H EALTH A SSESSMENT

INTRODUCTION TO HEALTH ASSESSMENT

CONCEPTS

PREPARED BY:
Mrs. SHAHZAD
 O BJECTIVES

B y the e n d of the unit, learners will b e able

to:
Discuss the need for health assessment in
general nursing practice.
Explain the concepts of health assessment, data
collection, and diagnosis.
Identify types of health assessments.
Document health assessment data using a
problem oriented approach.
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 N E E D OF HEALTH SSESSMENT IN
N URSING
Accurate physical assessment requires an organized and
systematic approach using the techniques of inspection,
palpation, percussion, and auscultation.

It also requires a trusting relationship and rapport between

the nurse and the patient to decrease the stress the patient
may have from being physically exposed and vulnerable.

The patient will be much more relaxed and cooperative if you

explain what will be done and the reason for doing it.

While the findings of a nursing assessment do sometimes

contribute to the identification of a medical diagnosis, the
unique focus of a nursing assessment is on the patient's 3
responses to actual or potential problems.
N URSING A SSESSMENT

Is a major component of nursing care.

Is a process which includes both physical and
psychological aspect to evaluate client’s condition.
Enables the nurse to m a k e a judgment about the
client’s health status , ability to manage his/her health
care and need for nursing.

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BASIC CONCEPTS

Health: (W HO)a state of complete physical, mental &

social Wellbeing, not merely the absence of disease.
W ellness: Level of wellbeing, a person perceives of
being healthy.
Disease: Alteration of structure and function of body.
Disease or discomfort.
Illness: A response a person has to an illness.

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C ONT …

The new definition, considers health as a dynamic state

of well being with different levels of functional abilities
at different point in time. So a diabetic patient no doubt
has a disease, but there are times when the client feels
well and can be called healthy.
Illness is a response to a disease and sickness is the
individual perception of its illness. Thus it is possible
that a person has a disease DM, has hypoglycemia
sometimes, but still feels that he is normal so thus does
not feel sick.

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PHASES OF THE NURSING PROCESS
It is systematic, deliberate, problem solving, decision making
process that nurses use to achieve a certain result.
It consists of A.D.P.I.E steps.

Diagnosis

Assessment Planning

Implement 7
Evaluation
ation
C ONTI ....
Phase Title D e s cr i pt i o n
I Assessm ent Collecting subjective a n d objective d a t a
II D i a gn o s i s A n a l y zi n g subjective a n d objective dat a to
m a ke a professional n u r s i n g ju d gm e n t
(nursing diagnosis, collaborative pr o b l e m ,
or referral.
III Planning D e t e r m i n i n g o u t co m e criteria a n d
de ve l o pi n g a pl a n
IV I m pl e m e nt a t i C a r r y ing out the plan
on
V E va l ua t i o n A sse ssi n g w h e t h e r o u t co m e criteria h a ve
b e e n m e t a n d revising t h e pl a n a s n e ce s s a r y

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C OMPONENTS OF H EALTH A SSESSMENT

Health
Assessm ent

Health History Physical Examination

History of present illness Inspection

Past /present Medical history Palpation
Family History, social Hx Percussion
Auscultation 9
FACTS ABOUT PHYSICAL ASSESSMENT:

a. Physical assessment is an organized systemic process of

collecting objective data based upon a health history and head-
to-toe or general systems examination. A physical assessment
should be adjusted to the patient, based on his needs. It can be
a complete physical assessment, an assessment of a body
system, or an assessment of a body part.

b. The physical assessment is the first step in the nursing

process. It provides the foundation for he nursing care plan in
which your observations play an integral part in the
assessment, intervention, and evaluation phases.

c. The chances of overlooking important data are greatly

reduced because the physical assessment is performed in an 10
organized, systematic manner, instead of a random manner.
 PURPOSES OF A PHYSICAL ASSESSMENT :

A. A comprehensive patient assessment yields both

subjective and objective findings. Subjective findings are
obtained from the health history and body systems
review. Objective findings are collected from the physical
examination.

(1) Subjective data: A re apparent only to the person

affected and can be described or verified only by that
person. Pain, itching, and worrying are examples of
subjective data.

(2) Objective data: A re detectable by an observer or can

be tested by using an accepted standard.
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A blood pressure reading, discoloration of the skin, and seeing
the patient in the act of crying are examples of objective data.
C ONTI … .
(3) Objective data are sometimes called signs, and
subjective data are sometimes called sym ptom s.
(4) Data means more than signs or symptoms; it also
includes demographics, or patient information that is
not related to a disease process.

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 C ONTI … .
B. T h e pu r pos e s for a physical assessm ent are:
(1) To obtain baseline physical and mental data on the
patient.
(2) To supplement, confirm, or question data obtained
in the nursing history.
(3) To obtain data that will help the nurse establish
nursing diagnoses and plan patient care.
(4) To evaluate the appropriateness of the nursing
interventions in resolving the patient's identified
pathophysiology problems
(5) To evaluate the physiological outcome of care.

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I MPORTANCE OF P HYSICAL A SSESSMENT :
1. To early detect and treat diseases and disorders.
2. To identify actual and potential health problems.
3. To establish a data based from which the subsequent
phases of the nursing evolve.
4. To assess the client’s impact of activity and exercise on
the client’s overall level of health.
5. To assess the client’s routine exercise pattern and
observe how the client’s body system response to
activity and exercise.
6. To establish the client-nurse relationship
7. To obtain information about the client’s health
including, physiologic, psychologic, sociocultural,
cognitive, developmental and spiritual aspects.
8. To identify the client’s strength and weaknesses. 14
 COMPARING SUBJECTIVE AND OBJECTIVE DATA
Su bje ct i ve Objective
Description Data elicited and verified Data directly or indirectly observed
by the client through measurement
Sources •Client Observations and physical
•Family and significant assessment findings of the nurse or
others other health care professionals.
•Client record Documentation of assessments made
•Other health care in client record.
professionals Observations made by the client's
family or significant others.
Methods used •Client interview Observation and physical
to obtain data examination
Skills needed Interview and therapeutic Inspection
to obtain data communication skills Palpation
Caring ability and Percussion
empathy Auscultation
Listening skills
Examples. "I have a headache." Respirations 16 per minute 15
"It frightens me." BP 180/100, apical pulse 80 and
"I am not hungry." irregular
l l f l
T YPES OF A SSESSMENT

Ty pe s of
Assessm ent

Initial Focus or
On going
Comprehe Problem Emergency
or Partial
nsive Oriented

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I NITIAL C OMPREHENSIVE A SSESSMENT
Also called an adm ission assessm ent, it is performed
when client enter health care system.

Involves collection of subjective data about the client's

perception of health of all body parts or systems, past
health history, family history, and lifestyle and health
practices (which includes information related to the client's
overall function) as well as objective data gathered during a
step-by-step physical examination.

The purposes are to evaluates client’s health status, to

identify functional health pattern that are problematic, &
to provide in an- depth, comprehensive data base which is
critical for evaluating changes in the client’s health status
in subsequent assessment. 17
O NGOING OR P ARTIAL A SSESSMENT
Consists of data collection that occurs after the
comprehensive database is established. This consists of a
mini-overview of the client's body systems and holistic health
patterns as a follow-up on his health status.
Any problems that were initially detected in the client's body
system or holistic health patterns are reassessed in less
depth to determine any major changes (deterioration or
improvement) from the baseline data.
This type of assessment is usually performed whenever the
nurse or another health care professional has an encounter
with the client. This type of assessment may be performed in
the hospital, community, or home setting.
For example, a client admitted to the hospital with lung cancer requires frequent
assessment of lung sounds. A total assessment of skin would be performed less
frequently, with the nurse focusing on the color and temperature of the extremities
to determine level of oxygenation.
A SSESSMENT
It is performed when a comprehensive database exists for a
client and he/she comes to the health care agency with a specific
health concern.

Consists of a thorough assessment of a particular client problem

and does not cover areas not related to the problem. For
example, if your client, John P.. tells you that he has ear pain,
you would ask him questions about the pain, possible hearing
loss, dizziness, ringing in his ears, and personal ear care. Sexual
functioning & bowel habits would be unnecessary and
inappropriate.

The physical examination should focus on his ears, nose, mouth,

and throat. At this time, it would not be appropriate to repeat all
system examinations such as the heart and neck vessel or 19
abdominal assessment.
E MERGENCY A SSESSMENT

An emergency assessment is a very rapid assessment

performed in life-threatening situations. In such
situations (choking, cardiac arrest, drowning), an
immediate diagnosis is needed to provide prompt
treatment.

An example of an emergency assessment is the

evaluation of the client's airway, breathing, and
circulation (known as the ABCs) when cardiac arrest is
suspected.

The major and only concern during this type of

assessment is to determine the status of the client's life- 20
sustaining physical functions.
P ROBLEM O RIENTED R ECORDING (POR)
Type of format for documentation where a data base
leads to a problem list and plan for some
interventions i.e. diagnostic, therapeutic,
educational.
S Subjective
O Objective
A Assumption / Diagnosis
P Planning
I Intervention
E Evaluation
R Revision

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D OCUMENTATION OF PE FINDINGS
Specific – avoid vague terms
Concise – use short simple words
Complete entry with date & sign
Describe observation clearly
Use standard abbreviations only
Record exact size, position of lesions
Use illustration
Use black pen

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R EFERENCES B OOKS

Bickley, L. S., Szilagyi, P. G., & Bates, B. (2007).

Bates' guide to physical examination and history
taking (11 th Edi). Philadelphia: Lippincott Williams &
Wilkins.

Weber, Kelley's. (2007). Health Assessment in Nursing,

3rd Ed: North American Edition. Lippincott Williams
& Wilkins.

Jarvis, Carolyn. (2011). Physical Examination and

Health Assessment - Text + Mosby's Nursing Video
Skills: Physical Examination & Health Assessment 23
Package. W B Saunders Co.