HEALTH ASSESSMENT (LEC)

Health Assessment 4. Emergency Assessment

- Essential nursing function which provides foundation - Takes place in life threatening situations in which the
for quality nursing and intervention ; helps to identify preservation of life is the top priority (ABC)
the strengths of the client in promoting health - Focuses on few essential health patterns and is not
comprehensive.
The Nurse & Health Assessment
- An accurate and thorough health assessment reflects Guidelines of an Effective Interview and Health History
the Knowledge and Skills of a Professional Nurse > Phases of Interview
1. Introduction Phase
Nursing Health Assessment - The nurse introduced himself to the client and explains
- The nurse focuses on how the client’s health status the purpose of the interview
affects activities of daily living (ADL) and how those ADL - The nurse also makes sure that the client is
affects the client’s health comfortable
- Considers mind, body and spirit to be interdependent 2. Working Phase
factors - The nurse elicits the client’s comments about major
biographic data, reasons for seeking care, etc.
Physician Medical Assessment 3. Summary and Closing Phase
- The physician focuses primarily on the client’s - The nurse summarizes information obtained during the
physiologic status. working phase and validates problems and goals with
- Less focus may be placed on psychological, the client; also identifies and discusses possible plans to
sociocultural or spiritual well being resolve the problem with the client

The Nursing Process Communication During the Interview

- A systematic guide to client-centered care with 5 > Two Types of Communication
sequential steps. 1. Verbal Communication
= Open-ended Questions
Steps in the Nursing Process = Close-ended Questions - Typically begins with words
1. Assessment ( and data collection) “when” or “did”; clients respond with 1 or 2 words
- The most critical phase in the nursing process = Well-placed Phrases - Encourage client verbalization
> Subjective Data - patient’s verbal information = Inferring - involve reading between the lines
> Objective Data - patient’s vital signs = Providing Information - provide the client with
information as questions and concerns arise
Types of Health Assessment = Laundry List - Providing client with list of words to
1. Initial Comprehensive Assessment choose from in describing symptoms, conditions or
- It is done within specified time after client admission feelings
to the hospital (e.g. Admission Assessment) = Rephrasing - Helps to clarify information the client
2. Ongoing or Partial Assessment stated
- Takes place after the initial assessment to evaluate any
changes in the client’s functional health (e.g. periodic 2. Nonverbal Communication
output patient clinic visits) = Appearance
3. Focused or Problem-oriented Assessment = Demeanor
- Collects data about a problem that has already been = Facial Expression
identified (e.g. Hourly Fluid Intake Assessment) = Attitude, Silence, Listening
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Special Consideration During Interview - Primary and secondary languages spoken, written, and
1. Gerontologic Variations in communication read.
- When interviewing an elderly client, you must first II. Reasons for Seeking Health Care
assess hearing acuity. - Client states one (possibly two) symptoms or signs and
2. Cultural Variations in Communication their duration. E.g. “chest pain for 2 hours, etc.; not a
- You may have to interview a client who does not speak diagnostic statement
your language. . Possibly the best interpreter would be a
culture expert (or culture broker). III. History of Present Health Concern
3. Emotional Variations in Communication - For the well person, “I feel healthy right now.” For the
- Clients’ emotions vary for a number of reasons. ill person, this section is a chronologic record of the
reason for seeking care
Types of data
1. Subjective Data (symptoms or covert data) Eight Critical Characteristics
2. Objective Data (signs or overt data) 1. Location - superficial or deep?
2. Character or Quality - terms such as burning, sharp,
Step 1. Collection of Data dull, aching, etc.
Data Collection 3. Quantity or Severity - quantify the sign or symptom
1. Observing - gather data by using senses such as “profuse menstrual flow soaking five pads per
2. Interviewing -planned communication with a purpose hour.
3. Examining - performance of physical examination 4. Timing (Onset, Duration, Frequency)
5. Setting - where & what
Steps of Health Assessment 6. Aggravating or Relieving Factors - what makes the
A. Collection of Subjective Data through: pain worse?
= Interview 7. Associated Factors
= Complete Health History - client is the primary source 8. Patient’s Perception - info from patient
and all others are secondary sources
IV. Personal Health History
> I. Biographical Data - Problems at birth
- Name - Childhood Illnesses
- Address - Immunizations to date
- Phone - Serious of Chronic Illness(physical, emotional, mental)
- Gender - Surgeries
- Provider of history (patient or other) - Obstetric Hx
- Birth date - Accidents
- Place of birth - Current medication
- Race or ethnic background - Allergies
- Educational Level
- Occupation V. Family Health History
- Significant others or support persons Genogram - helps to organize and illustrate the client’s
- Date and place of birth family history
- Nationality or ethnicity Key Symbols:
- Marital status = female relatives - indicated by a circle
- Religious or spiritual practices, and = male relatives - indicated by a square.
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= Relatives with no health problems – A/W (alive and Step 2. Validation of Data
well) - the process of confirming or verifying that the
= deceased relative - is noted by marking an X in the subjective and objective data you have collected are
circle or square (list the age at death and the cause of reliable and accurate
death)
= horizontal dotted line - indicate the client’s spouse Step 3. Organization of Data
= vertical dotted line - indicate adoption. - The nurse uses a written or computerized format that
organizes the assessment data systematically

VI. ROS for Current Health Problems Step 4. Documentation of Data

- The order of the examination of body systems is - Data are recorded in a factual manner and not
roughly head to toe. interpreted by the nurse

VII. Lifestyle and Health Practices Profile 2. Nursing Diagnosis (Analysis of Assessment Data) -
- clients describe how they are managing their lives, data analysis
their awareness of healthy versus toxic living patterns, 3. Planning - charting the best course to address the
etc. patient’s diagnosis
4. Implementation - the interventions should clearly
VIII. Developmental Level relate to the nursing diagnosis
1. Infant - trust vs mistrust; drive and hope 5. Evaluation - continuing process to determine if the
2. Toddler - autonomy vs shame and doubt; self-control goals have been attained
and will power
3. Preschooler - initiative vs guilt; direction and purpose
4. Schooler - industry vs inferiority; method and
competence
5. Adolescent - identity vs role confusion; deviation and
fidelity
6. Young Adult - intimacy vs isolation; affiliation and love
7. Middlescent - generativity vs stagnation; production
and care
8. Order Adult - ego-integrity vs despair; renunciation
and wisdom

B. Collection of Objective Data through:

- Physical Examination
- Diagnostic Test and Procedures
- Other sources e.g. client’s chart

Assessment Techniques
1. Inspection - close and careful visualization
2. Palpation - assessment using touch
3. Percussion - method of tapping body parts with hands
4. Auscultation - listening to sounds produced by body