HEALTH

ASSESSMENT &
PHYSICAL
EXAMINATION
 Course content
• Health assessment and physical examination (Purpose; history taking approaches-
Gordon’s Functional health patterns and systemic; preparation for examination,
organisation of the examination, techniques of physical assessment; General survey:
general appearance, vital signs: guidelines for measuring vital signs, body temperature,
pulse, respiration, blood pressure, recording vital signs; Systemic assessments).
• Basic life support (Adult, child and infant BLS, chain of survivals, chocking, and use of
an AED).
• Medication administration (principles, legal aspects of drug administration , systems of
medication measurement clinical calculations, types of orders, abbreviations, symbols,
and dose designations, medication errors, rights of medication administration,
medication administration procedures - oral medication, injection safety, parenteral
medication, topical medication; drug misuse in health care professionals).
• Diagnostic testing (nurse’s role for each of the phases involved in diagnostic testing,
common blood tests, nursing responsibilities and rationale in specimen collection;
Collection of specimen: Blood, stool, urine, sputum and throat specimens; nurses roles
in visualization procedures in gastrointestinal, urinary, and cardiopulmonary
alterations, in imaging studies & aspiration/biopsy procedures).
• Nursing Procedures (Activity and exercise, hygiene, oxygenation, Fluid, Electrolyte, and
Acid-Base Balance, Skin Integrity and Wound Care, Nutrition, Urinary Elimination,
Bowel Elimination)
• Purpose; history taking approaches- Gordon’s
Functional health patterns and systemic;
• preparation for examination, organisation of the
examination, techniques of physical assessment;
• General survey: general appearance, vital signs:
guidelines for measuring vital signs, body
temperature, pulse, respiration, blood pressure,
recording vital signs; Systemic assessments.
 Purpose of physical examination
• To make direct observations of any deviations from normal

• To validate subjective data gathered through the interview

• To determine eligibility for health insurance etc

• Identify and confirm nursing diagnoses.

• Make clinical decisions about a patient’s changing health

status and management.

• Evaluate the outcomes of care.

 Assessment models
• Assessment model
– A framework that provides a systematic method
for organizing data.

• Why use of a model

– Helps to ensure comprehensive and organized
data collection.
– Provides direction for decision making about
nursing diagnoses
 Nursing assessment models
①Functional health patterns
• 11 categories

②Human response pattern

• Developed by NANDA

• Nursing diagnostic categories are organized according to 9

human response patterns.

• Health status is evidenced by observable phenomena that

can be classified into one of these response patterns.
③Theory of self care
• Focuses on the appraisal of the client’s ability to
meet self care needs and the identification of
existing self-care deficits.

④Roy adaptation model

• Assessment is focused toward an individual’s
response to stimuli in the environment in the areas
of physiological status, self-concept, role function,
and interdependence.
 Non Nursing assessment models
①Body systems model
• Also called medical model

• Focuses on examining body systems

• Does not facilitate the formulation of nursing

diagnoses.

• Psychosocial aspects of the client’s status are often

neglected .
②Hierarchy of needs model
• Used to prioritize needs.

• Physiological needs should be assessed first

followed by higher-level needs.