AFREN KELLO College Harar Campus

Unit Title:Performing Nursing Assessment

Level -IV Nursing

Prepared by :I.M yaya)

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 INTRODUCITION
• Health assessment is a systematic,
deliberative and interactive process by which
nurses use critical thinking to collect, validate,
analyze and synthesize the collected
information in order to make judgement
about the health status and life processes of
individuals, families and communities.

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HOLISTIC NURSE ASSESSMENT
• The term holistic and holism are derived from the
Greek word meaning “whole”

• Is the study of mind, body and sprit beyond the sum

of the part of the individual

• It is difficult to attain and maintain health if the

essential aspects of health namely the physical,
psychological, social and spiritual perspectives are
not addressed
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 HOLISTIC NURSE ASSESSMENT…..

• The term holism also refers to the beliefs that all

parts of a living organism work together to
determine the health of the entire person
• When analyzing one part of the individual the nurse
must consider how the part relates to the whole
person
• Any disturbance in one part is a disturbance of the
whole system in other words the disturbance affects
the whole beings

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• The nurse also must consider the interaction or
relation ship of the individual to the external
environment and the other
• EXAMPLE: diabetes patient; the nurse should
explore impacts of DM on the patient
 appetite, rest/sleep, energy level,
 sense of well being,
 mood, usual activities,
 family relation ship, relationship with others,
 spiritual concern

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Holistic health care considers all the component of
health
– Health promotion
– Health maintenance and illness prevention
– Rehabilitative care
• The nurse advocates of the holistic approach view all
of the component with equal importance when
identifying health need, planning and implementing
care and evaluating the results.

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 Health
• Health is defined by world health organization as
“state of complete physical, mental, and social well
being, not merely the absence of disease or infirmity”
• Health is a state of being that people define in relation
to their own values, personality and life style.
• Each person has personal concept of health.
Individual view of health can vary among different
age groups, gender, race, and culture.
• It is difficult to define the idea with out reference to
society

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• Illness is an abnormal process in which aspects of the social,
physical, emotional or intellectual condition and function of a
person are diminished or impaired, compared with the
person’s previous condition.

• Sickness is a process of experiencing symptoms of physical

illness such as nausea, aches and pain, dizziness, weakness,
blurred vision or malaise.

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• Disease is a pathological condition of the body that present a
group of clinical signs and symptoms and laboratory findings.
Common causes of a disease
• The causation of a disease is called etiology.
Common causation of a disease include:
 Biological agent e.g. virus, bacteria, fungi, protozoa, helments
and toxin
 Inherited genetic factors e.g. sickle cell anemia
 Developmental defect resulting from exposure to
environmental element e.g. chemicals e.g. cleft palate.

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• Physical agent e.g. temperature extremes, radiation
and electricity
• Chemical agent e.g. alcohol, strong acids and bases,
many drugs, heavy metals, and industrial poison
• Tissue response to irritation or injury
• Faulty or chemical or metabolic process e.g.
excessive or inadequate production of body secretion
such as hormone and enzymes
• Emotional and physical reaction to stress

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 Risk factors for developing illness
• Risk factor is a phenomenon that increases the chance of
acquiring a specific disease.
• Some factors are:
 Age : age increase or decrease susceptibility to certain
illness e.g. heart disease increase with age
 Life style : many activities, habits and practices involve
risk factors e.g. over eating or poor nutrition, tobacco use,
drug abuse
 Stress : stress disturbs body physiology and increase the
risk of developing illness e.g. hypertensions

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• Environment : the physical environment in which a
person work or live can increase the risk of
developing illness e.g. some kinds of cancer and other
diseases are more likely to develop when industrial
workers are exposed to certain chemicals or when
people live near toxic waste disposal site

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 NURSING PROCESS

• is a systematic, rational method of planning and

providing individual nursing care
• Is the scientific problem solving process, which
focuses on the total health care need of clients
• Is action oriented, client centered, goal directed to
assess the client needs
• It is a cyclic i.e. systematic vehicle for critical
analyzing care
• It also assists you in responding to pt needs in a
timely & consistent manner to improve or maintain
the pt’s level of health
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 Purpose of nursing process

• To identify client health status, actual or

potential health care problems or needs
• To establish plan to meet the identified needs
• To deliver the specific nursing intervention to
meet these needs
• Increases care quality through the use of
deliberate actions

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 Characteristics of the Nursing Process

• Within the legal scope of nursing

• Based on knowledge-requiring critical thinking
• Planned-organized and systematic
• Client-centered
• Goal-directed
• Prioritized
There are 5 components of nursing process
 Assessment
 Nursing diagnosis
 Planning
 Implementation
 Evaluation
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 1.Assessment
• The first step in the nursing process.
• Is the foundation of the nursing process
Includes systematic
1. Collecting Data
2. Validating Data
3. Organizing (Clustering) Data
4. Identifying Patterns/Testing First Impressions
5. Reporting and Recording about the Patient/client health
status (current or past).
• unless a systematic approach is used in the data collection
phase, important needs will not be recognized and
consequently nursing action will not adequately address these
needs
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 Assessment….
Assessment include
• Nursing history
• Physical assessment
• Diagnostic test
SOURCES OF DATA
• Sources of data: -
 client
 support people
 client record
 health care professional
 literature
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 Assessment….

• Primary source–client or the major provider

of information about the illness.
• Secondary source–sources of data other than
client and include family members, other
health care providers, and medical records.

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 Assessment….

TYPES OF DATA
 Subjective data (symptoms or covert): –data from
client’s point of view, and include perceptions,
feelings, and concerns. Collected by interview. e.g.
pain, feeling of worry
 Objective data (signs or overt data ) –observable and
measurable, obtained through both physical
examination and the results of lab and diagnostic
testing.

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Type of assessment
1. Comprehensive (initial assessment)
2. Focus or on going assessment
3. Emergency assessment
4. Time-lapsed assessment

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 1.Comprehensive (initial assessment)

• Performed with specific time after admission to a

health care agency
• it include history taking, physical examination, and
laboratory test
Purpose: -
– Initial identification of normal function, functional
status, and collection of data concerning actual or
potential dysfunction.
– Baseline for reference and future comparison
E.g nursing admission assessment

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 2.Focus or on going assessment

• Is on going process integrated with nursing care,

a few minutes to a few hours between
assessments
Purpose:
– to determine the status of a specific problem
identified in an earlier assessment
– to identify new or over looked problem
E. g- hourly assessment for the client fluid in take
and urinary out put in an ICU
-Assessment of client ability to perform self care.
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 3.Emergency assessment
• is assessment during any physiological and
psychological crisis of
the client

Purpose:
• to identify life-threatening problem
• E.g. Rapid assessment of the person’s air way,
breathing status and circulations during a
cardiac arrest

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 4.Time-lapsed assessment

• is assessment made several months after

initial assessment

Purpose
• to compare the client’s current status to base
line data previously obtained
• E.g. reassessment of the client functional
health pattern in a home care or out patient
setting
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 APPROACH OF HEALTH ASSESSMENT IN NURSING

• there are three commonly used formats for

assessment data including
1. Body system approach
2. Functional health pattern approach
3. Human response pattern approach
1.Body system approach: is the traditional approach in
which the nurse observe and recorded data about
each of the body system
• This format does not usually permit the nurse to
collect all of the information needed to perform a
holistic nursing assessment
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it is difficult to perform nursing
by imad y.
diagnose 26
 2.Functional health pattern

• The format developed by Mr. jorie Gordon

• Organizes data in to 11 categories of
information which describe the sequence of
behavior over time rather than isolated
events.
• It permits the nurse to identify functional
pattern (client Strength ) and dysfunctional
patterns or nursing diagnose

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 3.Human response pattern
• This pattern divides a persons human health status in
to nine human response patterns :exchanging,
communicating, Relating, valuing, choosing, moving,
perceiving, knowing, and feeling.

• This approach is commented by experts for creating

confusion because nursing diagnoses are also
expressed in terms of human response

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 2.Nursing diagnosis
• Second step in the nursing process.

• is the process of identification of actual or potential

health problem of the patient
• is problem identification & gives meaning to the
data.
• Provides the basis for client care through the
remaining steps.

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 Types of nursing diagnosis
1.Actual nursing diagnosis: - is a judgment about a client
response to a health problem that is present at the
time of nursing assessment.
• It can be documented by a three part
statement(problem, etiology (related)& defining
characteristics)
2.Potantial nursing diagnosis: - is a clinical judgment that
a client is more vulnerable to develop the problem at
the future.
• It can be documented by using the two part statement.
Does not have sign and symptom of the diagnoses
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• Actual Nursing diagnosis has three statement components
problem statement is statement of the client response
describe the client health problem e.g. ineffective
breathing

the etiology is probable cause or factors contributing to

the response e.g. accumulation of secretion in the lung

sign and symptom is describing(defining) characteristics

e.g. difficulty of breathing

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• Actual diagnosis = problem + etiology + sign and
symptoms
E.g.
1. ineffective breathing related to accumulation of
secretion in the lung as manifested by difficulty of
breathing
2.Impaired skin integrity related to prolonged
immobilization as evidenced by wound on the back.
3.Fluid volume deficit related to excessive sweating
as manifested by dry oral mucosa.
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 .
Potential nursing diagnosis = problem + etiology
• E.g. high risk to injury related to restlessness and
unconsciousness.
• Risk for hypovolemia related to excessive sweating.

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N.B
• medical diagnosis is pathophysiologic response that are
fairly uniform from one client to another and focus on
disease process
• Medical diagnosis is identification of disease condition
based on specific evaluation of physical signs, symptoms,
Hx, diagnostic tests & procedures.
• Nursing diagnose is client physical, psychological, social
and spiritual response to an illness or potential health
problem. These response vary among individual

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 3. Planning
• Is 3rd step of the nursing process

• involves a series of steps in which the nurse and the

client set priorities, goals, expected out come and
formulating intervention

• During this step you identify a set of diagnoses, set pt

centered goals & prescribe nursing interventions

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 Setting priorities
What problems need immediate attention?
What problems have simple solutions?
What problems must be referred?

• Goal: - is a desired out come or change in client

behavior
• Expected out come: - is a more specific
measurable criteria used to evaluate whether the
goal has been met

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 4.Implementation
• Is putting the nursing care plan in to action
• During implementation phase the nurse carries out the
prescribed nursing activities
Nursing Interventions are activities performed by
the nurse to:
• Monitor Heath Status.
• Teach, Counsel, and Consult with, or referring to
the appropriate Health care professionals.
• Prevent, Resolve, or Control a Problem.
• Assist with Activities of Daily Living [ADL].
• Promote Optimum Health and Independence
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5.Evaluation
• The last phase of the nursing process
• Determines whether client goals have been
met, partially met, or not met.
• Is assessing the client response to the goal or
out come criteria written in the planning
phase

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 STRUCTURES OF MEDICAL APPROACH

• Biography
• Chief compliant
• History of present illness
• History of past illness
• Physical examinations
• Medical diagnose
• Deferential diagnose
• Diagnostic test
• Treatment

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 COMMUNICATION IN HEALTH
ASSESSMENT
• Listen attentively, using all your sense, and speak
slowly and clearly
• Use language the client understand, and clarify
points that are not understood, for instance by
asking the person to describe what a word mean to a
person
• Plan question to follow a logical sequence
• Ask only one question at a time, double question
limit the client to one choice and may confuses both
the nurse and the client

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• Do not impose your own value on the client
• Avoid using personal example, such as saying ‘if I
were you …’
• Non verbally convey respect, concern, interest and
acceptance
• Use and accept silence to help the client search for
more thought or to organize them
• Use eye contact and be calm, unhurried, and
empathetic

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 Empathetic listening

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 THE HEALTH HISTORY

• A nursing health history can be defined as the

systemic collection of subjective data (stated by the
client) and objective data (observed by the nurse)
used to determine a client functional health pattern
status

• The nursing health history is the first part of the

assessment of the client health status and usually
carried out before the physical examination

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 Purpose of history taking
• To identify patient health problem, both
actual and potential
• To establish a trusting relationship between
the nurse and the patient
• Identify patient strength
• Guides on which body parts or systems to
focus during physical examination
• It provide subjective data base
• It can be therapeutic

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 Phases of history taking
history taking has three basic phases
1. The introductory phase
2. Working phase
3. Termination phase

1. The introductory phase:

• in this phase the nurse introduces self and explains
the purpose of the interview to the patient.
• provided Comfort and privacy to the patient

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 The introductory phase….

The purposes of introductory phase are :

• To establish rapport
• To ensure a comfortable setting
• To state the purposes of the interview
2. Working phase:
 This is the most time-consuming phase because it is
the actual data collection phase.
The purposes of working phase are :
• To collect biographical data, reason for seeking health
care, functional health pattern responses.
• To identify respond to client’s needs
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 3. Termination phase
• The nurse summarizes information obtained
from the patient during the working phase
and validates problems and goals with the
patient .
• possible plan to resolve the problem are
identified and discussed with the patient.

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 .
Guide line for the effective history taking

1. Greet the patient, call by name, and give

undivided attention
2. Keep comfort and privacy, watch for
indication of discomfort poor positioning,
evidence of pain, or anxiety or signs of the
need to urinate
3. Never be in a hurry even when you are in a
limited time
4. Design question appropriately: avoid leading
question; begin with general questions
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 Guide line….
5.Facilitation: by posture, actions, or words you
encourage the patient to say more but do not
specify the topics.
6.Reflection: This is the repetition of the patient’s
words to encourage him to give you more details.
7. Clarification: when the Patient words are ambiguous
or associations are not clear, you must request for
clarifications
8. Empathetic response Conveying empathy is part of
establishing and strengthening rapport with
patients
9. Avoid Confrontation by imad y.
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 Component of history taking

As a general rule a complete adult health history

includes the following
1. Biographical data
2. Reason for seeking care
3. History of present illness
4. Past history
5. Family history
6. Review of system

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 1.Biographical data

The biographical data provides:

• you with direct information related to a current
health problem
• Alert you to risk factors for health problems, and
• point out the need for referrals.
• Your patient ability to provide biographical data
accurately reflects his or her mental status
Biographical data includes: Name, address, phone
number, age, birth place, sex, marital status,
ethnicity, occupation, contact person, race, religion,
and educational level.
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 2. Reason for seeking care/chief compliant

• Brief spontaneous statement in the person’s

own words that describes the reason for
visiting
• States one or two signs or symptoms and
duration
• It shouldn’t be greater than 3-5 complaints.
• Enclosed in quotation ,marks to indicate the
person’s exact words
• Ex. “chest pain” for two hours

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 3. History of present illness

• Amplifies the Chief Complaint

• describe each symptom developed Includes patient’s
thoughts and feelings about the illness.
• A full, clear, chronological account of how each of the
symptoms developed and what events were related
to them.
• how the patient thinks and feels about the illness
• what concerns have led to seeking attention, and
• how the illness has affected the patient’s life and
functions

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 History of present illness…
The principal symptoms should be well characterized, with
descriptions of
1. Pallative factor (Aggravating or reliving factors) –identify what
makes the pain worse. It is aggravated by weather, activity, food
medication, and time of the day. What relive it, rest, medication?
2.quality and quality-
Quality: This calls for specific description terms as burning, sharp,
dull, aching, gnawing, throbbing, and shooting
Quantity - quantify the sign and symptoms such as “profuse
menstrual flow soaking five pads per hour
3. Regiona and radiation- be specific, ask the person to point to it
like “pain behind the ear” jaw pain” Is the pain localized to this
site or radiating? Is the pain superficial or deep?

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 History of present illness…
4.Severity : this call for the specific description of mild
moderate and severe.
5.Timing (onset, duration, frequency)- when did the
symptoms first appears? give the specific time, state
specifically how long a go the symptom started prior
to arrival
6. Associated factors –Assess associated factors or
symptoms. Some disorders produce symptoms in
more than one body parts. Ex. Urinary frequency
and burning associated with fever and chills

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 4. Past history
• past health events may have residual effects on the
current health state.
• Childhood illnesses, such as measles, rubella,
mumps, whooping cough, chicken pox, rheumatic
fever, scarlet fever, and polio
• Accident or injuries-record any fracture, penetrating
wound, head injuries and burns
• Serious or chronic illness: indicate the presence of
diabetes, hypertension, heart disease and seizure
disorder.

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 Past history…
• Hospitalization-record the cause, name of the
hospital, how the condition was treated, length of
stay in the hospital

• Operations – record the type of surgery, date, name

of the hospital, and how the person recovered.

• Obstetric history- records the number of pregnancy

(gravida) number of viable births (parity) and the
number of abortions.

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 5. Family history

• Ask about the age and cause of death of blood

relatives, such as parents, grandparents and
siblings it may have genetic significance for
the client
• Ask about close family members, such as
spouse and children.
• Specifically ask for any family history of: heart
disease, high blood pressure, DM

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 6. Review of system( physical exam)

• Physical examination: is a systematic data collection

method that use observational skills (i.e the sense of
sight, hearing, smell, and touch) to detect health
problems.
• it is detailed account of signs referable to each
system of the body.
• The order of examination of body system is roughly
head to toe. When recording the information avoid
writing ‘negative’

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 Guide line for effective physical examination

• keep the patient informed

• use good light and quite environment
• thoroughly, systematically, and gently, listen,
look , and touch each region of the body
• If you forget a portion of your examination,
you should simply do that part out of
sequence smoothly.

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• You must avoid all negative reaction during
physical examination.
• a supine position is better examined for the
right side moving to the foot of the bed or
other side as necessary.

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 The End
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