NCM 201 - HEALTH ASSESSMENT

Health Assessment
Prof. Anna Suyko | BSN – 1G | A.Y. 2022-2023 – Prelims

HEALTH ASSESSMENT
● Plan of care that identifies specific needs of clients
● Assessment of signs and symptoms
● How these needs will be addressed by the health care organization, or skilled nursing facility
○ Nurse-patient collaboration is needed to be able to identify the needs of the client.

EXAMPLES OF NURSING ASSESSMENT

Client 1: Complains of abdominal pain

● Nurse does what type of assessment?
○ 1. Techniques of assessment: Inspect, percuss, palpate and auscultate the abdomen
Questions to be asked:
A. Can you rate the pain on a scale of 1-10?
B. Since when did you experience these symptoms of yours?
○ 2. Take and monitor vital signs

Client 2: Admitted due to head injury

● Nurse does what type of assessment?
○ 1. Assess the level of consciousness (GCSGlasgow Coma Scale)
○ The lower the GCS = The lower the level of consciousness
○ The higher the GCS = The better
○ 2. Assess pupillary reaction to light and accommodation
○ 3. Take and monitor the vital signs

Client 3: Prescribed a cardiotonic drug

● Cardiotonic Drug – drug for the heart
○ lowers the heart rate
● Nurse does what type of assessment?
○ 1. Assess the apical pulse and compare w/ baseline data

Client 4: Cast applied on lower leg

● Nurse does what type of assessment?
○ 1. Assess peripheral perfusion of toes
○ Perfusion – refers to blood circulation
○
○ 2. Do capillary blanch test or capillary refill test (CRT)
○ 3. Bipedal pulse (if applicable)
○ 4. Take and monitor vital signs

A.Y. 2022 - 2023 | EJAS

 Client 5: Has minimal fluid intake
● A dehydrated patient

INDICATIONS OF A DEHYDRATED PATIENT

● concentrated urine (dark yellow), dry skin, & pale
● Nurse does what type of assessment?
○ 1. Assess the color of the sole
○ 2. Assess the tissue/skin turgor
○ Skin turgor – refers to the elasticity of the skin and it can be assessed through
pinching the skin
○ 3. Monitor intake and output
■ Intake – fluids - “Pila ka Intravenous Fluid ang na consume?”
■ Output – measuring of the urine output according to the doctor’s order (every
hour/every shift)
○ 4. Take and monitor vital signs

EVOLUTION OF NURSE’S ROLE IN HEALTH ASSESSMENT

● The expansion of nurses’ responsibilities throughout the years

1800s to Early 1900s

WEBER & KELLY

● Nurses relied on natural senses. Observed for changes: color, temperature, muscle strength, use of
limbs, body output, nutrition, and hydration status
● Palpation used to measure pulse rate and quality, plus locate fundus of puerperal woman
● Independent nursing practices (inspection, palpation [GI], auscultation, testing CN VIII, and
examination of school children in school; system

1930s

WEBER & KELLY

● Routine client and home inspection by public health nurses
● Case finding, prevention of communicable diseases, routine assessment skills in poor inner-city
areas (Frontier Nursing Service, and Red Cross)

DILLON
● Observation notes only. Role is a skilled observer

A.Y. 2022-2023 | EJAS

 ● “Patient admitted to a ward in a wheelchair. Stated that he is unable to walk due to pinched nerves of
right foot. Patient is crying, and says he is homesick. Condition of my skin is good. Made as
comfortable as possible.

1950s

WEBER & KELLY

● Pre-employment health and physical examinations for major companies (occupational health
nursing)

DILLON
● Nurse’s notes trace the past and present history of an illness as well as observations
● The nurse's role has expanded to include interviewing skills that assess past and current health
status
“A 25-year old female was admitted to the ambulatory. Past history of ulcerative colitis. Now in because of
abdominal cramps and vomiting x 4 days. Is 8 months pregnant. TPR 99.4, 80,20. Ht. 5’4. Wt 116 ¼. Urine
to lab.”

1970s

WEBER & KELLY

● Primary health services and conducting health histories with physical and psychological
assessments
● Autonomous in making comprehensive initial assessments which become the bases for plans of
care

DILLON
● Records intravenous and blood therapy. Includes observations and information on past illness and
diet. Nurse role now includes observation, interview, performing procedures (venipuncture), and
monitoring

12-year old white female admitted to room 2o3 via stretcher from ER with leukemia. Parents don’t seem to
know of the diagnosis. TPR 102.8, 120, 24. Ht. 62 ¼. Wt. 100 lbs. No known allergies. Has not been eating
much for the last few days. Appears extremely pale. BP 150/70. No urine obtained. IV started. Blood started.
Vital signs are relatively stable. T 103 when blood started

1990s - Present

WEBER & KELLY

● Expanded from acute care setting and the community, into baccalaureate and graduate education
(holistic assessment)
● Because of budget cuts, nurse’s documentation of health care providers were used to justify health
care services

A.Y. 2022-2023 | EJAS

 ● Creation of critical pathways or protocols in the care of patients
● Advanced practice nurses as clinical nurse specialists and nurse practitioners in the hospital and
community setting respectively
● Rise of health maintenance organizations (HMOs) and preferred provider organizations (PPOs)

DILLON
● Nurse notes observation and assessment of the patient as well as the biophysical, psychosocial, and
cultural factors that influence the patient’s health problem. The nurse’s role has grown to include
holistic health assessment
● Lives with husband and daughter next door to sister-in-law; husband makes playgrounds equipment;
states they are able to ‘get by’ on his salary, sometimes borrow money and have difficulty paying it
back; have Blue Cross/Blue Shield which should pay for his hospitalization; husband

“Young obese Caucasian female states she came here to ‘get the sugar out of her blood’. States she found
out about her sugar 3 months ago by glucose tolerance test results (In Jan 1990 misaarried 2-month
pregnancy and GTT was part of workup); states she has seen her husband test his blood (fingerstick
method) and give himself some insulin but has done neither herself; has tried to prepare both 1,800 and
2,200 calorie American Diabetic Association diets as ordered for husband but ‘he doesn’t stick to it’; has
noted increased hunger, increased thirst, increased urination for several months and occasional blurred
vision.

In comparison:
Time Period Weber and Kelley (Authors) Dillon

Late 1800s to ● Focused natural sense on observable

Early 1900s changes

1930s ● PHNs do some home inspection, case Skilled observer

finding, prevention of communicable
diseases in inner city areas through FNS
and RC (Red Cross)

1950s ● Pre-employment examinations (OHN) – Traced past (History taking) and

Occupational Health Nurses current history as an interviewer
Association

1970s ● Primary health service, assessments Begins performing procedures

(physical and psychological), formulates (venipuncture) and monitoring
plans of care vital signs

1990s to ● Baccalaureate and graduate programs. Holistic health assessment.

Present Rise of advanced nursing practice, HMOs Includes biophysical,
and PPOs. psychosocial and cultural aspects

RAPID EXPANSION IN THE NURSE ROLE

● More prevalent today than in previous decades

A.Y. 2022-2023 | EJAS

 ● New fields are merging necessitating the development of their own related nursing diagnoses

HOME HEALTH NURSING

● Independent, nursing diagnosis, referrals, and collaborative care as needed
● Median salary $78,983 ($34- $41/hr)

PUBLIC HEALTH NURSING

● Needs of communities and monitor growth and health of children
● Median salary $56,111 ($24- $29/hr.)

SCHOOL NURSING
● Needs communities and monitor growth and health of children
● Median salary $49,168 ($21- $25/hr)

HOSPICE NURSING
● Assess the needs of terminally ill clients and their families
● Improving the quality of life of the patients
● Median Salary $71,654 ($31 - $37/hr)

ACUTE CARE NURSING

● Extensive focused assessments
● ICU, Emergency, Coronary Care Unit (PACU - Post Anesthesia Care Unit) areas
● Median salary $73,500 ($31-$38/hr)

FORENSIC NURSING
● Extensive focused assessments (reversed process)
● “How old is the bruise?”
● Median Salary $81,800 ($35-$43/hr)

CRITICAL OUTREACH NURSING

● Enhance assessment skills to safely assess clients outside the structured intensive care
environment
● Private duty nurses in the PH
● Median salary $62,822 ($27-$32/hr)
●

HOW CAN WE TELL THE AGE OF CONTUSION?

Contusion – any collection of blood outside a blood vessel. Type of hematoma

OXYHEMOGLOBIN
● 0 - 2 days

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 ● Red in color (Oxy HB)

DEOXYHEMOGLOBIN
● 2 - 5 days
● Blue (reduced Hb)

BILIVERDIN
● 5 - 7 days; -macrophages breaks down the hemoglobin into biliverdin
● green

BILIRUBIN
● 7 - 10 days
● yellow

HEMOSIDERIN
● 10 - 14 days

ACROSS ALL FIELDS OF NURSING

● Nurses nowadays increasingly document and retrieve assessment data through computerized
information systems
● Warrants why courses with informatics content are becoming the norm in baccalaureate programs

FUTURE TREND AS PREDICTED

● Continuing increased specialization and diversity of assessment skills of nurses
● Rise of integrated clinical practice for surgical care
○ Nurse follows a client’s care from preoperative care, to a multidisciplinary outpatient clinic,
and into the home through remote technology

There is tremendous growth of the nursing role in the managed care environment. The most marketable
nurses will continue to be those with strong assessment and client teaching abilities as well as those who are
technologically savvy

REASONS FOR THIS TREND

● Rising educational costs and focus on primary care (affects number of medical students)
● Increasing complexity of acute care
● Expanding health care needs of single parents
● Intensify mental health issues
● Expanding health service networks
● Increasing reimbursement for health promotion and preventive care services

SIGNIFICANCE OF HEALTH ASSESSMENT

● Allows the nurse to formulate the Nursing Diagnosis that require:
○ Nursing Care (Different nursing care plans for patients)

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 ○ Identification of collaborative problems (interdisciplinary care)
○ Identification of problems requiring immediate referral.
Not just about gathering information about the health status of a patient, but also:
○ Analyzing and synthesizing data
○ Making judgements about the effectiveness of nursing interventions
○ Evaluating client care outcomes

NURSING PROCESS
● Systemic and rational method of planning and providing nursing care
● It is cyclical, logical and more than one component (or phase) may be involved at one time
● The nursing process is composed of “ADPIE” cycle to make a Nursing Care Plan (NCP) that is
specific to your client.
“A D P I E”
5 Step Process
Assessment (Data Collection)
Diagnosis (Nursing Diagnosis)
Planning (How to address/Objective/Goal)
Implementation (Nursing Interventions)
Evaluation (Evaluate if it is achieved):
- Goal met
- Partially Met
- Unmet (Repeat cycle)

STEPS OF THE NURSING PROCESS

● 6-Step Process (New Updated)

Assessment (Data Collection)

Diagnosis (Nursing Diagnosis)
Outcome Identification (Goal)
Planning (Enumerate Possible Interventions)
Implementation (Choose appropriate Nursing
Action)
Evaluation (Evaluate if it is achieved)

PHASES OF THE NURSING PROCESS

PHASE TITLE DESCRIPTION

I Assessment Collecting subjective & objective data

A.Y. 2022-2023 | EJAS

 II Diagnosis Analyzing data to make a professional
nursing judgment (nursing diagnosis,
collaborative problem, or referral)

III Planning Determining outcome criteria and

developing a plan

IV Implementation/ Intervention Carrying out the plan

V Evaluation Assessing if outcome criteria have been

met and revising the plan as necessary.
(revisit all steps -> collect new data ->
adjustment)

RESPONSIBILITIES OF THE NURSE

● Conduct and document
● Collect data
● Modify the assessment
● Report assessment as needed

FUNCTIONS OF THE NURSE

● Nursing Interventions
○ Independent
○ Dependent
○ Interdependent/Collaborative

INDEPENDENT
● Licensed to initiate on the basis of knowledge and skills
● Do not require an order from another professional - Include physical care, ongoing assessment,
emotional support, teaching, counseling, environmental management, and making referrals
○ Examples:
■ Identify patterns of human responses to actual or health potential health problems
■ Assess health status
■ Select, perform, manage, and evaluate nursing actions
■ Provide health Provide health counseling/teaching
■ Teach, administer, supervise, delegate, and evaluate nursing practice

DEPENDENT
● Under orders or supervision of a licensed physician or another health care provider authorized
to write orders for nursing care (CPA, NP)
● Include providing medications, intravenous therapy, diagnostic tests, treatment, die, and
activity

A.Y. 2022-2023 | EJAS

 ● Nurse is responsible for assessing need for explaining, and administering medical orders (with
client)
○ Examples:
■ Administering medications
■ Giving treatment
■ Execute regimens prescribed by physicians

INTERDEPENDENT/COLLABORATIVE
● Implemented in collaboration or consultation with another professional (PT, social workers,
dietitians, and primary care providers)
● Includes physical therapy to teach crutch-walking. (Nurse coordinates with physical therapy
department, including PT sessions)
○ Examples:
■ Administration of oxygen
■ Referral to registered social workers
■ Physical therapy session

CRITERIA FOR CHOOSING INTERVENTIONS

○ Safe and appropriate for individual age, health and condition
○ Achievable with available resources
○ Congruent with client’s values, beliefs, and culture (as well as other therapies)
○ Based on nursing knowledge and experience from relevant science
○ Within established standards of care as determined by state laws and organization

“The amount of time the nurse spends in an independent versus a collaborative or dependent role varies
according to the clinical area, type of institution, and specific position of the nurse”

BEGINNING THE NURSING PROCESS

ASSESSMENT PHASE
● A systematic, and deliberate process
● Nurse collects and analyzes data about the patient
● Continuous process carried out during all phases of the nursing process
● Most critical and crucial
● Collection of data

FOCUS OF HEALTH ASSESSMENT

● Consists of:
○ Health history
○ Physical examination
Purpose:
● Collect holistic subjective and objective data to determine a client’s overall functioning
● To make a professional clinical judgment

A.Y. 2022-2023 | EJAS

● Includes physiological, psychological, developmental, and spiritual data

FOCUS OF HEALTH ASSESSMENT

● Focuses on how client’s health status affects activities of daily living, and how those ADLs affect the
client's daily living
● Assesses how clients interact within their family and community, and how client’s health status
affects the family and community. Also, how the family and community affect the client’s health
status

CASE: A DIABETIC PATIENT

● Diabetic patient cannot eat the same food the family enjoys
● Complication (amputation) limit him from performing his gardening tasks
● Cannot help in the community as a bus driver
● Supportive family may find alternative ways of cooking tasteful food considered healthy for the
entire family
● Community may or may not have a diabetes support group for the client and family

NHA VS OTHER HEALTH PROFESSIONALS

NURSING
● Includes subjective and objective data
● Physiologic, sociocultural, psychological and spiritual data

OTHER EXAMINATIONS/PROFESSIONS
● Focuses on one aspect only (MD, PT, and RT)
● Framework used is different

HOW ABOUT NHA VS MD ASSESSMENT?

ACCORDING TO DILLON:
● Very similar but there are important differences
● Differences are defined by the focus and scope of a medical vs nursing practice
● Questions may be similar but the underlying rationale differs
● Physicians diagnose and treat illness
● Nurses diagnose and treat the patient’s response to a health problem

CASE FROM DILLON

● Mary Johnson, 81 years old, admitted to the hospital due to a fractured hip

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 MEDICAL HISTORY
● Focuses on what caused the fracture in order to determine extent of injuries, also pre-existing
medical conditions which would increase surgical risk

NURSING HISTORY
● Focus on what caused the fracture, as well as determining the response to injury, how it affects
every aspect of her life
● How injury affects her ADLs, looking for strengths that can be incorporated into the plan of care,
identifying support systems, incorporated into the discharge plan
● Use data to develop care plan including perioperative and discharge (rehabilitative) plans

GS THIS IS HOW COLLABORATION LOOKS LIKE

● Nurse, doctor and co management

SKILLS ASSESSMENT

COGNITIVE SKILLS
● How you are going to rationalize things and how you are going to make judgements
● Considered to be a “thinking” process
● Nurse’s actions must be well-thought of, it should be purposeful
● Reflective, and reasonable thinking
● Not just doing, but asking why
● Involves inquiry, interpretation, analysis and synthesis

CRITICAL THINKING SKILLS

Identifying assumptions Distinguishing relevant from irrelevant Setting priorities

Identifying an organized Recognizing inconsistencies Determining patient-centered

and comprehensive expected outcomes
approach to assessment

Validation Identifying patterns Determining specific

interventions that will achieve
your outcomes

Distinguishing normal from Identifying missing information Evaluating and correcting

abnormal thinking

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 Making references Promoting health by identifying risk factors Determining correct plan of
care

Clustering related cues Diagnosing actual and potential problems

from the assessment data

TYPES OF ASSESSMENT ACCORDING TO WEBER

1. INITIAL COMPREHENSIVE ASSESSMENT

● Total or complete assessment
○ Example: first check-up
■ Other members of the health team may also participate
● This is the lengthiest assessment (check patient from head to toe and health history)
● Collection of data
● Subjective (verbalized by the patient)
● Objective (physical examination)
● Total or complete assessment

2. ONGOING OR PARTIAL ASSESSMENT

● Occurs after comprehensive database is established
● Mini-overview of body systems and health patterns (Review of systems, identify other problems
aside from what the patient is currently experiencing)
● Functions as a follow-up on the health status
● Problems initially detected are reassessed to determine changes (deterioration/improvement)

3. FOCUSED OR PROBLEM-ORIENTED ASSESSMENT

● IS SPECIFIC, addresses only the problem the patient will be complaining
● Does not replace comprehensive assessment
● Done after database is established
● Thorough assessment of particular problem
● Does not cover areas not related to the complaint

4. EMERGENCY ASSESSMENT
● Very rapid assessment during life-threatening situations (choking, cardiac arrest, drowning)
● Immediate assessment to provide prompt treatments (check ABC airway, breathing, circulation)
● Major and only concern is determining status of client’s life-sustaining physical functions
(making the client’s vital signs stable)

A.Y. 2022-2023 | EJAS