HEALTH ASSESSMENT

#1
 Objectives
• To explain the concept of health assessment
• To identify the nurse’s role in health assessment
• To highlight the importance of the client’s participation in
health assessment
• To review various communication strategies across the life
cycle
• Interviewing strategies
• Preparation of the client for assessment
 Health Assessment
DEFINITION
• Collection of data about an individual’s health state

• An evaluation of the health status of an individual by

performing a physical examination after obtaining a
health history.
 Health Assessment
• A general survey, an overall review or first impression a
nurse has of a person’s well being.

• This is done head to toe, or cephalo-caudal, lateral to lateral,

proximal to distal, and front to back.
 Health Assessment
• Assessment is the most critical phase of the nursing process

• Inadequate or incorrect nursing judgment may be made and that

can adversely affect the other phases of the process

• For this module we will be exploring techniques of collecting

subjective and objective data as well as other elements needed to
complete the data base of the assessment of the client’s health
 Health Assessment
• The purpose of nursing assessment is to collect objective
and subjective data to determine the client’s level of
functioning in order to make professional clinical judgment.

• The nurse collects physiologic, psychological, sociocultural,

developmental and spiritual data about the client( Holistic
data collection)
 Why Should a Nurse Conduct a Physical Assessment?

• To screen the patient and to establish

a baseline for future assessments from
which subsequent phases of the nursing
process can evolve

• To validate the complaints that initiated

the need for health care

• To identify and manage a variety of

patient problems (actual and potential)
 The Nursing Process
• Assessment- collection of subjective and objective data

• Diagnosis-analyzing of data to make nursing judgment

• Planning- determining outcome criteria and developing a plan

• Implementation- carrying out plan

• Evaluation- Assessing whether the outcome criteria have been met and
revise plan
 Health Assessment
Critical phase of Nursing Process
• Nurses use physical assessment skills to:
– to monitor the client’s current health problems
– to aid in the formulation and evaluation of nursing diagnoses and
treatments
– evaluate the effectiveness of nursing care
– enhance the nurse-patient relationship
– make clinical judgments
 Preparing for the Assessment
• Review client’s record
( biologic data base provides background about chronic disease and
gives clues as to how present illness may impact client’s ADL).

• Keep an open mind

• Get familiar with diagnoses or tests performed
• Be as objective and open as possible
• Obtain and organize materials that may be needed for assessment
 Steps of Health Assessment

• The assessment phase of the nursing process has four major

steps:
• Collection of subjective data
• Collection of objective data
• Validation of data
• Documentation of data
 Gathering Data
• Subjective data - Said by the client • Objective data - Observed by
(S) the nurse (O)

SOPIER: Document
• Analysis - identifies a nursing diagnosis

• Plan - describes nursing interventions

• Implementation - records how those actions were carried out

• Evaluation - reports the actual patient outcome or response.

 Health History

Subjective Data
• A comprehensive age and sex appropriate patient history
should be done, including:
• chief complaint or reason for the visit
• a complete past family and/or social history should be
obtained on the first encounter by a registered nurse
• a complete review of systems
 Physical Examination
Clinical practice guidelines recognize the following body areas and organ
systems for purpose of the examination:
Head (including the face); Neck; Chest (including breasts and axillae); Abdomen;
genitalia, groin, buttocks; Back (including spine); and each extremity

Organ Systems: Constitutional (vital signs, general appearance), Eyes, Ear, Nose,
Throat; Cardiovascular; Gastrointestinal; Genitourinary; Musculoskeletal;
Dermatological; Neurological; Psychiatric;
Hematological/lymphatic/immunological

Integumentary: Both overall body and organ systems should have skin
assessments integrated into them. Integument includes skin, hair and nails.
 Collection of Subjective Data
• The COLDSPA mnemonic may be useful in exploring unusual signs
and symptoms
• Character: describe the sign and symptom. How does it feel, look,
sound, smell etc.
• Onset: when did it begin?
• Location: where is it?
• Duration : how long does it lasts?
• Severity: how bad is it
• Pattern: what makes it better? What makes it worse?
• Associated factors: what other symptoms occur with it?
 Collection of Subjective Data
• Sensations Or Symptoms( Pain, Hunger)
• Feelings (Happiness, Sadness)
• Perceptions
• Desires
• Preferences
• Beliefs
• Ideas
• Personal information
• values and personal information that can be elicited and verified only by the
patient)
• Effective interviewing skills are essential to elicit accurate subjective data
 Interviewing
• Obtaining a valid nursing health history requires professional,
interpersonal and interviewing skills

Phases of the Interview

• Introductory phase( explains purpose of the interview, assures
confidentiality, promotes physical and emotional comfort and privacy).
Establishes trust and rapport
 Interviewing
Phases of the Interview
• Working phase (information about biologic data, reason for
seeking care, health history. The nurse listens, observes cues and
uses critical thinking skills to interpret information)

• Summary and closing phase( the nurse summarizes information

obtained during the working phase and validates problems and
goals with the client
 Communication
The interview involves two types of communication
• Non verbal
• Verbal
Non verbal
• Appearance
• Demeanor
• Facial expression
• Attitude
• Silence
• listening
 Communication
• Effective verbal communication is essential to client interview.
• The goal is to elicit as much data about the client’s health status as
possible.
• Techniques used during the interview include:
– Open Ended Questions
– Closed –Ended Questions
– Laundry List
– Rephrasing Well-placed Phrases
– Inferring
– Providing information
 Interview Techniques
Open ended questions:
– Promote rapport
– Give the patient a chance to speak freely
– Allow the patient to discuss issues that concerns them most
Closed –ended questions:
– Provide specific answers
Note Level of consciousness
– Orientation
 Communication
Special consideration
• Three variations must be considered as you interview
clients:
• Gerontologic
• Cultural
• Emotional
 Summary
• Collecting subjective data is an essential step in the assessment of a
client

• Subjective data is information elicited and verified by the client

• Subjective data are gathered by means of an interview

• Verbal and non verbal communication are useful for interviewing

• Variations in communication with respect to gerontologic cultural and

emotional variations must be considered
 Collection of Objective Data
A complete nursing assessment includes both the collection of subjective
data and the collection of objective data
To be proficient with physical assessment skills the nurse must be
knowledgeable in the following areas:
– Types and operation of equipment needed for particular examination
– Preparation of the setting, oneself and the client
– Performance of the four assessment techniques
 Assessment Techniques:

• The order of techniques is as follows

– Inspect
– Palpation
– Percussion
– Auscultation

• Except the abdomen which is

– Inspect
– Auscultation
– Percuss
– Palpate
 Inspection
Critical observation *always first*
• Take time to “observe” with eyes, ears, nose (all senses)

• Used from the moment you meet the client and continues throughout the
examination

• Make sure the room is a comfortable temperature. Too cold or too hot can
alter normal behavior and client’s appearance

• Use good lighting preferably natural ( fluorescent lights can alter the true
color of skin, dim light can cause some abnormalities to be overlooked)
 Inspection
• Note color, size, location, consistency, shape, symmetry,
position movement, behavior, odors

• Compare the appearance of symmetric body parts(e.g. eyes,

ears, arms hands) or both sides of any individual body parts

• Develop and use nursing instincts

• Inspection is done alone and in combination with other
assessment techniques
 appears to be reported age;
Appearance sexual development appropriate;
alert & oriented;
facial features symmetric;
no signs of acute distress
 

Body structure mobility weight and height within normal Body Mass Index (BMI) [adult] or BMI-for-age and gender forms
[children]);
body parts equal bilaterally;
stands erect,
sits comfortably;
gait is coordinated;
walk is smooth and well balanced;
full mobility of joints
 

Behavior maintains eye contact with appropriate expressions;

comfortable and cooperative;
speech clear;
clothing appropriate to climate; looks clean and fit;
appears clean and well-groomed
 
 
 Palpation
Using parts of the hand to touch and feel the following characteristics:
• Texture( rough/ smooth)
• Temperature( warm/cold)
• Moisture( dry/wet)
• Mobility and turgor
• Consistency(soft, hard, fluid filled)
• Strength of pulses
• Size
• Shape
• Degree of tenderness
 Palpation
• Three different parts of the hand
– The finger pads
– Palmar surface
– Dorsal surface
• Are used during palpation because each part is sensitive to
certain characteristics
• Several types of palpation can be used:
– Light, moderate, deep or bimanual
 Palpation
light and deep palpation
• Use fingers to assess texture, moisture,
areas of tenderness use circular motion

• Note size, shape, and consistency of lesions

and organs

• Deep = 5-8 cm (2-3”) deep; Light = 1 cm deep

 Palpation
Deep palpation
• Use dominant hand on the skin surface
and place non dominant hand on top of
dominant hand to apply pressure.

• This is to feel deep organs or structures

 Palpation
Bimanual Palpation:
• Place one hand on each side of the body part to
be palpated

• Use one hand to apply pressure and the outer

hand to feel the structure

• Note and document the size, shape,

consistency and mobility of the structures
palpated
 Palpation
• Back of hand (dorsal aspect) to assess skin temperature
 Percussion
Sounds produced by striking body surface to produce
sounds that helps determine :
• Density: Percussion produces different notes depending
on underlying mass (dull, resonant, flat, tympanic)
• Pain: Percussion of inflamed structures produces pain.
• Location, size and shape: Used to determine size and
shape of underlying structures by establishing their
borders and indicates if tissue is air-filled, fluid-filled, or
solid
• Action is performed in the wrist.
 Percussion
• Detecting abnormal masses: can detect superficial abnormal
structures or masses.

• Eliciting reflexes: Deep tendon reflexes are elicited using the

percussion hammer.
 Percussion
Three types of percussion are direct, blunt and indirect

Direct: tapping of the body part

with one or two finger tip
 Percussion
• Blunt: to detect tenderness over
the organs

• Indirect : or mediate percussion.

this type of percussion produces
sounds that varies with the
density of the underlying
structures
 Percussion
• Takes time to develop and use
effectively.

• Follow steps as outlined in

handout.
 Auscultation
• Auscultation is the act of
listening

• Body sounds are often not

audible to human ear

• Requires the use of a

stethoscope
 Auscultation
listening to sounds produced by the body
• Direct auscultation – sounds are audible without stethoscope
• Indirect auscultation – uses stethoscope
• Know how to use stethoscope properly [practice skill] ]
• Describe sound characteristics (frequency, pitch intensity,
duration, quality) [practice skill]
• Flat diaphragm picks up high-pitched respiratory sounds best.
• Bell picks up low pitched sounds such as heart murmurs.
 Validating and Documenting Data
• Validation of data is the process
of confirming or verifying that
the subjective and objective
data you have collected are
reliable and accurate
 Validating Data
Methods
• Recheck your own data through repeat assessment

• Clarify data by asking additional questions

• verify the data with another health care professional

• Compare your objective findings with your subjective findings to

uncover discrepancies
 Documentation
• Provides a chronologic source of client assessment
data that outlines the client’s course of care

• Ensures that client’s information is easily

accessible
• Aides in effective communication

• Prevents repetition, fragmentation and delays in

carrying out plan of care
 Documentation
• Is a source of information
• Establishes a basis for screening or validating proposed
diagnosis
• Becomes part of a permanent , legal record for care that
was given to client
 Documentation
• The data base is the foundation for care of the client.

• It identifies health problems, formulate nursing diagnoses

and plan immediate and ongoing interventions

• Establishes a means of communication within the

multidisciplinary team
 Documentation
generally organized according to the following headings:
S: subjective data (e.g., how does the client feel?)
O: objective data (e.g., results of the physical exam, relevant vital
signs)
A: assessment (e.g., what is the client’s status?)
P : plan (e.g., does the plan stay the same? is a change needed?)
I : intervention (e.g., what occurred? what did the nurse do?)
E :evaluation (e.g., what is the client outcome following the
intervention?)
R : revision (e.g., what changes are needed to the care plan?)
 Documentation
• Deviations from what would generally be considered to be
normal or expected should be documented and may require
further evaluation or action, including a report and/or
referral.
 Reference
Weber, J. & Kelly, J.(2003)Health Assessment in
Nursing. (3rd ed.).Philadelphia: Lippincott
Williams & Wilkins.