HEALTH ASSESSMENT

GOLDEN GATE COLLEGES | MRS. GYPSYROSE AROJADO

HEALTH ASSESSMENT
STEPS OF HEALTH ASSESSMENT
• process of evaluating a person's physical, mental, 1. Collection of subjective data.
and social wellbeing to identify any potential health" 2. Collection of objective data
problems or concerns. 3. Validation of data
• It is an important part of health care, as it allows 4. Documentation of data
health care providers to assess a person's overall
health. and identify any areas of concern. NURSING DIAGNOSIS
• ASSESSMENT. DIAGNOSIS. PLANNING. ▪ alteration in comfort
INTERVENTION/ IMPLEMENTATION. ▪ related to post operative.
EVALUATION ▪ procedure done.
COMPONENTS OF NURSING PROCESS
A - Assessment ➢ Type - initial assessment.
D - Diagnosis ➢ Time performed - performed within specified time
P - Planning after admission to a health care agency.
I - Intervention ➢ Purpose - to establish a complete data base for
E – Evaluation problem identification, reference and future
SYSTEMATIC AND CONTINUOUS comparison.
• Collection ➢ Example: Nursing admission assessment.
• Organization NPI- Nurse-patient Interaction
• Validation METHODS OF DATA COLLECTION
• Documentation of data
1. Observing
DIAGNOSIS 2. Interviewing
• After your assessment, you will take all the gather 3. Examining
information and diagnose the patient’s condition and
medical needs. TYPES OF QUESTIONS
F - Focus - Diagnosis (Objective & subjective) • Closed Question
D - Diagnosis - Nursing Diagnosis • Open-ended question
A – Action - Intervention • Neutral question- non-directive question
R – Response – Evaluation • Leading question - Used in directive interview & this
directs client answer.
PLANNING
• plan a course of treatment that makes into accounts STAGES OF AN INTERVIEW
short and long term. • Examining Assessment
• Physical examination
✓ Febrile – fever ✓ Preparation of the Equipment
✓ Afebrile - no fever ✓ Preparation of the Client Physical
✓ Higher temperature may lead to seizure or Preparation Mental Preparation
compulsion.
✓ 1SB - tepid sponge bath PREPARE THE PHYSICAL SETTING.
✓ OFI - oral fluid intake • comfortable, warm room temperature. Provide a
✓ Paracetamol warm blanket.
✓ Light clothing • private are free of interruptions from others close the
door or curtains.
IMPLEMENTATION OR INTERVENTION (ACTION) • provide quiet areas, free from distraction.
• when you put the treatment plan into effect. • Adequate lightning
• Firm examination table or bed at a height face from
EVALUATION stooping
• The rest of the medical staff should renew the steps • Provide bedside table tray to hold the equipment
taken and determine whether they work as expected needed for the examination.
or not me.
REVIEW OF SYSTEM APPROACH - EXAMINE ONLY
ASSESSMENT PARTICULAR AREA AFFECTED
TYPES OF HEALTH ASSESSMENT To conduct examination in this approach nurse uses
techniques of Inspection.
1. Initial Comprehensive Assessment • Systematic visual examination of the client or it is the
2. Focused or problem-oriented Assessment. process of performing deliberate purposeful
3. Emergency Assessment observations in a systematic manner.
4. Ongoing or partial Assessment.
ACRONYM FOR PE
PURPOSE OF ASSESSMENT I – INSPECTION
1. The nursing health history P – PERCUSSION
2. Physical examination P – PALPATION
3. The physician's history A – AUSCULTATION
4. Results of laboratory and diagnostic rests

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HEALTH ASSESSMENT
GOLDEN GATE COLLEGES | MRS. GYPSYROSE AROJADO

GENERAL INSPECTION (EYES)

1. overall appearance of health of illness.
2. signs of distress.
3. Facial expression and mood body size.
4. Grooming and personal Hygiene

PALPATION (TOUCH)
• use of the hands and fingers to gather information
through touch.

PRINCIPLES OF PALPATION
• you should have short fingers.
• You should warn your hands price to be placing them
on the patient.
• Encourage the patient to continue to breathe
normally throughout the palpitation.
• If pain is experience during the palpation, discontinue
the palpation immediately.
• inform the patient where, when, and how the Touch HEALTH HISTORY ASSESSMENT "SAMPLE"
will occur. especially when the patient cannot see S – Symptoms (patient's chief complaints)
what you are doing. A – Allergy (seeking to know what type of allergic reaction
they experienced.)
PERCUSSION M - Medications (prescribed, OTC drugs, herbal meds, etc.)
• the examination by tapping the fingers on the body P - Past Medical History (seeking to know the previous state
to determine the condition of the internal organs by of health and previous illness.)
the sounds that are produced. L - Last Oral Intake (seeking what are the last oral intakes of
the client)
2 TYPES OF PERCUSSION E - Events leading up to the illness or injury (Events
1. Direct percussion leading up to the illness or injury.)
2. Indirect percussion
FAMILY HISTORY ASSESSMENT “BALD CHASM”
AUSCULTATION (LISTENING) B – BLOOD PRESSURE
A – ARTHRITIS
• process of listening to sounds that are generated
L – LUNG DISEASE
within the booty.
D – DIABETES
C – CANCERS
PATIENT POSITIONING
H – HEART DISEASE
1. Supine position
A – ALCOHOLISM
▪ used for general examination or physical
S – STROKE
assessment.
M – MENTAL HEALTH DISORDERS
2. Prone position
▪ The prone position is used primarily to
SIGNS VS. SYMPTOMS
assess the hip joint. The back can also be
SIGN
assessed with the client in this position.
• Is objective and discovered by the healthcare
Clients with cardiac and respiratory
problems cannot tolerate this position. professionals during an examination.
3. Lateral recumbent (left or right) • Something I can detect even if the patient is
▪ This position makes it easier to access a unconscious.
patient's right/left side. SYMPTOMS
4. Lithotomy position • Is subjective, observed and experienced by the
▪ commonly used for vaginal examinations patient, and cannot be measured directly.
and childbirth.
5. Knee-chest position PAIN ASSESSMENT "OPQRSTUV"
▪ is assumed for a gynecologic or rectal O - Onset
examination. P - Provoking or Palliating factors
▪ Knee-chest position can be lateral or prone. Q - Quality
6. Fowler s position R - Region and Radiation
▪ Used for patients who have difficulty S - Severity
breathing because in this position, gravity T - Time & Treatment
pulls the diaphragm downward allowing U - Understanding & Impact
greater chest and lung expansion. V – Values
7. Trendelenburg's position CLASSIFICATION OF PAIN
▪ Patients can benefit from this position According to duration and etiology:
because it promotes venous return. 1) Acute pain
▪ Used to provide postural drainage of the ▪ usually associated with a recent injury
basal lung lobes. 2) Chronic nonmalignant pain

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HEALTH ASSESSMENT
GOLDEN GATE COLLEGES | MRS. GYPSYROSE AROJADO

▪ usually associated with a specific cause or WARNING SIGNS OF CANCER "CAUTION US"
injury and described as constant pain that C -Change in bowel or bladder habits
persists for more than 6 months. A -A sore that does not heal
3) Cancer pain U - Unusual bleeding or discharge
▪ often due to the compression of peripheral T-Thickening elsewhere or lump in breast or
nerves or meninges or from the damage to I - Indigestion or dysphagia
these structures following surgery, O - Obvious change in wart or mole
chemotherapy, radiation, or tumor growth N-Nagging cough or hoarseness
and infiltration. U - Unexplained anemia
According to location: S -Sudden & unexplained weight loss
4) Cutaneous pain (skin or subcutaneous tissue)
5) Visceral pain (abdominal cavity, thorax, cranium) EMERGENCY TRAUMA ASSESSMENT "ABCDEFGHI”
6) Deep somatic pain (ligaments, tendons, bones, A - Airway
blood vessels, nerves) B-Breathing
According to location whether it is perceived at the site of C-Circulation
the pain stimuli: D - Disability
7) Radiating E - Expose & examine
▪ perceived both at the source and extending F - Full set of vital signs
to other tissues. G -Give comfort measures
8) Referred H - History and head-to-toe
▪ perceived in body areas away from the pain I - Inspect posterior surface.
source.
9) Phantom pain NORMAL VITAL SIGNS
▪ can be perceived in nerves left by a PULSE 60-100 bpm
missing, amputated, or paralyzed body BLOOD PRESSURE 120/80 mmHg
part. RESPIRATION 12-20 breaths per min
other types of pain: O2 SATURATION 95-100%
10) Neuropathic pain TEMPERATURE 36.5 - 37.7°C (96.0 - 99.9
▪ caused by damage or injury to the nerves °F)
that transfer information between the brain
and spinal cord from the skin, muscles, and COLLECTING SUBJECTIVE DATA
other parts of the body. Subjective data are sensations or symptoms (e.g., pain,
11) Intractable pain hunger), feelings (e.g., happiness, sadness), perceptions,
▪ A type of pain that can't be controlled with desires, preferences, beliefs, ideas, values, and personal
standard medical care because of its high information that can be elicited and verified only by the client.
resistance to pain relief. • Biographical information (name, age, religion,
occupation)
DIMENSIONS OF PAIN • History of present health concern: Physical
1) Physical - effect of anatomic structure and symptoms
physiologic functioning on the experience of pain. • related to each body part or system (e.g., eyes and
2) Behavioral - verbal and nonverbal behaviors ears, abdomen)
associated with pain. • Personal health history
3) Cognitive - thoughts, beliefs, attitudes, intentions, • Family history
and motivations related to the experience of pain. • Health and lifestyle practices
4) Sensory - qualitative and quantitative descriptions of
pain. COLLECING OBJECTIVE DATA
5) Sociocultural - effect of social and cultural This type of data is obtained by general observation and by
backgrounds on the experience of pain using the four physical examination techniques: inspection,
6) Affective - feelings and emotions that result from palpation, percussion, and auscultation.
pain. • Physical characteristics (e.g., skin color, posture)
7) Spiritual - ultimate meaning and purpose attributed to • Body functions (e.g., heart rate, respiratory rate)
pain, self, others, and the divine • Appearance (e.g., dress and hygiene)
• Behavior (e.g., mood, affect)
PAIN RATING SCALE
• Measurements (e.g., blood pressure, temperature,
height, weight)
• Results of laboratory testing (e.g. platelet count, x-
ray findings)

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