NCM 101 HEALTH

ASSESSMENT
DIANNA ROSE BELEN, RN, LPT
 INTRODUCTION TO HEALTH
ASSESSMENT

• Case Study
Mrs. Gutierrez, age 52, arrives at
the clinic for diabetic teaching. She
appears distracted and sad,
uninterested in the teaching. She is
unable to focus, and paces back and
forth in the clinic wringing her hands.
What should the nurse suspect of Mrs.
Gutierrez?
• Nursing – the protection, promotion, and
optimization of health and abilities,
prevention of illness and injury, alleviation
of suffering through the diagnosis and
treatment of human responses and
advocacy in the care of individuals,
families, communities and populations.
(Nursing: Scope and Standards of Nursing
Practice (American Nurses Association
(ANA), 2010)
• -Nursing Scope and Standards of
Practice Standard 1 – The RN
collects comprehensive data
pertinent to the patient’s health or
situation. (ANA p.21)
• -Nursing Scope and Standards of
Practice Standard 2 – The RN
analyses the assessment data to
determine the diagnosis or issues.
 ASSESSMENT: STEP ONE OF THE
NURSING PROCESS

• Assessment is the first

and most critical phase of
the nursing process.
 PHASES OF THE NURSING PROCESS

Phase Title Description

I Assessment Collecting subjective and
objective data
II Diagnosis Analyzing subjective and
objective data to make a
professional nursing judgment
(nursing diagnosis, collaborative
problem, or referral)
III Planning Determining outcome criteria and
developing a plan
IV Implementation Carrying out the plan
V Evaluation Assessing whether outcome
criteria have been met and
revising the plan as necessary
 FRAMEWORK FOR HEALTH
ASSESSMENT IN NURSING

• A nursing framework helps to organize

information and promotes the collection of
holistic data.
• The questions asked in each physical
systems focus on that particular body
system and are broken down into four
sections:
• History of Present Health Concern
• Personal Health History
• Family History
• Lifestyle and Health Practices
• The end result of a nursing
assessment is the formulation of
nursing diagnoses to know:
• nursing care
• identify collaborative problems requiring
interdisciplinary care
• identify medical problems that require
immediate referral
• client teaching for health promotion.
 USING EVIDENCE TO PROMOTE
HEALTH AND PREVENT DISEASE

• There are many models used to

analyze health promotion and
disease prevention.
• Two of the major models are:
• The Health Belief Model (Becker
& Rosenstock)
• The Health Promotion Model
(Pender)
 THE HEALTH BELIEF MODEL

• based on three concepts:

• the existence of sufficient motivation;
• the belief that one is susceptible or
vulnerable to a serious problem;
• the belief that change following a
health recommendation would be
beneficial to the individual at a level
of acceptable cost.
THE HEALTH PROMOTION MODEL

• also focused on behavioral outcomes.

• Pender proposes that individual
characteristics and experiences (prior
related behavior and personal biologic,
psychological, and cultural factors) affect
behavior-specific cognitions and affect
(perceptions of benefit, barriers, self-
efficacy, and activity-related affect; as well
as interpersonal and situational
influencers), which in turn yield the level
of commitment to a plan.
TYPES OF HEALTH ASSESSMENT

• Initial comprehensive
assessment
• Ongoing or partial assessment
• Focused or problem-oriented
assessment
• Emergency assessment
STEPS OF HEALTH ASSESSMENT

• Four major steps:

• 1. Collection of subjective
data
• 2. Collection of objective data
• 3. Validation of data
• 4. Documentation of data
PREPARING FOR THE ASSESSMENT

• review the client’s medical

record.
• keep an open mind and to avoid
premature judgments
• Use this time to educate yourself
about the client’s diagnoses or tests
performed.
• (laboratory manual, textbook, or
electronic reference resource, such
as a smart phone application)
• Once you have gathered basic data
about the client, take a minute to
reflect on your own feelings
regarding your initial encounter with
the client.
• Remember to obtain and organize
materials that you will need for the
assessment.
STEP 1 COLLECTING SUBJECTIVE DATA

• Subjective - sensations or
symptoms (e.g., pain, hunger),
feelings (e.g., happiness,
sadness), perceptions, desires,
preferences, beliefs, ideas,
values, and personal information
that can be elicited and verified
only by the client.
 CASE STUDY

• As the assessment progresses, the nurse learns

through the interview with Mrs. Gutierrez that she
has no appetite and no energy. She feels as
though she wants to stay in bed all day. She
misses her sisters in Mexico, and cannot do her
normal housekeeping or cooking. The nurse
thinks that Mrs. Gutierrez is probably suffering
from depression. But when the nurse asks Mrs.
Gutierrez what she believes is causing her lack of
appetite and low energy, Mrs. Gutierrez says she
was shocked when her husband was hit by a car.
He could not work for a month.
STEP 2 COLLECTING OBJECTIVE DATA

• This type of data is obtained by

general observation and by using the
four physical examination
techniques:
• Inspection
• Palpation
• Percussion
• Auscultation
 STEP 3 VALIDATING ASSESSMENT
DATA

• crucial part of assessment that often

occurs along with collection of
subjective and objective data.
• It serves to ensure that the
assessment process is not ended
before all relevant data have been
collected, and helps to prevent
documentation of inaccurate data.
 STEP 4 DOCUMENTING DATA

• Documentation of assessment data is an

important step of assessment because it
forms the database for the entire nursing
process and provides data for all other
members of the health care team.
• Thorough and accurate documentation
is vital to ensure that valid conclusions are
made when the data are analyzed in the
second step of the nursing process.
 CASE STUDY

• Consider Mrs. Gutierrez, introduced at the

beginning of the chapter, to help illustrate
the reason for seeing the client in context.
The nurse continues to listen to Mrs.
Gutierrez and learns that she is also
suffering from “susto.” Mrs. Gutierrez
states that a few days in bed will help her
recover her soul and her health. The nurse
decides to reschedule the diabetic
teaching for a later time and provide only
essential information to Mrs. Gutierrez at
this visit.
 QUESTIONS

• The nursing process is utilized to:

A. Provide a systemic, organized and
comprehensive approach to meeting the
needs of clients.
B. Encourage the family to make decisions
regarding patient's care.
C. Increase involvement of allied healthcare
professionals in decision-making
D. None of the above
• Objective data might include:
A.Chest pain.
B.An evaluation of BP
C.Complaint of dizziness
D.None of the above
• The following is the most important
purpose of documentation except
A.For Communication

B.For Reimbursement
C.For Quality assurance

D.To provide comfort

• Subjective data might
include:
A.Heart rate
B.Oral temperature of 37.7 C
C.Pain Scale of 4/10
D.Poor hygiene
• A teenage girl spends most of her free time with
friends or at school. Sharing their concerns about
this behaviour with the school nurse, the parents
are worried about their child seeming to draw
away from them. The nurse's best reply is:
A. "You should really keep better track of your
child. It's hard to tell what kinds of trouble they
may be getting into.
B. "Use stricter guidelines for curfew and
punishment if curfew is broken."
C. "Is it possible that your child might be taking
drugs?"
D. "Independence is really important for this age
group. Try to be extra attentive when your child
does spend time at home."