HEALTH

ASSESSMENT
IN NURSING
INTRODUCTION
NURSING PROCESS: an
overview
NURSING 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)
 It is the fundamental blueprint for how to
care for patients.
INTRODUCTION
NURSING PROCESS: an overview
INTRODUCTION:
HEALTH ASSESSMENT IN NURSING

ASSESSMENT
- is the deliberate and systematic
collection of information/data about
a patient to determine his or her
current and past health and
functional status and his or her
present and past coping patterns.
* Carpenito-Moyet, 2009
STEPS FOR HEALTH ASSESSMENT

1 2 3 4
Collection of Collection Validation Documentation
Subjective of Objective of data of data
data data
 4. Terminating the
Data
Interview Collection

You perform assessment to

gather information needed
to make an accurate
judgment about a patient’s
current condition
*Magnan and Maklebust, 2009
 Data Collection
Information comes from:

SIGNIFICANT
PATIENT OTHERS HEALTH CARE MEDICAL
TEAM RECORDS
best secondary
identifying checking the
source of sources of
and consistency
informatio informatio and
n verifying similarities of
n information observations
 Two sources of data: Subjective and Objective
observations or
verbal descriptions of
measurements of a
their health problems.
patient’s health status.

SUBJECTIVE SIGNS
Only patients provide
1 Measurement is based on
subjective data an accepted standard
2
SYMPTOMS OBJECTIVE
Celsius - thermometer
feelings, perceptions,
Inches - measuring tape
and self-report of
symptoms
DATA COLLECTION METHODS

1. OBSERVATION
gather data using
the senses

2. INTERVIEW
a conversation
with a purpose
COLLECTING SUBJECTIVE DATA
• Interview
• Nursing Health History
• Genogram
INTERVIEW

Patient-Centered Interview
is an approach for obtaining
from patients the data that are
needed to foster a caring nurse-
patient relationship, adherence
to interventions, and treatment
effectiveness
(Smith et al., 2006).
INTERVIEW
patient – centered interview involves:

1. setting the stage

2. gathering information about the
patient’s chief concerns or
problems and setting an agenda
3. collecting the assessment or a
nursing health history
4. terminating the interview.
1. Setting the
Stage
 Greet the patient using his or her
full name
 introduce yourself and explain
your role
 remove any barriers to privacy by
closing a room curtain or shutting
a door.
 orientation phase of an interview.
 2. Set an Agenda

 begin an interview by gathering

information about the patient’s
current chief concerns
 interview focuses on the patient, not
your agenda.
 ask the patient for his or her list of
concerns or problems.
 3. Collect the
Assessment

 Start with open-ended questions that

allow patients to describe more
clearly their concerns and problems.
 begin by having the patient explain
symptoms or physical concerns
 Use attentive listening and encourage
a patient to tell his or her story.
4. Terminating the
Interview

 summarize your discussion with

the
patient and check for accuracy of
the information collected.
 Give your patient a clue that the
interview is coming to an end.
 helps the patient maintain
direct
attention
 Interview Techniques
Open-ended Questions

 does not presuppose a

specific answer.
 leads to a discussion in which
patients actively describe
their
health status.
 Begin by asking the patient
an
open-ended question to elicit
his or her story
 Interview Techniques
Back Channeling
 Reinforce your interest in what
the patient has to say through
the use of good eye contact
and listening skills.
 active listening prompts such
as
“all right,” “go on,” or “uh-
huh”
 encourages a patient to give
more details.
 Interview Techniques
Probing

 encourage a full description without

trying to control the direction the
story takes.
 “Is there anything else you can tell
me?” or “What else is bothering
you ?”
 Ask as many questions as it takes
until the patient has nothing else to
say.
 Interview Techniques
Closed-ended Questions

 limit answers to one or two words

such as “yes” or “no” or a number
or
frequency of a symptom
 For example, ask, “How often does
the diarrhea occur?” or “Do you
have pain or cramping?”
 require short answers and clarify
previous information or provide
additional information.
 Interview Techniques
Closed-ended Questions

 limit answers to one or two words

such as “yes” or “no” or a number
or
frequency of a symptom
 For example, ask, “How often does
the diarrhea occur?” or “Do you
have pain or cramping?”
 require short answers and clarify
previous information or provide
additional information.
 Interview Techniques
Laundry List
• To provide the client with a choice of
words to choose from in describing
symptoms, conditions, or feelings
• It helps you obtain specific answers
and reduces the likelihood of the
client’s perceiving or providing an
expected answer.
• Always repeat choices as necessary.
• Sample question: “Is the pain severe,
dull, sharp, mild, cutting or
piercing?”
 EXAMPLES OF OPEN- AND
CLOSED-ENDED QUESTIONS

Open-Ended Questions
• Tell me how you are feeling.
• Tell me how your health has
been.
• Describe how your wife has
been helping you.
• Give me an example of how
you get relief from your pain
at home.
Closed-Ended Questions
 Do you think the
medication is helping you?
 Who helps you at home?
 Do you understand why
you are having the x-ray
examination?
 Are you having pain now?
 On a scale of 0 to 10, how
would you rate your
pain?
Nursing Health History
during either your initial or an
early
contact with a patient.
history is a major component of
assessment.
based on information you gained
from your patient’s story
A comprehensive history covers
all
health dimensions, allowing you
 Nursing Health History
** Taking the health history should begin with an explanation to
the client of why the information is being requested.

Health History has eight sections/ components: 

1. Biographic Data
2. Reasons for Seeking Health Care
3. History of Present Health Concern
4. Past Health History
5. Family History of Illness
6. Review of Body Systems (ROS) for current health
problems
7. Lifestyle and Health practices profile
8. Developmental Level
an excellent way to begin the
assessment process because it
lays the ground for identifying
nursing problems and provides a
focus for the physical
examination
Nursing Health History
I. BIOGRAPHIC DATA
 Primary Source of Data: Client

 Informant: in case the client is

unconscious, mentally, emotionally
and physically incapacitated, too
young or too old, the one who
provided the information or the
informant’s full name and his/ her
relationship to the client must be
indicated.
 I. BIOGRAPHIC DATA
 

Includes:
Name, Address, Contact Numbers, Gender,
Provider of History- Informant, Birth date, Place of
Birth, Race or Ethnic background, Occupation and
working status at this point- if regular, probationary,
on leave, etc., Educational Level, Significant
others/ support persons, Health Maintenance
Organization membership- SSS, Philhealth,
Medicare number etc., Nationality, Marital Status,
Religious and Spiritual Practices, Languages
Spoken.
 II. REASON/S FOR SEEKING HEALTH CARE
(CHIEF COMPLAINT)
 

This category answers two questions:

 What is your major health problem or
concerns at this time?
 Why are you here?
 How can I help you?
 How do you feel about having to seek health
care?
 Encourages the client to discuss fears and
other feelings about having to seek a
health practitioner.
 
 III. HISTORY OF PRESENT HEALTH
CONDITION
 
This section of the health history takes into account
several aspects of the health problem and asks
questions whose answers can provide detailed
description of the concern.
 
Includes the following:
Signs and Symptoms Present or felt: COLDSPA
 
 

 
 III. HISTORY OF PRESENT HEALTH
  CONDITION

COLDSPA
C - haracter (How does it feel, look, smell, sound?)
O - nset (When did it begin; is it better, worse, or same as it
began?)
L - ocation (Where is it? Does it radiate?)
D - uration (How long it lasts? Does it recur?)
S - everity (How bad is it? From the scale of 1-10, where 10 is
the most painful?)
P - attern (What makes it better? What makes it worse? What
aggravates the condition?)
A - ssociated factors (What other symptoms do you have with
it? Will you be able to continue doing your work, exercise or
Activities of Daily Living?)
 
  III. HISTORY OF PRESENT HEALTH
CONDITION

PQRST Method for Pain Assessment

P = Provokes
What causes pain?
What makes it better?
Worse?
Q = Quality
What does it feel like?
Is it sharp?
Dull?
Stabbing?
Burning?
Crushing? (Try to let patient describe the pain, sometimes
they say what they think you would like to hear. )
 
  III. HISTORY OF PRESENT HEALTH
CONDITION

PQRST Method for Pain Assessment

R = Radiates
Where does the pain radiate?
Is it in one place?
Does it go anywhere else?
Did it start elsewhere and now localized to one spot?
S = Severity
How severe is the pain on a scale of 1 - 10?
(This is a difficult one as the rating will differ from patient to
patient.)
T = Time
Time pain started?
How long did it last?
 
 III. HISTORY OF PRESENT HEALTH
  CONDITION

If the client is in the hospital, include:

 medications taken/ being
administered at present
 intravenous fluids infused
 laboratory findings
 other pertinent and relevant
information.
 
 
IV. PAST HEALTH HISTORY

• portion of the health history focuses on

the questions related to the client’s
past, from the earliest beginnings to
the present.
• information gained from these
questions assists the nurse to identify
risk factors that stem from previous
health problems.
 IV. PAST HEALTH HISTORY

Includes:
 Birth, growth, development (congenital
abnormalities and other birth defects)
 Childhood Illnesses (chicken pox, measles,
mumps etc.)
 Immunizations to date (BCG, DPT, OPV, Hepa
B, Measles, MMR, Tetanus Toxoid etc.-
determine if Fully Immunized or not)
 Allergies – to food, drugs and other allergens
 Previous health problems (simple to
complicated illnesses)
 IV. PAST HEALTH HISTORY

Includes:
 Previous confinement or hospitalization (reason
for confinement, date/year and place of
hospitalization)
 Surgeries
 Pregnancies and Obstetric History (number and
type of pregnancies)
 Previous Accidents, Injuries (mild to severe
cases)
 Pain Experiences
 Emotional or Psychiatric Problems
 V. FAMILY HEALTH HISTORY

include as many genetic relatives as the client

can recall.
maternal and paternal grandparents, aunts and
uncles on both sides, parents, siblings, and the
client’s children.
Include the client’s spouse but indicate that
there is no genetic link.
Identifying the spouse’s health problems could
explain disorders in the client’s CHILDREN, not
indicated in the client’s family history.
 V. FAMILY HEALTH HISTORY
Includes:
 Age of parents (if living or deceased – to
determine longevity)
 Parent Illnesses (HTN, DM, CA, Obesity, Arthritis
etc.)
 Grand parent’s Illnesses
 Aunt’s and uncle’s age and illnesses
 Children’s age and illnesses
 Other lifestyle related cases or habits such as
alcoholism and smoking
 VI. REVIEW OF BODY SYSTEMS FOR
CURRENT HEALTH PROBLEMS
 important in determining the client’s reason/s for seeking
medical assistance.
 client is asked specific questions to draw out current
health problems from the recent past that may still affect
the client or that are recurring.
 Care must be taken in this section to include only the
client’s subjective information and not the examiner’s
observation.
 During the review of systems, document the client’s
descriptions of his/ her health status for each body system
 Questions should be asked in terms that the client
understands
 VI. REVIEW OF BODY SYSTEMS FOR
CURRENT HEALTH PROBLEMS

 Gastrointestinal
 Appetite, dysphagia, indigestion, food
idiosyncrasy, abdominal pain, heartburn,
eructation, nausea, vomiting, hematemesis,
jaundice, constipation, or diarrhea, abnormal
stools (clay-colored, tarry, bloody, greasy, foul
smelling), flatulence, hemorrhoids, recent
changes in bowel habits
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE

 
it deals with the client’s human responses, which
include: nutritional habits, activity and exercise
patterns, use of medications and substances, self-
concept and self- care activities, social and
community activities, relationships, values and
belief systems, education and work, stress level,
coping style and environment.
•Description of a Typical Day
---------Necessary to elicit an overview of how the
client sees his usual pattern of daily activity.
---------”Please tell me what an average or typical
day is for you. Start with awakening in the morning
and continue until bedtime.”
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE

Nutrition and Weight Management

• Average 24 hour intake (food/ fluid)
• Food eaten: type of food based on the food
pyramid, who buys, prepares and cooks the
food, frequency of meal times: snacks,
breakfast, lunch and dinner, fluids/
substances consumed and its amount, when
and where meals are eaten, changes in
eating pattern: prior to and during
admission or hospital stay.
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE

Activity Level and Exercise

Level and type of activity in the
workplace or at home during an
average week
Inquire about regular exercise and its
schedule: calisthenics, aerobics,
sports, etc.
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE

Sleep and Rest

 Inquire whether the client is getting enough rest
and sleep
 Focus on sleep patterns: how many hours a night
the person sleeps, interruptions, whether the
client feels rested, problems with sleeping, rituals
to promote sleep, concerns the client may have
regarding sleeping habits.
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE

Elimination
 Frequency of voiding, its amount and
characteristic, problems, etc
 Frequency of bowel movement, characteristics,
problems, etc.
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE

Medication and Substance Use

 Use of drugs, of any form and in excessive amounts can
increase the client’s risk for disease
 Use of vitamins and herbal supplements
 Prescribed medications may interact with some herbal
supplements (drug interaction)
 Alcohol and Tobacco use: type and amount of alcohol
intake, number of cigarettes per day, how long that the
client has been taking alcohol/ smoking, etc.
 Use of Over-the-Counter drugs and those who self-
medicate
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE

Self- Concept and Self- Care Responsibilities

 Health Attitudes
 Talents/ Special Skills or Abilities
 Self Care and Hygiene
 Ability to perform Activities of Daily Living
 Health related practices: Health Promotion and Disease
Prevention such as Immunizations, Screening and
regular Check-up, Practice of Safe Sex, etc.
 Physical Competencies: Ability to move about, perform
routines, household chores, etc
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE

Social Activities
 Family Living and Interaction
 Leisure and Relaxation activities
 “With whom does the client socialize frequently?”
 “Do you think you have enough time to socialize?”
 Time Management
 Community Activities and Organizations Involvement
 Contribution to society
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE

Relationships
 The most important person/s in life
 Significant others and support system
 Composition of family
 Relationship with spouse and children
 Relationship with in- laws, relatives, extended family
members
 Relationship with co- workers, superiors
 Sexual relationship
 Decision making
 Pets at home
 
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE

Values and Belief Systems

• Philosophical, spiritual and religious beliefs
• The most important thing in life
• Religious affiliation: Status of membership and its
importance to the client’s life
• “Is a relationship with God an important part of your
life?”
• “What gives you strength and hope?”
• What do you hope to accomplish in your life?
• Mass attendance, Church Service, Rituals and other
Religious activities involvement
• How does religious belief affect health?
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE
Education and Work
 Helps to identify areas of stress and satisfaction in
life
 Level of understanding and client teaching
 Future educational plans to pursue
 Occupation, Status of Employment
 Nature of work and its effect to health
 Work- related stress
 “Who is the main provider in the family? Is the
income enough to meet the family’s needs?”
 Problems encountered at work and feeling of
satisfaction and enjoyment 
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE

Stress Levels and Coping Styles

 Types of things that make the client angry, upset
 Stress level- based on the client’s perception
 Stress relievers
 Greatest Stressors in life
 Support System in times of crises
 Conflict management
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE
Environment
 Environmental hazards
 Presence of breeding sites of vectors
 Riverbanks, fields, irrigation and drainage, presence of
trees
 Stray dog, snakes and other rodents
 Type of neighborhood, congested houses
 Juvenile delinquency, crime rates and incidence,
violence
 Presence of community facilities: health center,
hospital, church, hall, school, market, etc.
 Distance of house to community facilities and hospitals
 VII. LIFESTYLE AND HEALTH PRACTICES
PROFILE
Environment
 Environmental hazards (home, neighborhood, work or
recreational environment)
 Presence of breeding sites of vectors
 Riverbanks, fields, irrigation and drainage, presence of
trees
 Stray dog, snakes and other rodents
 Type of neighborhood, congested houses
 Juvenile delinquency, crime rates and incidence,
violence
 Presence of community facilities: health center,
hospital, church, hall, school, market, etc.
 Distance of house to community facilities and hospitals
 VII. DEVELOPMENTAL LEVEL

State of Maturity (based on Erikson’s Psychosocial

Development)
Mental and Emotional Competencies
Ability to maintain eye contact
Coherence, appropriateness of response, answers, mood
and actions
Congruence between verbal and non- verbal
communication
Presents the right attitude and behavior at the right time
and place
Coping ability and Self- acceptance
Thank You