Health Assessment in

Nursing

Dr Mercydina A. M. Caponpon, DPPS, MPH

Asst City Health Officer, SPC
Nursing Data Collection,
Documentation and Analysis
Learning Objectives
• Discuss importance of well developed nursing assessment skills are
needed in making clinical judgement
• Holistic nursing assessment vs physical medical assessment
• List and Describe the steps of the nursing process
• Describe which phase involve assessment by the nurse
• Describe steps of the analysis phase of the nursing process in making
sound clinical judgement
• Compare and Contrast the 4 basic types of nursing assessment
Observation and Data Collection

• Shall occur in any setting

• Hospital, clinic, home, community etc

• Can be conducted everyday/in any informal assessment activity

• Shall determine nursing clinical judgements that will result in client

care interventions that will affect improvement of health status
HEALTH ASSESSMENT (Phases: ADPIE)
• First/Most Critical phase of nursing assessment
• Inadequate/inappropriate: incorrect clinical judgement that can adversely
affect the remaining phases of the process
Diagnosis

Health
Planning
Assessment

Evaluation Implementation
HEALTH ASSESSMENT
• First/Most Critical phase of nursing assessment
• Inadequate/inappropriate: incorrect clinical judgement that can adversely
affect the remaining phases of the process

• More than just a gathering of information about the health status of a

client
• Analyzing, synthesizing the data and making judgements about the client

• Circular (nursing process)

PHASES OF NURSING PROCESS
Assessment Diagnosis Planning Implementation Evaluation
Collection of Analysis of Generating Solution Implement Plan The outcome of the
Subjective and Subjective and Developing a Plan intervention
Objective Data Objective Findings

History/ interview ID priority Determine which Prioritizing the Did the intervention
Observation/ professional clinical outcomes need to planned did not make a
Physical judgment be meet first intervention difference
Examination -client’s concern
-collaborative
problems
-Referrals
COLLECTION ANALYSIS PLAN SOLUTION TAKE ACTIONS ASSESS OUTCOME
 Diagnosis
(Analysing collected
data)

Assessment Planning (Generate

(Collection) solution/Plan)

Implementation
Evaluation
(Taking
(Assessing
actions/implement
outcomes)
plan)
FOCUS (HEALTH ASSESSMENT)- For judgement

• Comprehensive health assessment

• Health History
• Physical Examination

• Purpose: collect holistic subjective and objective data to determine a

client’s level of functioning
• Collects physiological, psychological, sociocultural, developmental, spiritual
data
• MD usually focuses on physiological
• Nurses focus on the other level of functioning of a client
• Eg: Diabetes: respiratory (RT), musculoskeletal (PT), DIET (Nutritionist)
Assessment:
Subjective
• From the patient
• Verbalized by the
patient/guardian
• Gather from what the patient
tells us
• Symptoms that can be
quantified by the patients
• Symptoms
Objective
• As seen by the examiner
• Observed or perceived by another
• What an observer can see or get
From physical examination (Manually or
Digitally)—5 senses
• BP/Temperature/Respiration
• Weight/Height
• Wound appearance
• How patient ambulate
• Signs
Subjective Assessment: FRAMEWORK

• Help to an organize Information

• Promote the collection of holistic data
• Generic nursing history framework
• Starts with the: Biographical Data
Other Important Data During an assessment
• History of present health concern
• Reasons for Seeking Health Care
• Chief Complaint (COLDSPA)
• Characteristic (pricking, gnawing, heavy)
• Onset: Time/date
• Location (Where is it/where it radiates)
• Duration (how long does it last, is it recurring)
• Severity (gauging)- from 1 to 10
• Pattern (What makes it better/worst)
• Associated Factor (what other symptoms with it, can continue working with it)
• Type (continuous, on, and off)

• Personal Health History/Past Health History/Past Medical History

• Previous illness/Diagnosis (At birth, childhood)
• Past surgeries, accidents, allergies
• illness that can be connected to the current complaint
• Immunization
• Medications (Past and Current)
• Physical/Emotional, Social, Spiritual; Strengths and weaknesses
Other Important Data During an assessment
• Family History:
• Age of parents (living ? Dead?-longevity)
• Idea of illnesses common to their family
• Hereditary illnesses (grandparents, aunts
• Habits of family/Same Food
• Family hx of Dm or Hypertension (Food likes)
• Handicaps
Other Important Data During an assessment
• Lifestyle/Health Practices
• Nutrition and weight management
• Fast food if all are working
• Habits of family/Same Food
• Vaccinations in the family
• Sleep and rest habits/activities in a typical day
• Exercise
• Type of work
• Social activities
• Stressors, Finances
• Use of substances
• Values, religion, Residence/type of environment/neighborhood
• Past, current, and future plans for education
Other Important Data During an assessment
• Developmental Level

• Psychosocial History
 TYPES OF HEALTH ASSESSMENT
Initial Comprehensive
Complete with PMH, Fam Hx
Lifestyle, Health Practices, etc
Done in any health setting
Entire PE (body systems)
Ongoing/Partial Focused or Problem Emergency Assessment
Oriented
Follow-up data Already with a Very Rapid assessment
Mini overview comprehensive data but performed during life
To determine changes came due to a particular threatening situations
(Deteriorate, improved) problem Eg DOB (focus on Eg First AID
chest auscultation
 STEPS OF HEALTH ASSESSMENT
Collection
(Subjective/Objective Validation of Data
Data)

Documentation of Data

Preparation for the assessment: shall review clients data/interview sheet (Name, sex, age, marital status, medical illnesses
Verify information from history/record
If with laboratories attached, educate yourself on the Normal values , indications of meds being taken
***Reflect
I. Collection of Subjective Data
• Sensation/symptoms
• Should elicit accurate subjective data
• Effective interpersonal skill
• Introduce yourself and your role in the health facility
• First name basis, thru review history provided like biographical information, etc
• Use Open ended questions
• Tackle all (hx of present concern, personal, fam hx, PMH, Lifestyle)
• Example:
• Nurse: Ano po ang dahilan ng inyong pagdalaw sa HC?
• May ubo ako…
• Or Nirefer po ako ng midwife namin sa iyo (Set up in Tb cases) then COLDSPA, PMH, FH,
Lifestyle, Developmental, Psychosocial
II. Collection of Objective Data
• Examiner directly observe the patient
• This data shall include the following:
• Physical characteristics (Skin color, posture, hygiene)
• Body Functions (heart rate, respiration)
• Appearance (the way he dress, neatness)
• Behavior, mood
• Measurements (BP, weight, height, temperature)
• Results (Laboratory, x-ray findings)
• Others: data obtained from PE like inspection, palpation, percussion, and
auscultation -4 physical examination technique)
• another objective: observation from family or by significant others
• Eg: Pale, looks poorly nourished, underweight, LGF, in mild respiratory distress
III. Validation of Data Collected
• To ensure data collected are reliable
• Failure to validate may result to premature closure of the assessment
or collection of inaccurate data (Results were not seen)

• Though not all data collected must be verified (only if needed or with
conflicting subjective and objective findings)
• Feel dizzy but BP is normal
• Appears very lean but the weight is overly high
• Temperature is Normal but when touched skin was warm or looked flushed
Need to know the normal (Vary with age)

120/80 60-100
36.5-37.4 12-18
How to validate data
• Recheck/Repeat assessment
• With different apparatus
• With different collector

• Clarify data by asking additional questions

• Repeat question to confirm. Abdominal pain but on palpation, there is none. Ask if on and off

• Compare subjective and objective findings and quantify.

• No LBM but with abdominal hypermotility
• Validate perception of LBM

• Missed Data
• On history client says: “sobrang payat ko ngayon”, so need to ask his previous weight so as to
quantify info
IV. Documentation of Data
• Crucial
• Chronological source of client assessment data/accessible to patient and families
• Requirement
• Accreditation/reimbursements
• Legal matters
• Complaints/client concerns
• Follow-up
• Improvement of processes
• Research
• Epidemiological data
Mandate
• Health Information System/Technology
• Eliminate handwritten clinical data, replace with computer (Electrical medical
Record)
• EMR- accessible data across health facilities
• Easier to control

• *OPD Set-up in our Health Centers: not anymore done by nurses

• True to Hospitals
 Diagnosis
(Analysing collected
data)

Assessment Planning (Generate

(Collection) solution/Plan)

Implementation
Evaluation
(Taking
(Assessing
actions/implement
outcomes)
plan)
Analyzing Cues
• Second phase

• Require a nurse to use his clinical judgement

• Analyze/synthesize cues from collected data to identify a plan, see if

needing an immediate referral to clinician
Steps in Making Clinical Judgement
• Id Abnormal cues and client/supportive cues
• Know the Normal Values/standard (height, weight, normal BP etc)
• Idea of Risk factors (predisposition, gender, age, lifestyle, fam hx
• Hx of Stroke in the family, if occupation is sex worker probably if with discharge, you’ll
think of STDs
• Nurse shall have data or info on risk factors for a specific disease vs those of the client

• Should have a knowledge of anatomy and physiology

• Abdominal pain epigastric area
• High sugar after meals
Steps in Making Clinical Judgement
• Id of Cluster Cues
• Pneumonia:
• Subjective: cough and DOB as verbalized
• History: Exposure to COVID-19 HH member
• Labored breathing, rales, cyanotic nailbeds

• Draw inferences to propose or hypothesize Possible Clinical

Judgement
• It is where the referral should set in
• Should know the proper referral process and availability of bed
Steps in Making Clinical Judgement
• Id Possible Client Concerns
• Pneumonia:
• Subjective: cough and DOB as verbalized
• History: Exposure to COVID-19 HH member
• Labored breathing, rales, cyanotic nailbeds

• Identify the client concern of his situation, his need to improve his health status
• Validate client’s concern to family, significant others and Health Team
Members
• Document Clinical Judgement
Subjective Data
Learning Objectives
• Discuss the Purpose of the 4 phases of the client’s interview (Pre-introductory,
Introductory, Working Phase, Summary/Closing Phase)
• Describe Effective verbal and nonverbal communication Techniques
• Types of Communications to avoid in the client’s interview
• Interviewing Older clients
• Interviewing clients with emotional issues
• How Ethnicity can affect Communication patterns
• Major Categories of Complete Client Health History
• Use of Genogram to illustrate family health history
• Process of Performance of ROS
• Questions in assessing lifestyle and health practices
• COLDSPA Mnenomic to analyze a client symptoms
SUBJECTIVE DATA
• Integral part of an interview to obtain a nursing health history
• Subjective Data: elicited/verified only by clients
• Sensation
• Symptoms
• Feelings
• Perception
Biographic data, Reason for seeking health care, chief complaint
• Desires
Hx of Present illness, PMH, FH, Current RX, Lifestyle, Developmental level
• Preferences Psychosocial history, ROS
• Beliefs
• Ideas
• Values
• Personal Information
• Provide clues to possible psychological, physiological, sociological problems
• Reveal risk for a problem/strengths of a client
Interview
• Tool to obtain a valid nursing health history
• Shall establish rapport/trusting relationship
• Gathering of information that enhance client-nurse collaboration
• Phases:
• Pre-introductory- position where client hear best, review of records

• Introductory-introduce self, explain the purpose of interview, reason of taking notes,

confidentiality, make patient comfortable physically and emotionally, at same eye level,
time to develop rapport and trust

• Working Phase-nurse elicit client’s comments and information, health issue, problems,
lifestyle etc. Nurse listen and observe cues, use critical thinking to interpret and validate
information. Collaborative to know the problem

• Summary and Closing Phase- summarizing of information, discuss plan to resolve issues.
Listen for further questions if any
 NON VERBAL
Communication
• Appearance –professional, neat
• Demeanor-display poise and focus to patient/Professional distance
• Facial expression- show what one truly is thinking, expression should be neutral (use right
expression at the right time)/friendly
• Attitude-non judgmental, most impt. All clients regardless of beliefs, ethnicity, HC practice.
Don’t act as if you’re superior or appeared shock, disgusted- as client may feel
uncomfortable
• Silence-period of silence allow you and client to reflect and organize thoughts
• Listening- need to develop to collect complete and valid data. Need
• good eye contact
• Smile/appropriate facial expression
• Maintain open position (open hand/arm)
Avoid several non verbal affects, avoid crossing arms, sitting
Back, tilting head away from client, inattentive, looking blank
Engaging in e devices
Verbal Communication
• Open ended questions: elicit feelings, uses how and what that require more words
• Closed ended: to obtain facts and focus on specific info, use to keep interview on
course
• When did your headache started?
• Use LAUNDRY LIST: to provide with a list of word.
• is the pain piercing, cutting, gnawing
• Use Rephrasing: technique to clarify things
• Well phrase phrases: using uh-huh, yes, oh, I agree to encourage them to continue
• Inferring: concluding what the client have said
• Providing information: provide an answer if during the convo he asked questions
What to avoid during an interview
• Excessive or insufficient eye contact
• Distraction and distance-avoid being occupied by something else
during the interview
• Avoid standing while client is sitting (same eye level). Not to see you
are superior
• Avoid Biased and leading questions-might provide questions that are
not true
• Rushing through the interview
• Reading the questions
Special Considerations during an interview
• Hearing loss- need to modify verbal technique
• Gerontologic Variation- Do not assume that geriatric people has health
issues. Should assess hearing acuity first
• More often go for consult
• Need to believe they can trust you
• Shall speak clearly and straightforward
• Cultural and ethnic variability
• Difference in beliefs, communication styles, language, cultures and healthcare
practices
• Emotional variation in Communication
• Indifferent client, angry, depressed, manipulative, seductive or sensitive
Interacting with clients presenting with
various Emotional Stress
• Anxious client-provide simple , organized info
• Angry client-approach shall be calm, reassuring and in-control manner
• Depressed client- express interest
• Manipulative client- provide structure and st limits
• Seductive client-set firm limits and avoid responding to subtle
seductive behaviors
• Discussing sensitive issues-sexuality, dying, spirituality, be aware of
your own thoughts, nonjudgemental. Refer
Review of System (ROS)
• Description of current health problem
• From Head to Toe
• Review the current health status of each body system
• Eg:
• Skin- rashes, excessive sweating, balding, dandruff
• Head/neck- sore throat, enlarged lymph nodes
• Eyes- vision, excessive tearing, blurring
• Ears- difficulty in hearing, discharge
• Mouth- lesions, pain in swallowing, caries
Collecting Objective Data
(Physical Exam Techniques)
• Explain how to prepare oneself, the physical environment, and the
client for physical examination
• Survey the various physical equipment needs in performing PE
• Describe various client positions used in PE
• Demo: correct I-P-P-A
• Identify the difference between light, deep and bimanual palpation
• Describe the purposes of direct, indirect, and blunt percussion
• Purpose of bell and diaphragm of the stethoscope
• Use objective data thru the PE technique to make a clinical judgement
Basic knowledge of a nurse to become
proficient with PE
• Types and operational equipment
• Penlight, BP apparatus, Sphygmomanometer, otoscope, tuning fork

• 3 aspects: for physical assessment

• Preparation of the physical setting/set-up
• Yourself/Oneself and
• The client

• Performance of the 4 examination techniques

• Inspection
• Palpation
• Percussion
• Auscultation
Collecting Objective Data
• Penlight, Sphygmomanometer, otoscope, tuning fork, stethoscope,
metric ruler, percussion hammer
• Watch with second hand
• Others: Snellen’s chart, tongue depressor, vaginal speculum, cotton
applicator

• Dependent on the body parts one will be examining

• Minimum: Gloves and gown
PHYSICAL SETTING
• Various Physical settings
• Comfortable, room temperature
• Provide a warm blanket if the room temp can’t be adjusted
• Private area, free of interruption; free from distractions
• Adequate lighting
• Firm Examination Table, a height to prevent stooping (a stool maybe
used as necessary)
• Need a bedside tray to hold equipment
Preparing Oneself
• Assess feelings and anxieties
• Anxiety-easily conveyed, can adversely affect assessment and outcomes of
clinical judgment
• *practice

• To prevent transmission of infectious agents

• Practice standard precautions
• HAND HYGIENE
• either with soap/water (washing), antiseptic handwash/hand rub (sanitizers), or
surgical hand antisepsis
• Reduces: the spread of deadly germs, and vice versa patients and nurse
• Done before and after touching clients, before performing an aseptic technique, before
moving to a soiled body site to clean the body site in a patient
• After contact with body fluids or contaminated surfaces
• Immediately after gloves removal
Methods of Hand Hygiene
ALCOHOL-BASED Hand Sanitizers- 20
seconds
• the most effective way in
reducing the number of germs
on the hands of HCW;
• Preferred in most clinical
conditions
SOAP and WATER-15 seconds
• Preferred: If visibly dirty, before
eating and after using a restroom
(handwashing is preferred)
• After caring for a person with
known/suspected infectious
diarrhea
• Known/suspected exposure To
spores (Clostridium
botulinum/Anthrax)
Gloves
• If anticipated contact with potentially infectious materials, fluids, skin,
surfaces
• When you have an open wound
• Performing examination of the mouth, genitalia, open wound, rectum
• To handle bodily fluids (blood, sputum, wound drainage, urine, stool
• Hand hygiene shall be done before and after wearing gloves (not to replace)
• Frequency of changing
• Per patient
• If becomes damaged
• If visibly soiled with blood and other body fluids
• From soiled body parts to clean
• Carefully remove to prevent hand contamination
Others
• Skin and nail care
• Less than ¼ inch long nails
• Not recommended to use artificial nails/extension
• Respiratory Etiquette
• Cover mouth and nose with tissue when coughing or sneezing
• Use of nearest receptacle to dispose used tissue
• Perform hand hygiene after having contact with respiratory secretions and contaminated
objects
Preparing the Patient
• Establish a nurse-client relationship to alleviate any tension and
anxiety.
• Explain that PE will follow, and describe what the examination will
include
• Explain that clothing shall be removed
• Respect the client’s desires/requests. Shall explain the importance of
examining genitalia/breast (as can miss something if not done)
• Sign consent sometimes
• Approach from RIGHT-HAND SIDE of the examination table
Process
• Begin with the least intrusive (allow client to feel more comfortable
and help to ease anxiety)
• Temperature
• Pulse
• BP
• Height
• Weight

• Integrate health education and promo during examination

POSITIONS
• Sitting- sitting upright on the side of the examination table, allows full
expansion of lungs; symmetry of the upper back
• Supine- lying down with legs together-allow the abdominal muscle to relax;
easy access to peripheral pulses
• Dorsal recumbent- lying down with knee bent, legs separated; abdomen shall
not be assessed in this position (contracted)
• SIMS position-patient lies on any side. Rectal and vagina exams.
• Standing- posture, balance, and gait; male genitalia exam
• Prone position- lies on abdomen; assess hip joint and back not for those with
heart and respiratory problems
• Knee-chest-rectal examination-patient kneels on the examination table.
Hands above the head. Recommended to examine the rectum
• Lithotomy position- normal vaginal deliveries. Hips at the end of examination
EXAMINATION TECHNIQUE
• Inspection:
• uses senses of vision, smell, hearing
• Identify: color, patterns, size, location, consistency, pattern, symmetry,
movement, odor, sounds
• Compare both sides
• Few require the use of equipment (otoscope, penlight, ophthalmoscope)
• Guidelines:
• Comfortable temperature
• Good lighting source, preferable from sunlight. Some lights alter the color of the skin
• Look and observe first before touching
• Expose whole body parts inspecting while covering the rest
EXAMINATION TECHNIQUE
• Palpation:
• uses hand to touch
• Identify texture, temperature, moisture, mobility, consistency, strength of pulses,
size, shape, degree of tenderness

• Part of hand used in Palpating:

• Finger pads- pulses, texture, size, consistency, shape, crepitus
• Ulnar/palmar surface, vibration, thrills, fremitus
• Dorsal-temperature

• 4 types:
• Light-very little or no pressure, <1 cm
• Moderate- note consistency, size, mobility 1-2 cm
• Deep- 2.5-5 cm deep. Dominant hand on skin surface, nondominant hand on top of dominant
• Bimanual-uses both hands, 1 on each side of the body. 1 applies pressure, other hands to feel
for the structures
EXAMINATION TECHNIQUE
• Percussion:
• Tapping body parts to produce sound
• The sound waves/vibration enable the examiner to assess the underlying
structures
• Use in:
• Eliciting PAIN- Patient will report tenderness, soreness, or pain
• Determines: LOCATION, SIZE and SHAPE
• Determines: DENSITY, whether filled with fluid (tympanitic) or Solid 9(dull)
• Detects: ABNORMAL MASSES, which can detect superficial abnormal structures
• percussion vibrations penetrate approximately 5 cm deep
Eliciting Reflexes (Deep Tendon Reflex by using a percussion hammer)

• Types (Direct/Blunt/Indirect)
Percussion
• Blunt: Use to detect tenderness of organ (Kidneys)
• Place 1 hand flat on the body surface and use the fist of the other hand to
strike the back of the hand on the flat surfACE

• Direct: Direct tapping of body parts with 1 or 2 fingertips to elicit

tenderness (Sinuses)

• Indirect: Commonly used. This type produces a sound that may vary
• Solid (soft tone); fluid (louder sound)
Procedure (Indirect Percussion)
• Middle finger of the nondominant hand to an organ you need to
assess
• Keep other fingers off the body part being percussed as it will dump
the tone you’ll elicit
• Use the pad of the middle finger of the other hand to strike the
middle finger of your non-dominant hand placed on the body part
• Ensure with short nails
• Withdraw the finger immediately to avoid damping the tone
• Deliver 2 quick taps, listen carefully to the tone
• Quickly flex your wrist not the arms
Sounds during percussion
• Resonance (Part air part solid)– normal lungs
• Hyperresonance (mostly air)– Emphysema
• Tympany (air)– gastric bubble
• Dull (more solid tissue)—Liver, diaphragm pleural effusion/fluid on
the lungs
• Flatness (heard over dense tissue)—muscle, bone, sternum
EXAMINATION TECHNIQUE
• Auscultation:
• Requires the use of the stethoscope
• Used if the sound is not audible to the human ear
• Listening to heart sounds, movements of bowels, and movement of air to
the respiratory tract

• 4 Classification of sounds
• Intensity (loud or soft)
• Pitch (high or low)
• Duration (length)
• Quality (musical, crackling, raspy/harsh
Do’s and Don’t’s
• WARM the diaphragm
• Explain what you are listening for - before placing to the patient’s
body
• Expose body parts you are going to auscultate. Cloth may obscure the
sound
• Eliminate distracting or competing noises from the environment
• Avoid too much pressure in using the bell, to avoid it to function as a
diaphragm