Steps in Health

Assessment
Four major steps:
Collection of SUBJECTIVE DATA
Collection of OBJECTIVE DATA
VALIDATION of data
DOCUMENTATION of data
Preparing for the Assessment
Review the client’s record.
Basic biographical data (age, sex, religion and
occupation)
It provides background of CHRONIC diseases and
gives clues to how a present illness may impact on
client’s activities of daily living (ADL’s).
These gives the nurse the opportunity to verify
what you read with what the client tells you.
Preparing for the Assessment
REVIEW THE CLIENT’S HEALTH STATUS
WITH OTHER HEALTH CARE TEAM
MEMBER:
Often a client may reveal and share important data
with some team members and not with others.
Preparing for the Assessment
KEEP AN OPEN MIND, TO AVOID
PREMATURE JUDGMENT.
Do not assume a 30-year old female client who
happens to be a nurse knows everything regarding
hospital routine and medical care.
60-year-old male client with Diabetes Mellitus
(DM) needs client teaching regarding diet.

KEEP AN OPEN MIND!!!

Preparing for the Assessment
USE THIS TIME TO EDUCATE YOURSELF
ABOUT THE CLIENT’S DIAGNOSIS OR
TESTS PERFORMED.
Medical diagnosis that you never heard of or that
you have not dealt with the past.
Special blood tests and the results were abnormal
and that you are not familiar with this test.
CONSULT THE NECESSARY RESOURCES!
(laboratory manual, textbook, blood laboratory)
Preparing for the Assessment
TAKE a minute to REFLECT on your own
FEELINGS regarding your initial encounter
with the client:
EXAMPLE:
A client may be a 22-year old with a drug addiction.
If you are 22 years old and are a very health-
conscious person who does not drink, smoke, take
illegal drugs, or drink caffeine.
YOU NEED TO TAKE TIME TO EXAMINE YOUR
OWN FEELINGS
Preparing for the Assessment
To avoid BIASES, JUDGMENT, and the
tendency to project your own feelings onto
the client.

You must be as objective and OPEN as

possible.
Preparing for the Assessment
OBTAIN AND ORGANIZE MATERIALS
THAT YOU WILL NEED FOR THE
ASSESSMENT:
Guide to interview questions
Forms on which to record data collected during the
health history interview and physical examination.

GATHER ANY EQUIPMENT!!!.

STEPS IN HA
COLLECTING
SUBJECTIVE DATA
 Collecting Subjective Data
SENSATION or SYMPTOMS (pain, hunger)
FEELINGS (happiness, sadness)
PERCEPTIONS
DESIRES
PREFERENCES
BELIEFS
IDEAS
VALUES
PERSONAL INFORMATION
 Collecting Subjective Data
Major areas of Subjective Data include:
Biographical information
Physical symptoms related to each body part or
system
Past health hx
Family hx.
Health and lifestyle practices
COLLECTING
OBJECTIVE DATA
 Collecting Objective Data
DIRECTLY observe BY the examiner… includes…
Physical Characteristics (skin color, posture)
Body functions (heart rate, respiratory rate)
Appearance (dress and hygiene)
Behavior (mood, affect)
Measurements (blood pressure, temperature,
ht.,wt)
Results of laboratory testing (platelet ct. x-ray
findings)
 Collecting Objective Data
Obtained through:
GENERAL OBSERVATION
PHYSICAL EXAMINATION TECHNIQUES
 Inspection
 Palpation
 Percussion
 Auscultation
 Comparing subjective and objective
subjective objective
Data is elicited and Data directly or indirectly
verified by the client observed through
measurement

Client Observation and PA

Family and significant Documentation of
others assessments
Client record Observations made by the
Other health care client’s family or SO
professionals
 Comparing subjective and objective
subjective objective
Client interview Observation and Physical
examination

Interview and therapeutic Inspection

communication skills Palpation
Caring ability and empathy Percussion
Listening skills Auscultation
 Comparing subjective and objective
subjective objective
“I have a headache.” Respirations 16 per minute

“It frightens me.” BP 180/100, apical pulse 80

and irregular
“I am not hungry.”
X-ray film reveals
fractured pelvis.
VALIDATING
ASSESSMENT DATA
 Validating Assessment Data
Validation of assessment data is crucial part of
the 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.
Helps to prevent documentation of inaccurate
data.
DOCUMENTING
DATA
 Documenting Data
Documentation is an important step of
assessment.
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 valid conclusions are made when the data
are analyzed in the second step of the nursing
process.