ASSESSMENT

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 ASSESSMENT

University of Gondar
College of Medicine & Health science
Department:Emergency &critical care nursing
Category: BSC Emergency Nursing students(Yr III)

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 Assessment

The course is designed:

 to provide adequate level of knowledge and psychomotor
skills necessary for assessing the health status of client

 to perform physical examination in a systematic manner so as

to determine the health status of individuals => patient
diagnoses

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 References
1. Bates’ guide to physical examination and history taking
2. Fente Ambaw:health assessment lecture note for
professional nurses
3. Janet W (1997), nurses’ handbook of health assessment
4. Routh F. Craven(1992), foundamental of nursing

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 Objectives
At the end of this session the students will be able to:
1. Define health assessment
2. List the components of the comprehensive history
taking
3. Elucidate the purpose of history taking
4. Identify the techniques of skilled interview
5. Differentiate the role of the nurse in health
assessment
6. Perform/assist physical examination techniques

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 Nursing?

Health?

Health assessment?

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Nursing
Definition
 It is the provision of optimal conditions to enhance the
person’s reparative process and prevent the reparative
process from being interrupted (F.Nightingale)

 It is human science dedicated to compassionate concern

with maintaining and promoting health, preventing illness
and caring for and rehabilitating the sick and disabled (V.
Henderson)

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 Health
“A state of complete mental, physical and social
wellbeing and is not merely as the absence of disease
or infirmity” (WHO).

“Health is a state of body and mind weel-functiong

which affords man the ability to strive towards to his
both functional and objective and culturally desired
goals” (Balog).

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 Holism health model
 Interdependence of body, mind and sprit.
 interaction with environment.

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 Health Assessment
Definition
Health assessment is a process by which one
analyze collected information in order to make
judgments about health problems or determine
a person’s need for nursing care.
It is also described as the foundation of nursing
process.
It’s process is an independent nursing
activity.
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 Assessment Data Obtained From

History
Physical examination
Laboratory & other diagnostic tests

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The role of the nurse in health assessment

Current nursing role comprises:

 Direct care
 Communication
 Counseling
 Hx taking and assessment
 Advocacy
 Leadership
 Supporting =include-psychosocial and emotional support.

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 Cont…
 Educative –nurse teaches self care activities for example:
-Self medication
-Health promotion
-Health screening
 Managerial role-nurse under takes a range of administrative
activities by exercising managerial skills
 Providing high quality and safe care
 Preventing harm and medication errors

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 General Approaches in health Ass’t
Avoid “leading” questions, which suggest a desired or
expected answer
Avoid questions leading to “yes” or “no” response.
Keep note-taking to essentials during the interview.

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The Techniques Of Skilled Interviewing

Active listening
Adaptive questioning
Non-verbal communication
 Facilitation
 Echoing
 Empathic responses
Reassurance
Summarization
 Highlighting transitions from Hx--- PE

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 The Techniques Of Skilled Interviewing
1. Active Listening.
Active listening is the process of
-Fully attending to what the patient is
communicating
- Being aware of the patient’s emotional state
-Using verbal and nonverbal skills to encourage the
speaker to continue and expand.

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 The Techniques Of Skilled Interviewing..
2. Adaptive Questioning
 Directed questioning—from general to specific.
*This is useful for drawing the patient’s attention to
specific areas of the history

*To minimize bias, offer multiple-choice answers. “Is your

pain aching, sharp, pressing, burning, shooting, or what?”

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 Cont…
 Questioning to elicit a graded response
 Offering multiple choices for answers
 Asking a series of questions, one at a time
 Clarifying what the patient means

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 The Techniques Of Skilled Interviewing…

3. Non-verbal Communication
Communication that does not involve speech occurs
continuously and provides important clues to
feelings and emotions.

Becoming more sensitive to nonverbal messages

allows you to both
- To “read the patient” more effectively and
- To send messages of your own.
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 Non-verbal Communication cont’d
Pay close attention to:
Eye contact
Facial expression,
Head position
Posture
Movement such as shaking or nodding, interpersonal
distance, and placement of the arms or legs, such as
crossed, neutral, or open.

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 The Techniques Of Skilled Interviewing…
4. Facilitation
You use facilitation, by posture, actions, or words, you
encourage the patient to say more but do not specify the
topic.
Leaning forward
Making eye contact

 Using continuers like “Mm-hmm,” “Go on,” Eh, or

“I’m listening” all maintain the flow of the patient’s
story/or help to maintain the patient to continue.
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 The Techniques Of Skilled Interviewing…

5. Echoing (Reflection)
Simple repetition of the patient’s words to encourages
the patient to give you more detail both factual and
feelings, as in the following Example:
Patient: The pain got worse and began to spread.
(Pause)
Response: Spread? (Pause)

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 The Techniques Of Skilled Interviewing…
6. Emphatic responses
 This is the recognition of feelings such as:
 Embarrassment
 Shame/suffering and
 Responding to patient in a way that shows
understanding and acceptance.
E.g. “I understand your problem” or it may be
behavioral such as providing a piece of soft for a
patient in tears or gently placing your hand on the
patient’s arm to show understanding.
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 The Techniques Of Skilled Interviewing…
7. Reassurance
 When you are talking with patients who are anxious or
upset, it is tempting to reassure them.
 “Don’t worry. Everything is going to be all right.”
 The first step to effective reassurance is identifying and
accepting the patient’s feelings without offering
reassurance at that moment.
 The actual reassurance comes much later after you
have completed the interview, the physical
examination, and perhaps some laboratory studies.
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 The Techniques Of Skilled Interviewing…
8. Summarization
Clarify or interpret what has been said.
It indicates to the patient that you have been listening
carefully.
It can also identify what you know and what you
don’t know.
9. Highlighting transition
From Hx--- PE…????

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 The “SOAP” Format
S – Subjective
Symptoms that the patient reports
What the patient feels
The history
O – Objective
Signs that can be observed by the examiner
Physical examination findings
Laboratory data & other diagnostic tests

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 The “SOAP” Format..
A – Assessment
Interpretation
& evaluation of data
Differential diagnosis
Medical diagnosis
Problem list
P - Plan
Diagnostic studies
Therapeutic regimen
Patient education

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 Group work
Think of symptoms that are assigned both in
subjective and objective data
present to the class.
5 min

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 Purpose of nursing assessment/Assessement.
 To gather data about the client that can be used in
diagnoses, identifying the outcomes, planning and
implementing care.

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 Types of Assessment
1. Initial assessment
Performed at the time the patient enters the health care
facility.

Broad and leads us to a center of our diagnosis

The aim of initial assessment is collection of data concerning

actual or potential dysfunction.

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 Types of Assessment…
2. Focused Assessment
Determines status of specific problems identified
during previous assessment.
To helps to identify overlooked problems.
It leads us to the general condition of the specific
diagnosis.

Its aim is to determine status of a specific problems

identified during previous assessment

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 Types of Assessment…
3. Time lapsed assessment (after several months of
initial assessment).
It is the final assessment done after a period of time.
This assessment is focused type.

Its aim is comparing the patient’s current status to

baseline data obtained previously after a period of time
has passed.
Detection of changes

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 Types of Assessment…
4. Emergency assessment
Assessment done on the life treating situation
This assessment should be done quickly, and leading to
aggressive management.

Its aim is identification of life threatening situations.

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 Ass’t setting and Environment
In any setting where nurses care for clients and their
family members.
Conducive environmental factors to the collection of
accurate and complete assessment data.
Quite, private setting
Restrict/secluded to prevent the clients undue
embarrassment during interview & P/examination.
Ask visitors and family members to leave the room.

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 Assessment skills
1. Observation: ability to observe and identify problems.
vision, smell, hearing and touch

2.Interviewing (history taking): interaction and

communication process for gathering data by questioning
and information exchange.

3. Physical examination
To verify & expand the data gathered during interview
using techniques of IPPA.
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 Assessment Activities (Components)
 Collect data: Gathering information about the patient
 Validate data: double checking, the process of
confirming the accuracy of assessment data collected.
e.g. “ I feel hot” check body temperature how is it?
 Organize data
 Recording data

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 Types of data

Subjective data
 Also known as symptoms or covert data, include the patients
feeling and statements about his or her health problems
 Obtained through interview
 It should always be taken by the patient own words
 E.g-I haven’t felt good for the last couple of months
 E.g. -“I get sharp pain in my chest.”

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 Types of data…
Objective data

Also known as signs or overt data or cues that are

observable and measurable.
Obtained through observation and physical assessment
techniques.

It is an information witnessed by the examiner

E.g Bp, RR, heart or breathing sound…

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 Source of Data
Primary sources
The patient

 Secondary sources
Family members or significant others
Health record, literature review
Laboratory test

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 Characteristics of data
Complete

Patient related problems should be identified

Factual and accurate

Relevant

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 Comprehensive Health Assessment
It includes:
 History taking
 Physical examination and
 Laboratory investigation

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 The Health History
Definition:

A nurse health history can be defined as the systemic

collection of data that is used for determining a
client’s functional health pattern status.

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 Purposes of history taking
To establish trusting relationship between the nurse
and the patient.
Develop understanding about the patient.
Help the patient to feel understood.
Guides on which body part or systems to focus during
physical examination.
Establish a therapeutic relationship
Gather pertinent information
Formulate a treatment plan

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 Phase of history taking
History taking has three basic phases:
1. Introductory phase:
In this phase the health personnel (Emergency nurse)
introduce self and explain the purpose of interview to
the patient, an explanation of taking note, assuring
confidentiality, comfort and privacy of the information.

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2.Working phase:
 The health professional facilitates the patient’s major

reason for seeking the health care and functional health

pattern responses.
 This is the actual data collection phase.

3. Summary and closure phase:

The nurse summarizes information obtained from the
patient during working phase and validates problem and
goals with patient.
-Possible plans to resolve the problems are identified and
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Complete health history
 Biographical data
 Source of history
 Chief complain: reason for seeking health care
 History of present illness/HPI
 History of past illness
 Family history
 Personal and social history
 Review of system/ROS

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 Biographical data
Name
Age
Sex
Residence
Occupation
Income
Religion
Ethnicity
Marital status…

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Chief complain (c/c)
This is the main reason that the client is seeking
medical advice/care

Make every attempt to quote the patient’s own words.

For example, “My stomach hurts and I feel awful.”

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History of present illness (HPI)
 Including analysis of the symptom like
OPQRST
Onset =the acuteness or chronicity
Provokes =what makes symptom worse/better
Quality =what does pain feels like (colic, throbbing,
cramp…
Radiation = where does pain shift
Severity =on a scale of 0-10 or other scale
Time = when, how often/frequent, how long.

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HPI…
Any intervention made and response it should be
reported
Contact and travel history

Positive and negative symptoms for differential diagnosis

at respective body system

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 History of past illness
This explores injuries, childhood illness, operations,

hospitalization and medical interventions.

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Family history
Outlines or diagrams of age and health, or age and cause

of death of siblings, parents, and grandparents

Documents presence or absence of specific illnesses in

family, such as hypertension, coronary artery disease,

etc.

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Review of systems

A summary of unreported symptoms in the HPI

(symptoms related to C/C will go to HPI)

A series of question regarding on patient current and past

health including health promotion practices.

Inquire about sign and symptom as well as disease related to

each body system.

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 Physical Examination

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 Introduction
Physical assessment: is an objective data about a client .
PURPOSE:
 Gather base line data
 Supplement, confirm, or refute (disprove) data in patient’s
history.
 Confirm and identify nursing diagnoses.
 Make clinical judgment about changing status

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 Purpose
 To have systematic examination and enable you reach

to meaningful diagnosis.
 Evaluate the patient’s current status

 Identification of health problem

 Give you better picture of the patients problem.

 Establishment of data base for intervention

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Physical assessment has 4 main parts

1. General survey/GA/

This is the initial observation of client’s general appearance

& behavior.
 Apparent State of Health: healthy looking or sick

looking (Acutely, chronically and acutely sick looking on

chronic bases)
 Eg-Chronically sick if zygomatic prominence.
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05/23/2021
 Level of Consciousness:-is the patient conscious
(awake, alert and responsive to you and others in
the environment?), lethargy and comatose?

Signs of Cardio-respiratory distress (Not…

severe)
Nutritional status (well nourished,
malnourished and extremely emaciated)

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 Cont…
2. Vital signs
It is important method for measuring & monitoring vital body
functions.
Includes To, pulse, respiration & blood pressure and O2
saturation.
Take v/s at least every 4 to 6 hrs for hospitalized pts
In acute situation every 1 to 2 hr
After surgery & any other procedure take v\s every 15
minute.

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 Cont…
3. Assessment of height & weight

4. Physical examination/body exam

 Refers to assessment of all structures, organs of the
body & body systems
 Uses four techniques of P/E
 Needs specific skills to examine each body parts

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 Assessment Sequencing
Head – to - Toe Assessment

Body Systems Assessment

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 Physical Assessment Techniques

There are 4 basic techniques to perform the physical

assessment
1. Inspection
2. Palpation
3. Percussion
4. Auscultations

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 Inspection
Is systemic and deliberate visual observation to determine
health status thorough observation in a head to toe
Fashion
Take time to “observe” with eyes
Perform at every encounter with your client
Good lighting
Position and expose body part with optimal viewing
Inspect for size, shape, color, symmetry and position

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 Palpation

With palpation you rely on the sense of touch to make

judgments about:
The size, shape, texture, and mobility of structures and
masses
The quality of pulses
The condition of bones and joints
The extent of tenderness in injured areas or structures
Skin temperature and moistures
Fluid accumulation and edema
Chest wall vibration

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 Palpation …

Different parts of the hand are used to palpate different

types of structures.
Breast, lymph nodes, and pulses should be palpated with
finger tips, where nerve endings are most concentrated.

The thumb and index tips are used to evaluate tissue

firmness.

Temperature can be quickly assessed with the back of

hand, where temperature sensory nerves are most
concentrated and the skin is thin.
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 Palpation…
Palpation may be light, deep, or bimanual.

Light palpation is the safest and least uncomfortable,

involving exerting gentle pressure with the finger tip of your
dominant hand, moving them in a circular motion and
depress the skin surface approximately 1-2cm

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 Palpation …

Deep palpation-which is done after light palpation is used

to detect abdominal masses.
The technique is similar to light palpation except that the
fingers are held at a greater angle to the body surface and
the skin is depressed about 4-5 cm.

A variation of this technique involves placing the finger

tips of one hand over the finger tips of the palpating hand.
The top hand should press and guide the hand to detect
underlying masses.

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 Palpation …
Bimanual palpation involves using both hands to trap
a structure between them.
This technique can be used to evaluate the
Spleen
Kidney
Breast, and
Uterus.

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 Percussion

Tapping to evaluate size, boarder, consistency of body organs

and discover fluids in the body cavities.
Characteristics of sound depend on density of underlying
tissue.
• Produces different notes depending on underlying
mass (dull, resonant, flat, tympani, Hyper
resonance)
Abnormal sound suggest mass, air, or fluid in organ or body
cavity.

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 Auscultation
Sounds produced by body
Quiet environment
Good stethoscope
Stethoscope placed next to skin
Diaphragm used for high-pitched sounds
Bell used for low pitched
sounds

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 Auscultation…
Auscultation is the skill of listening to body sounds
created in the lungs, heart, blood vessel, and
abdominal viscera by the help of a stethoscope.
Auscultation is usually the last technique used during the
examination.
 The sequence usually progress from inspection to
palpation, percussion, and auscultation, except during the
abdominal examination when auscultation is the second
step (following inspection).

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 QUESTIONS ?

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