocal cues or paralinguistics
▪ action cues or kinetics
▪ object cues
▪ personal space
▪ touch
Example: a patient who tells you he is having
“crushing chest pain” should look like he is
having “crushing chest pain.”
▪ Vocal Cues or Paralinguistics
→ the quality of your voice and its
inflections, tone, intensity, and
speed when speaking
→ Anger, doubt, disbelief, or
disapproval can all be conveyed
by the tone of your voice
→ If your patient is in pain,
moaning or the inflections in
her or his speech may alert you
to the pain’s severity
→ Someone who is afraid may
speak softly, with trepidation
▪ Action Cues and Kinetics
→ body movements that convey
messages
→ Posture, arm position, hand
gestures, body movements,
facial expressions, and eye
contact all convey a message
→ message may reflect a feeling, a
mood, or an underlying
physiological or psychological
problem
→ A tense, guarded posture may
also indicate pain
→ A relaxed posture with arms at
the sides conveys openness,
whereas a tense posture with
arms crossed may reflect anger,
discomfort, or mistrust.
→ A tripod position (sitting
position, leaning forward with
elbows on table and hands
supporting head) is assumed to
ease breathing.
▪ Object Cues
→ patient’s dress and grooming
reflect his or her identity and
how he or she feels about
himself or herself
→ Poor grooming or disheveled
clothing may indicate a
psychological problem such as
depression
→ Poor grooming may also signal
an underlying physical problem
that has affected the patient’s
ability to care for himself or
herself
→ A depressed patient may not
take much interest in how he or
she looks
→ can also be furnishings or
possessions
→ Example: your jewelry or the
seating arrangement for a
meeting. These cues are usually
selected on a conscious level to
convey a specific message, so
they are not as revealing as
nonverbal communications.
▪ Personal Space
→ the territory surrounding a
person that she or he perceives
as private or the physical
distance that needs to be
maintained for the person to
feel comfortable
→ often defined by culture and is
also influenced by the situation
→ Public space, such as in a
classroom or when giving a
speech, is about 12 feet or more.
→ Social-consultative space, such
as in impersonal conversations
or interviews, is about 4 to 12
feet.
→ Personal distance, such as in
personal conversation, is about
18 inches to 4 feet.
→ Intimate distance, such as in
intimate conversations and
maximum sensory stimulation,
is 0 to 18 inches
▪ Touch
→ means of communication
→ array of feelings, including
anger, caring, and
PILONES,RISHELLE MAE M.
 protectiveness, can be
conveyed through touch
→ interpretation of touch is often
culturally prescribed
→ can be easily misconstrued.
→ It may be seen as an invasion of
one’s personal space or a threat
→ How a person responds to
touch often depends on the
trust established within a
relationship
Cultural Considerations
− Cultural communication patterns need to
be considered when obtaining a health
history
− Culture can influence every aspect of
communication
− If you and your patient do not speak the
same language, you will need an
interpreter to communicate
− Cultural Considerations:
▪ language
▪ Vocal characteristics
▪ expressing thoughts and feelings
▪ Use of touch
▪ Personal space and eye contac
▪ Facial expression
▪ Acceptable greetings
▪ Body language
Patient Interview Communication Techniques
 Affirmation/Facilitation
→ Acknowledge your patient’s responses
through both verbal and nonverbal
communication to reassure him that you
are paying attention to what he is saying.
 Silence
→ Periods of silence allow your patient to
collect her or his thoughts before
responding and help prevent hasty
responses that may be inaccurate
→ usually more uncomfortable for you than
for your patient
→ Use this “quiet time” to focus on your
patient’s nonverbal behavior and what
she or he is feeling.
 Clarifying
→ If you are unsure or confused about what
your patient is saying, rephrase what she
said and then ask the patient to clarify
→ Use phrases like “Let me see if I have this
right,” or “I want to make sure I’m clear
on this,” or “I’m not sure what you mean.”
 Restating
→ Restating the patient’s main idea shows
him that you are listening
→ allows you to acknowledge your patient’s
feelings, and encourages further
discussion
→ also helps clarify and validate what your
patient has said and may help identify
teaching needs
 Active Listening
→ Pay attention, maintain eye contact, and
really listen to what your patient tells you
both verbally and nonverbally
→ conveys interest and acceptance
 Broad or General Openings
→ effective when you want to hear what is
important to your patient
→ Use open-ended questions such as, “What
would you like to talk about?”
 Reflection
→ allows you to acknowledge your patient’s
feelings, encouraging further discussion
→ For example, if the patient states, “I am so
afraid of having surgery,” your response
would be, “You’re afraid of having
surgery?”
 Humor
→ can be very therapeutic when used in the
right context
→ It can reduce anxiety, help patients cope
more effectively, put things into
perspective, and decrease social distance.
 Informing
→ Giving information allows your patient to
be involved in his or her healthcare
decisions
→ Example would be explaining the
postoperative course and the importance
of coughing and deep breathing to your
patient preoperatively.
 Redirecting
→ helps keep the communication goal-
directed
→ useful if your patient goes off on a
tangent
→ you might say, “Getting back to what
brought you to the hospital . . .”
 Focusing
→ allows you to hone in on a specific area,
encouraging further discussion
→ Examples include: “You said your mother
and sister had breast cancer?” or “Do you
do BSE, and have you ever had a
mammogram?”
 Sharing Perceptions
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→ you give your interpretation of what has
been said in order to clarify things and
prevent misunderstandings
→ For example, you might say, “You said
you weren’t upset, but you’re crying.”
 Identifying Themes
→ may help your patient make a connection
and focus on the major theme
→ For example, you might say, “From what
you’ve told me, it sounds like every time
you were discharged from the hospital to
home you had a problem.”
 Sequencing Events
→ help her or him place the events in
proper order
→ Start at the beginning and work through
the event until the conclusion
→ You might say, “What happened before
the problem started?” “Then what
happened?” “How did it end?”
 Suggesting
→ Presenting alternative ideas gives your
patient options
→ particularly helpful if the patient is
having difficulty verbalizing his or her
feelings
→ also a good teaching tool
→ For example, if the patient says, “I’ve
tried so hard to lose weight, but I can’t,”
you might say, “Have you tried combining
diet and exercise?”
 Presenting Reality
→ help her or him reexamine what has
already been said and be more realistic
→ For example, if she or he says, “I waited
all day for someone to answer my call
light,” you might respond, “All day?”
 Summarizing
→ useful at the conclusion of a major
section of the interview
→ allows the patient to clarify any
misconceptions you may have
→ For example, you might say, “Let me see
if I have this correct: You came to the
hospital with chest pain, which started an
hour ago, after eating lunch.”
THE ASSESSMENT PROCESS
 American Nurses’ Association (ANA) has
identified assessment as the first
Standard of Nursing Practice (ANA, 1998)
 The Standard describes assessment as
the systematic, continuous collection of
data about the health status of patients
 Purpose of Assessment
● to collect data pertinent to the patient’s
health status
● to identify deviations from normal
● to discover the patient’s strengths and
coping resources, to pinpoint actual
problems, an
● to spot factors that place the patient at
risk for health problems
 Types of Assessment
▪ can be comprehensive or focused.
◘ comprehensive assessment
− is usually the initial assessment
− very thorough and includes a
detailed health history and
physical examination
− examines the patient’s overall
health status
◘ focused assessment
− is problem oriented and may be
the initial
− assessment or an ongoing
assessment
− frequently performed on an
ongoing basis to monitor and
evaluate the patient’s progress,
interventions, and response to
treatments
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