Apr-24 1

Objectives
At end of this chapter students will be able to:

 Define Nursing Assessment

 Explain the principles of health assessment

 List types of Health Assessment in Nursing

 Discuss approaches of health assessment in nursing

 Explain the components of complete health assessment

Apr-24 2
 Introduction…

Definitions of health

• is a state of complete physical, mental, and social

well-being and is not merely the absence of disease or
infirmity (WHO)

• The American Holistic Nurses’ Association (1994)

describes health as a maintenance of harmony and
balance among body, mind, and spirit.

Apr-24 3
 Introduction …
Definition of Nursing
 The act of utilizing the environment of the patient to assist
him in his recovery (F. N)

 The protection, promotion alleviation of suffering and

optimization of health and abilities, prevention of illness and
injury through the diagnosis and treatment of human responses
and advocacy (ANA, 2010)

 It includes the promotion of health, the prevention of illness,

and the care of ill, disabled and dying people.
Apr-24 4
 What is nursing health assessment?

Apr-24 5
 Nursing health assessment
Definition:-
 is a systematic and interactive process by which nurses
use critical thinking to collect, validate, analyze and
synthesize data in order to make judgment about the
health status of pt.
 Is the collection of data about an individual’s health state.
Types od data
Objective data (observed by the nurse)
Subjective data (stated by the client)
Apr-24 6
 Nursing health assessment…
Sources of data
1.primary source
 client is the major provider of information about self.
 The information obtained from the client is relatively
accurate and very important
2. secondary sources
other than the client include family members, other
health care providers, and medical records

Apr-24
. 7
 Definition, NHA..
 HA: is the evaluation of the health status by performing a
physical exam after taking health hx.

 It is an essential nursing function which provides foundation

for quality nursing care and intervention.

 It also helps to identify client’s needs, clinical problems or

nursing diagnoses and to evaluate responses of the person to
health problems and intervention

 The more precise assessment, the better results would be

obtained and the quality of patient care would be improved
Apr-24. 8
 Purposes of Nursing assessment

To establish a database concerning a client’s physical,

psychosocial, and emotional health in order to identify
actual and/or potential health problems

To determines the client’s functional abilities and the

absence or presence of dysfunction.

To assess client’s normal routine for activities of daily living

and lifestyle patterns.

To obtain general information of patient health status

Apr-24 9
 Responsibilities of the nurse….NHA
 The nurse has the responsibility to carry out health
assessment on every person under his/her care
 The nurse should regularly perform focused assessments in
response to client needs.
 The nurse needs to obtain client’s consent prior to health
assessment.
 The nurse should demonstrate a caring attitude, respect and
concern for each client when doing a health assessment

Apr-24 10
 Responsibilities …
 The nurse has to keep confidentiality.
 Nurse has to draw inferences from data collected in order to
make appropriate & sound clinical judgment
 The nurse has to acquire specialized skills and competence
in collecting accurate and relevant information.
 The nurse should document the results of health assessment,
analyze the data collected, evaluate the client’s response to
interventions, and provide feedback to the client

Apr-24 11
 Principles of health assessment
 In HA, The nurse needs to consider the ff:
 An accurate and timely health assessment provides foundation for
nursing care & intervention
 Go for comprehensive assessment.
 HA should be practiced in all settings whenever there is nurse-client
interaction.
 The HA process should include data collection, documentation and
evaluation of the client’s health status.
 Information gathered should be communicated to other HCP.
 Keep the confidentiality
Apr-24 12
 1. Complete health assessment

2. Focused assessment

3. Follow up assessment

4. Time lapsed assessment

5. Emergency assessment

Apr-24 13
1. Complete or Total Health Data Base

 This includes a complete health history and a full PE

i.e. covers all body system, or functional patterns

 It describes the current and past health state and form a

baseline

 Is collected in any setting for well or ill person

Apr-24 14
 For the ill person, the data includes a description of the
person’s health problems, perception of illness, and
response to problems.

 For a well person, it describes the person’s health state

perception of health, health maintenance behaviors,
individual coping patterns, current developmental tasks
and any risk factors.

 Based on the data base the nursing diagnoses could

farther be developed

Apr-24 15
2. Episodic or problem centered Data Base

 Collects a “mini” data base, smaller in scope than the

completed database.

 It concerns mainly one problem or one system.

For ex: 2 days following surgery, a patient suddenly develops a

congested cough, shortness of breath, and fatigue. The history
and examination focuses primarily on the respiratory and CVS.

Apr-24 16
 3. Follow up Data Base

 The status of any identified problems should be evaluated at

regular and appropriate intervals.

 What change has occurred? is the problem getting better or

worse?

4. Time lapsed assessment

 It is the final assessment done after a period of time

 Aim:- Comparing the patient’s current status to baseline

obtained previously after an extended period of time
Apr-24 17
 4. Emergency assessment
 Assessment done on the life treating situation

 This calls for a rapid collection of the data base with life-
saving measures.
 For ex, a person with poisoning the first history question
could be “what did you take?” The pt. is questioned
simultaneously while the ABC are being maintained.

 History should not delay treatment??

Apr-24 18
 Medical approach

Functional health patterns/Gordons approach

Apr-24 19
 Also called body systems model
Traditional approach to health care in which the focus is
on treatment and cure of disease
is frequently used by physicians to investigate presence
or absence of disease
This method organizes data according to the organ and
tissue function in various body systems (e.g.
cardiovascular, respiratory, gastrointestinal)
Apr-24 20
 Medical Approach …
 Although nurses often use this, does not facilitate the
formulation of NDX

 In addition, psychosocial aspects of the client’s status are often

neglected.

 The purpose of a NHA is to collect holistic subjective and

objective data to determine a client’s overall level of
functioning in order to make a professional clinical judgment.

• In contrast, the physician performing a medical assessment

focuses primarily on the client’s physiologic status
Apr-24 21
 Structures of MA, medical….
Components of history taking Components of P/E
 General appearance
 Socio-Demographic Data  Vital signs
 Source of referral  H.E.E.N.T
 Source of the history  Lymph glandular system
 Chief complaints  Respiratory system
 History of present illness  Cardiovascular system
 Past illness  Gastro intestinal system
 Personal- Social history  Genitourinary system
 Family history  Integumentary system
 Systemic review  Musculoskeletal system
Apr-24  Central nervous system 22
 The Functional Health Patterns (FHP) assessment
framework was scientifically developed by Marjory
Gordon’s to standardize the structure for NHA
 Data are clustered based on its type under each 11
functional health patterns
 The sequence of 11 patterns provides an efficient and
effective flow for the nursing assessment

 It guides the history-taking and PE by nurses,

Apr-24 23
 Functional approach…

 Name of the client  Source of referral and

 Date and time Source of information

 Age and birth date, Sex  Date of admission

 Address, Religion, Ethnicity  Medical diagnosis

 MRN, Bed number,  Past hospitalization

 Ward/ Unit  Assessment of Gordon’s

11 FHP.
Apr-24 24
 Functional approach…

 The 11 Functional Health Patterns

1. Health perception-health management pattern

2. Nutritional-metabolic pattern

3. Elimination pattern

4. Activity- exercise pattern

5. Sleep- rest pattern

6. Cognitive -sensory -perceptual pattern

Apr-24 25
 Functional health patterns…

7. Self-perception-self-concept pattern
8. Role-relationship pattern

9. Coping-stress tolerance pattern

10. Sexuality- reproduction pattern

11. Value- belief pattern

Apr-24 26
 Functional approach…
1. Health perceptions-health management pattern
A. Subjective data
 Determine how the client perceives and manages his
or her health.
– His/her definition of health
– His/her perception of current health problem and
its cause
– His/her perception of treatments given for current
health problem
 Health maintaining activities (at home)
Apr-24 27
 Health perceptions pattern…

 Reason for seeking health care

 Home made treatment of the current illness if any, (include

alternative/complementary therapies)

 Past medical history

 Current medication history: type, dose, route, frequency,

duration

 Compliance with treatment

 Substance use-type, unit/ measurement ,frequency, effect

Apr-24 28
 Health perceptions pattern …

 Life style risk factors

 Familial risk factors: (indicate relationship): such as DM;

CVD/hypertension; stroke; kidney disease; mental illness;
communicable diseases; cancers(type) other

 Health maintenance practice

B. Objective data: General health survey such as appearance,

grooming, Vital sign

Apr-24 29
 Functional health patterns…

2. Nutritional-metabolic pattern

 Daily consumption of food and fluids

 Favorite foods

 Use of dietary supplements

 Condition of the integument ( skin, hair and nail)

 Skin lesions and ability to heal

 Weight, height, temperature

Apr-24 30
 Functional health patterns…
Subjective data

 Eating pattern: individual, common

 Eating time

 Food and fluid preference

 Types of daily food and fluid intake

Typical dietary intake at home/prescribed Home

Diet (date/ % eaten): Breakfast, Lunch,
Snacks, and Dinner
Apr-24 31
 Functional health patterns…
Types of diet in the hospital (date/ % eaten):
Breakfast, Lunch, Snacks, and Dinner
 Any supplementary diet
 Food intolerance
 Problems eating/digesting foods: appetite, difficulty
of chewing, dysphagia, abdominal pain, antacid use,
other
 Fever
Apr-24 32
 Functional health patterns…

 Appetite (normal, decreased, increased)

 Taste Sensation (normal or impaired)

 Sore tongue

 Hot and Cold intolerance

 Ideal body weight

Apr-24 33
 Functional health patterns…

Objective

 Height; Weight ; Body mass index (BMI)

 Recent increase (amt/time) or decrease(amt/time)- if

obese or undernourished(explain)

 Mouth examination: Oral mucosa(intact, pink, moist,

dry, lesion, teeth no other); Dentition condition;
Denture (upper or lower);Tongue; Gums
Apr-24 34
 Functional health patterns…

 Skin: color, lesions, texture, moisture, dry, turgor

 Hair: texture, scalp lesion,

 Nails: shape, color, condition, texture, tenderness

 Drains: Site(s); Color

 Edema if present: site; grade (0-4+)

 Abdominal examination

Apr-24 35
 Functional health patterns…

 Home Blood Glucose Monitoring

 Tube Feeding (TF)

 Total Parenteral Nutrition (TPN); drop rate

 Appearance of IV Site

 Intake per (24 hrs): PO; tube feeding; IV

 Output per (24hrs): urine; stool; emesis/NGT; drains

Apr-24 36
 Functional health patterns…

3. Elimination pattern
 Patterns of bowel and urinary excretion
 Perceived regularity or irregularity of elimination
 Use of laxatives or routines
 Changes in time, modes, quality or quantity of
excretions
 Use of devices for control

Apr-24 37
 Functional health patterns…
Subjective data

Bowel habit

 Stool Frequency: specify

 Stool: color; consistency; amount per day

 Pain specify

 Duration

 Incontinence

Apr-24
Use of Laxatives: specify 38
 Functional health patterns…
 Enemas: specify
 Use of Suppositories
 Ostomy: Ileistomy; Colostomy (type)
Bladder habit
 Bladder Function: Incontinence (duration), Frequency
(specify); Retention (duration); urgency; nocturia;
dribbling, pain (specific); Foley catheter; suprapubic
catheter; urostomy; voiding schedule

Apr-24 39
 Functional health patterns…
 Bladder distention

 Urine: color (clear, yellow, cloudy, sediment);

amount per day

 Dialysis: hemo, peritoneal

Objective Data

 Abdomen examination

 Rectal assessment: Rashes, Lesions, Tenderness,

bleeding
Apr-24 40
 Functional health patterns…

4. Activity-exercise pattern

 Patterns of personally relevant exercise, activity,

leisure, and recreation

 ADLs that require energy expenditure

 Factors that interfere with the desired pattern

(e.g., illness or injury)

Apr-24 41
 Functional health patterns…

Subjective data

 Daily activities: eating/feeding, bathing,

dressing, toileting, bed mobility, cooking,
ambulating, grooming, shopping, yard working

Apr-24 42
 Functional health patterns…
 Activities of Daily Living/Self Care Ability:
0= Independent/ Requires no assistance;

1=Requires use of an Assistive Device;

2= Requires One Person Assistance;

3= Requires One Person Assistance and an Assistive

Device;

4= Requires Two Person Assistance; Dependent

Apr-24 43
 Functional health patterns…

 Response to Activities of Daily Living: if any

fatigue/dyspnea

 History of: Weakness, Dyspnea, Palpitations,

Fatigue, SOB, Dizziness, Blurred vision, Epistaxis,
Chest pain (location) Joint pain (location),
Coughing, Smoking, Myalgia

 Current use of tobacco and history of tobacco use

(duration)
Apr-24 44
 Functional health patterns…

 Effect of illness on activities

 History of falls

Objective Data

 Vital sign: RR,PR,BP and To

 Musculoskeletal assessment (Gait, Posture,

Extremity swelling, Symmetry, ROM, Crepitus,
Tone, Strength)

Apr-24 45
 Functional health patterns…

 Upper extremity: strength (equal, unequal, strong,

moderate, weak); ROM: full/limited
 Lower extremity: strength (equal, unequal, strong,
moderate, weak); ROM: full/limited
 Gait: steady, unsteady
 Assistive Devices Used: cane, crunch, walker,
wheelchair
 Whether Participate in physical therapy or not
Apr-24 46
 Functional health patterns…
Respiratory assessment: inspection, palpation,
percussion and auscultation
 Supplemental Oxygen: method of delivery,
concentration, percent
 Chest tube drainage and Suctioning
 Encentive spirometer
Cardiovascular assessment:
 inspection, palpation, percussion and auscultation
Apr-24 47
 Functional health patterns…

 Apical rhythm: regular/irregular

 Capillary refill: < 3mins/delayed

 Palpable Strength of Peripheral Pulses: 0=None;

1=Weak; 2=Moderate; 3=Strong; D=Doppler

 Pulse: Brachial; Radial; Popliteal; Femoral;

Dorsalis Pedis; Posterior Tibial

Apr-24 48
 Functional health patterns…
5. Sleep-rest pattern
 Patterns of sleep and rest/relaxation in a 24-h
period
 Perceptions of quality and quantity of sleep and
rest
 Use of sleep aids and routines
Subjective data- History of:
 Sleep time (hrs/night) and Relaxation time
Apr-24 49
 Functional health patterns…

 Problems of readiness for work after awaking from

sleep

 Early awakening

 Difficulty falling Sleep onset problems, insomnia,

sleep apnea

 Use sleep aid specify

 Dreams/nightmares
Apr-24 50
 Functional health patterns…

Objective data

 Appearance

 Yawning and frequency of yawning; Irritability

 Dark circles around the eyes

 Puffiness around the eye

Apr-24 51
 Functional health patterns…

6. Cognitive- sensory- perceptual pattern

 Language, judgment, memory

 Adequacy of vision, hearing, taste, touch, smell

 Pain perception and management.

Apr-24 52
 Functional health patterns…

I. Cognitive
Subjective data
 Memory status
 Thought
 Language
 Ability of: Speaking, Reading, Writing
 Educational status; Academic standing/rank
Apr-24 53
 Functional health patterns…

Objective data
 Level of Consciousness: Glasgow Coma Scale
 Level of Consciousness: alert, drowsy , lethargy,
semi coma, deep comma
 Mental Status: Orientation to time, person, place
 Mood: Happy/pleasant, Euphoria,
Depression/Sadness, Irritable, Labile, Flat

Apr-24 54
 Glasgow coma scale

Apr-24 55
 Functional health patterns…

 Memory and Language: Aphasia, Short-term

memory, Long-term memory

 Judgment

 Thought process: answers question appropriately,

answer unreliably/poor historian, confused,

 Ability to compressed directions (yes/no),

Apr-24 56
 Functional health patterns…

II. Sensory Function

Subjective data
 Visual problems; Aids of vision
 Hearing problems; Aids for hearing
 Taste
 Smell
 Sensation

Apr-24 57
 Functional health patterns…

Objective data
 Visual acuity: OD,OS,OU
 Visual field; EOMs
 PERRLA
 Fundoscopic exam: Red reflex, Optic disc
 Macula
 Arterioles/venules
 Hearing: Weber, Rinne test
Apr-24 58
 Functional health patterns…

 External Canal; Tympanic membrane

 Sensations: Superficial/ Deep pressure

 Two point discrimination

 Cranial nerves:

I. Olfactory, II. Optic, V. Trigeminal, III.

Oculomotor, IV: Trochlear, VI: Abducens, VII.
Facial, VIII: Acoustic
Apr-24 59
 Functional health patterns…

III. Pain
Subjective Data
 Any pain/discomfort: Duration
 PQRS/COLDSPA of pain
Objective data
 Acute pain: Diaphoresis; Body position;
Grimacing, Guarding, Refusal to move body part,
Rubbing body part
Apr-24 60
 Functional health patterns…

 Restraints: Indication for use; Restraint Type

 Chronic pain: Flat facial expression , Dull eye

appearance; Fatigue, Crying, Moaning, yelling

 Aggravating Factors:

 Alleviating Factors:

Apr-24 61
 Functional health patterns…
7. Self-perception/self-concept pattern
 Attitudes about self
 Perceived abilities, worth, self-image, emotions
 Body posture and movement, eye contact, voice and
speech patterns
Subjective data
 Self-description
 Feeling differently because of illness
 Things frequently make you angry, Annoyed, Fearful,
Anxious, Depressed ,Ever feel you lose hope
Apr-24 62
 Functional health patterns…
Objective data

 Eye contact; Posture; Expression

 Voice and speech pattern

 Indicators of culture: cultural cues evidenced in

communication style, family patterns, space
orientation, time orientation and nutritional patterns

 Emotional/Behavioral State: calm, happy, sad,

agitated, combative, angry, anxious
Apr-24 63
 Functional health patterns…

8. Role- relationship pattern

 Perception of major roles, relationships, and

responsibilities in current life situation

 Satisfaction with or disturbances in roles and

relationships

Subjective data

 Retired or Current Occupation

 Marital status
Apr-24 64
 Functional health patterns…
 Primary role at work

 Primary role at home

 Living arrangement

 Family structure

 Dependants

 Source of help

 Income

 Belong to social group/close friends

Apr-24 65
 Functional health patterns…

 Problems affecting health at work or home

 History conflicts with other’s
Objective data
 Interaction with family members and significant
others
 Socialization: Visitor’s flow, receives phone calls,
cards
 Verbalized Fear of Violence
Apr-24 66
 Functional health patterns…

9. Coping-stress tolerance pattern

 Capacity to resist challenges to self-integrity

 Methods of handling stress

 Support systems

 Perceived ability to control and manage

situations

Apr-24 67
 Functional health patterns…

Subjective data
 Any big changes in your life in last year or two
 Crisis
 Who is most helpful in talking things over
 Stressors
 Resent stress
 Tense or relaxed most of the time

Apr-24 68
 Functional health patterns…

 When tense, what helps? Use any medications,

drugs, alcohol to relax/cope?
 When (if) there are big problems in your life, how do
you handle them
Objective data
 Behaviors/statements indicating adjustment to
stressors/illness
 Behaviors/statements indicating impaired
adjustment to stressors/illness
Apr-24 69
 Functional health patterns…

10. Sexuality-reproductive pattern

 Satisfaction with sexuality or sexual relationships

 Reproductive pattern

 Female menstrual and premenopausal history

Apr-24 70
 Functional health patterns…

Subjective Data

Female

 Menstruation: Date began, Last cycle, Length,

Problems

 Gravida, Para, Abortions, Still Birth

 Current pregnancy, Infertility

 Self breast examination, When

Apr-24 71
 Functional health patterns…

Male-Female

 Sexarche

 Contraception used

 Undesirable side effects

 Problems with sexual activities

 Effect of illness on sexual activities

Apr-24 72
 Functional health patterns…

 STDs , Pain, Burning, Discomfort during

intercourse, Discharge

 Verbalized impact of illness, meds and treatment

on sexuality

 Annual/Monthly Screening Exams

Male

 Testicular self examination: when

Apr-24 73
 Functional health patterns…

Objective Data

 Breasts examination

 Male genitalia examination

 Female genitalia examination

Apr-24 74
 Functional health patterns…

11. Values-belief pattern

 Values, goals, or beliefs (including spirituality) that
guide choices or decisions
 Perceived conflicts in values, beliefs, or
expectations that are health related
Subjective data
 Values
 Goals
Apr-24 75
 Functional health patterns…

 Source of hope/strength
 Significant religious persons
 Religious practices
 Relationship with God
Objective data
 Presence of religious articles
 Religious activities
 Visits from clergy
Apr-24 76
Apr-24 77
 I. History Taking /health interview

 Health History/collecting subjective data

 Nursing health history – is the systematic collection of

data that is used for determining a client’s functional health
patterns status.

 Health history is a review of the client’s FHP prior to the

current contact with a health care agency

 Nursing theory such as one developed by Sister Callista Roy,

Wanda Horta, or Dorothea Orem, or Marjory Gordon’s Functional
Health Patterns.
Apr-24 78
 History taking…

While the medical history concentrates on symptoms

and the progression of disease, the nursing health
history focuses on the client’s FHP, responses to
changes in health status, and alterations in lifestyle.
The health history is also used in developing the plan of
care and formulating nursing interventions.

Apr-24 79
 History taking…
Purposes of History taking in Nursing

Develops understanding about the patient.

Enables to make clinical judgment

To establish a trusting relationship b/n the nurse and pt.

Guides on which body parts or systems to focus during

physical examination

Apr-24 80
 Subjective Data
 It consists of sensations or symptoms (e.g., pain, hunger),
feelings (e.g. Happiness, sadness), perceptions, desires,
preferences, beliefs, ideas, values, and personal information
that can be elicited and verified only by the client.

 Data about a patient's symptoms

 To elicit accurate subjective data, learn to use effective
interviewing skills with a variety of clients in different
settings.
Apr-24 81
 Subjective Data…
 Subjective data provide clues to possible physiologic,
psychological, and sociologic problems

 The information is obtained through interviewing.

Therefore, effective interviewing skills are vital for
accurate and thorough collection of subjective data.

 Source of primary data Data is collected via an interview

with the patient and / or significant other

Apr-24 82
 Interviewing
 The interview is personal dialogue b/n the patient and the
nurse that is conducted in order to obtain information
 The nursing interview is a communication process that has
two focuses:
1. Establishing rapport and a trusting relationship with the
client
2. Gathering information on the client’s developmental,
psychological, physiologic, socio-cultural, and spiritual
statuses
Apr-24 83
 Establishing a therapeutic relationship is building of
an effective nurse–patient relationship.
 Single most important factor for successful
interviewing is establishing rapport to gain client’s
trust

Apr-24 84
 Interview phases
 Nursing interview typically consists of three distinct phases/
sections: (1) introduction, (2) discussion/working, and (3)
summary & closing

Apr-24 85
 Communication During the Interview
The interview involves two types of communication
nonverbal and verbal
Verbal Communication
• Several types of questions & techniques to use
during interview are;
 Open-ended questions,
 closed-ended questions,
 laundry list,
 rephrasing,
 well-placed phrases,
 providing information.
Apr-24 86
 Verbal communication

 Open-ended questions : are used to elicit the client’s

feelings and perceptions.
 They typically begin with the words “how” or “what
 An example of this type of question is “How have you been
feeling ?”
 These types of questions are important because they require
more than a one word response from the client &, therefore,
encourage description.
Apr-24 87
 Verbal Communication….
Closed-ended Questions
 The questions typically begin with the words “when” or
“did.”
 An example of this type of question is “When did your
headache start?”
 Closed-ended questions are useful in keeping the
interview on course

Apr-24 88
 Verbal communication….
Laundry list
 Provide the client with a choice of words to choose
from in describing symptoms, conditions, or feelings
For example,
 “Is the pain severe, dull, sharp, mild, cutting, or
piercing?”
 “Does the pain occur once every year, day, month, or
hour?” Repeat choices as necessary.

Apr-24 89
 Verbal communication….
Rephrasing
• This technique helps you to clarify information the
client has stated; it also enables you and the client to
reflect on what was said.
• For example, your client, Mr. X., tells you that he has
been really tired and nauseated for 2 months and that he is
scared because he fears that he has some horrible disease.
You might rephrase the information by saying, “You are
thinking that you have a serious illness?”
Apr-24 90
 Verbal communication….
Well-placed phrases
 Client verbalization can be encouraged by well-placed
phrases from the nurse

 Listen closely to the client during his or her description

and use phrases such as “um-hum, ”yes,” or “I agree”
to encourage the client to continue.

Apr-24 91
 Verbal communication….
Providing Information
 Another important thing to consider throughout the
interview is to provide the client with information as
questions and concerns arise.

Apr-24 92
 Verbal communication….
Special considerations
 Avoid using biased or leading questions.
 Rushing through the interview:
 Avoid reading questions from the history form. :This deflects
attention from the client & results in an impersonal interview
process
 NB: Be aware of possible variations in the communication
(language , culture) styles of yourself & client i.e interpreter

Apr-24 93
 Nonverbal communication
 Nonverbal technique used during the interview
process
 Appearance
 Demeanor
 Facial expression
 Attitude
 Listening

Apr-24 94
 Non verbal….
 Appearance
 First take care to ensure that your appearance is professional.

 The client is expecting to see a health professional; therefore,

you should look the part.

Ex: Wear comfortable, neat clothes and a laboratory coat or a

uniform.

 Be sure your name tag, including credentials, is clearly

visible
Apr-24 95
 Non verbal….
 Demeanor
 Your demeanor should also be professional.
 When you enter a room to interview a client, display poise.
 Do not enter the room laughing loudly
 Do not be overwhelmingly friendly or “touchy
 It is best to maintain a professional distance.

 Facial Expression
 No matter what you think about a client or what kind of day
you are having, keep your expression neutral
 If your face shows anger or anxiety, the client will sense it and
may think it is directed toward him or her
Apr-24 96
 Non verbal….
Attitude
 All clients should be accepted, regardless of beliefs,
ethnicity, lifestyle, and health care practices

 Do not act superior to the client or appear shocked,

disgusted, or surprised at what you are told.

Apr-24 97
 Non verbal….
Listening
 Listening is the most important skill to learn and
develop fully in order to collect complete and valid data

Apr-24 98
 History taking …

General guide lines for effective History taking

 Greet the patient, call by name, and give undivided attention.

 Keep comfort and privacy, watch for indications of discomfort

such as poor positioning, evidence of pain, or anxiety

 Never be in a hurry even when you are in limited time.

 Design questions appropriately:- avoid leading questions,

 The nurse should be empathetic

 Consider the Cultural variations

Apr-24 99
 Cont’d

Components of complete nursing Health History

Biographic data.

Chief complaint

History of present illness.

past health History.

Family History of illness.

Life style and social data.

Review of systems.

Apr-24 100
 Components of complete Health….

1. Biographic data

 Name  Address
 Age  Occupation
 Sex  Religion
 Race  Marital status
 Birth place  Educational level

Apr-24 101
 Cont’d

N.B. Before considering the biographic data the following

data should also be included:-
A. date- The date of assessment should always important,
and in rapidly changing conditions the time should also
be added.
B. source of referral- if any & the purpose of it.
C. source of History- may include the patient himself, a
relative, a friend, a patients medical record, or a referral
letter.

Apr-24 102
 cont’d

2. Chief complaint ( “Reason For Hospitalization”.)

This is the starting point of the main part of the history.

It can be defined as one or more symptoms or other

concerns for which the patient is seeking care or advice i.e.
issue that brings the patient to seek help.

When possible it should be recorded in patients own words

using in quotation mark

Questions such as ‘what brings you to our clinic to day?” or

“why are you admitted to the hospital?

Apr-24 103
 Chief complaint…

 When the patient have more than one problems, they

should be written but prioritize under the complaint

Examples of chief complaints:

 Chest pain for 3 days.

 Swollen ankles for 2 weeks.

 Fever and headache for 24 hours.

Apr-24 104
 cont’d

3. History of present illness (HPI)

• A full, clear, chronological account of how each of the
symptoms developed and what events were related to them

• It is the amplification of the chief complaint.

• Patient’s response to their own symptoms and incapacities,

 It is usually useful to start the history of the present illness with

the phrase “the patient was perfectly or relatively well until….”

Apr-24 105
 HPI…
Includes eight critical characteristics:
1. Location
2. Quality or character
3. Quantity or severity
4. Timing (onset, duration, and frequency)
5. Setting in which it develop
6. Aggravating or relieving factors
7. Associated factors
8. Negative-positive statements

 NB: OLDCARTS (onset, location, duration, character, associated or

aggravating factors, relieving factors, timing, severity)
Apr-24 106
 HPI…

The principal symptoms should be described in

terms of:-
Location- pinpoint the body systems or organs
involved. A question you may ask is “where does it
hurt?’
Quality- usually a person will equate a symptom with
an analogy: by stating it is like some thing. E.g. ‘’ My
chest pain feels like a knife is being trust in my chest’’

Apr-24 107
 Cont’d

Quantity [ severity]- the clinician need to quantify the

symptom according to the level of intensity, how it
affects ADL, or extent of the symptoms.
Timing- [ onset, duration, and frequency] the time the
symptom first appeared, whether the symptom begins
suddenly or gradually, whether it stays the same in
intensity or changes with time, and frequency,

Apr-24 108
 cont’d

 The setting in which the symptoms occur. is the

description of where and what the person was doing
when the symptom occurred.
 Aggravating or relieving factors. Identifying what
worsens(aggravates) or relieves(alleviates) the
symptoms.
Example”- does the chest pain change with exercise,
emotional upset or rest

Apr-24 109
 Cont’d
 Associated manifestation:-

 Assess associated factors or symptoms.

 Some disorders produce symptoms in more than one

body parts.

Example:- a person with CHF have swollen ankles and

Abdomens and may experience shortness of breath.

 Negative- Positive statements:

 Also note significant negatives:- the absence of

certain symptoms that will aid in differential diagnosis.
Apr-24
110
 Complete history…

4. Past Health History

• Childhood illnesses: such as measles, rubella, mumps,
whooping cough…
• Medical (such as diabetes, hypertension, hepatitis,
asthma, HIV disease, information about admission
• Surgical (include dates, indications, and types of
operations)
• Accident / Injuries head injuries, burns, auto accident,
fracture
• Obstetric/gynecologic (relate obstetric history,
menstrual history, birth control, and sexual function);
Apr-24 111
 Complete history…

5. Family History of illness.

 Family health History is a past medical history of
relatives.
 The following disorders may be considered:-
 diabetes, Heart disease, high blood pressure,
 stroke, kidney disease, tuberculosis, cancer, arthritis,
 anemia, asthma, head ache, epilepsy, mental illness,
 alcoholism, drug addiction, obesity and others.

 Also ask about family allergies, deformities or

serious illness.
Apr-24 112
 Complete history…
6. Life style and social data ( Psychosocial history).

 to identify some contributory factors in illness and to evaluate

the patient’s source of support, reactions to illness, coping
mechanisms, strength and concerns.
 substance abuse (Tobacco, Alcohol, drugs and related substance )

 psychosocial history include:

 Home situation and significant others.
 “ who live at home with you?, who help you when you are
sick? Or need assistance?,
 Religious beliefs (perceptions of health, illness, and rx)
Apr-24 113
 complete history…
7. Review of systems
 is a series of questions about all body systems that
helps to reveal concerns as part of a comprehensive
health assessment
 Ask the patient about any symptoms related to each
body system
 data collected is subjective information
 Advantages of review of systems.
 Is a double check of the history of present illness.
 It guides the examiner to concentrate on specific
systems during the P/E when he/she is in a hurry.

Apr-24 114
 Review of system….

ROS: should be recorded as following

General- usual weight, recent weight change,
any clothes that fit tighter or loose than before,
weakness, fatigue, fever

Skin- A history of Rashes, lumps, sores, itching,

dryness, color change, change in hair or nail

Apr-24 115
 Cont’d
H.E.E.N.T. (Head, Eye, Ear, Nose, Mouth and Throat)

 Head- Head ache, head injury

 Eye- vision, last eye examination, pain, redness, excessive

tearing, double vision, blurred vision, spots, flashing lights,
glaucoma, cataracts

 Ear- Hearing, earaches, infection, discharge. if hearing is

decreased, use of hearing aid

 Nose and sinuses; frequent colds, nasal stiffness,

discharge, itching, fever, nose bleeding
Apr-24 116
 Cont’d
 Mouth and throat ;Condition of teeth and gums,
bleeding gums, dentures if any, how they fit, last dental
examination, sore tongue, dry mouth, frequent sore
throats, hoarseness
 Neck- lump, swollen glands’’ goiter” pain or stiffness in
the neck
 Breast- lump, pain or discomfort, nipple discharge,
self examination

Apr-24 117
 Cont’d
Respiratory- A history of cough, sputum,[ color,
consistency], hemoptysis, wheezing, TB, last chest
x-ray film etc..

Cardiac- A history of high blood pressure,

rheumatic fever, heart, murmurs, chest pain or
discomfort, palpitation, dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, edema, past
electro cardiogram or other heart test results
Apr-24 118
 Cont’d
 Gastro intestinal; A history of
 trouble swallowing, heart burn, appetite,
 nausea, vomiting, regurgitation, vomiting of blood,
 indigestion, frequency of bowel movements,
 color and size of stools, change in bowl habits,
 rectal bleeding or black tarry stools, hemorrhoids,
 constipation, diarrhea,Abdominal pain,
 food intolerance, excessive belching, Jaundice,
 liver or gall bladder trouble, hepatitis…..
Apr-24 119
 Cont’d
 Urinary- frequency of urination, polyuria, nocturia,
burning or pain on urination, heamaturia, urgency,
dribbling in continence, urinary tract infection, stone…

Genitalia

 Male- hernia, discharge from or sores on the penis,

testicular pain, or masses, history of sexual
performance, interest, function, satisfaction, and
problems [ dysfunction].

Apr-24 120
 Cont’d

Females- Age at menarche, regularity, frequency,

and duration of periods, amount of bleeding,
bleeding b/n periods or, last menstrual period,
dysmenorrheal, age at menopause, Discharge
,itching, sore, lumps, any STI

Apr-24 121
 Cont’d
 Musculo skeletal. Muscle or joint pain, stiffness, arthritis,
gout, back ache,if present describe location and
symptoms { ex. Swelling, redness, pain, tenderness,
stiffness, weakness, limitation of motion or activity].

 Neurological. Fainting, seizure, weakness, paralysis,

numbness or loss of sensation, tingling or” pins and
needles” tremor or other involuntary movements.

Apr-24 122
 Cont’d
 Hematologic. Anemia, easy bruising, or bleeding,
past transfusion and any reaction to them

 Endocrine: heat or cold intolerance, excessive

sweating, diabetes, excessive thirst or hunger,
polyuria.

 Psychiatric. Nervousness, tension, emotional

upset, mood including depression, memory,
orientation.

Apr-24 123
 Physical examination

Apr-24 124
 Physical Examination (Objective Data )
 are observable and measurable data that are obtained through
physical examination and diagnostic tests
Laboratory and health records.
 To become proficient with physical assessment skills, the nurse
must have basic knowledge in three areas
 Types and operation of equipment, Preparation of the setting,
oneself, and the client and Performance of the four assessment
techniques
Apr-24 125
 PA : Equipment and Supplies

Apr-24 126
 Equipment…

Apr-24 127
 Equipment..

Apr-24 128
 Equipment….

Apr-24 129
 Equipment….

Apr-24 130
 Equipment….

Apr-24 131
 PA : Preparing the patient for PA

 Emotional – explain exactly what will occur

 Physical – offer the bathroom and instruct the patient

on how to disrobe (undress) and don an exam gown,
Positioning and draping

 assume needed exam position and drape to provide

privacy and keep patient warm

Apr-24 132
 PE: Position

Apr-24 133
Apr-24 134
 PA: Techniques/ Skills

Apr-24 135
 Check it

Apr-24 136
 Inspection
• It is a concentrated watching or looking of patients
• Always comes first
• Compare right and left side of the body
• It requires good lightening, adequate exposure and
occasional use of certain instruments (othoscope,
ophtalmoscope and pen light) to enlarge your view
• Ex: lesion, cyanosis, scar, deformity …..

Apr-24 137
 Palpation
• The process of examining part of the body by careful
feeling with hands and finger tip.

• In palpation we use sense of touching to assess

temperature, moisture, organ location and size as well as
any swelling pulsation, rigidity, presence of lumps or
masses and presence of tenderness etc…

Apr-24 138
 Palpation …
 Palpation may be light, deep, or bimanual.

 Light palpation:- is the safest and least uncomfortable,

involving exerting gentle pressure with the finger tip of your
dominant hand, moving them in a circular motion and
depress the skin surface approximately 1-2cm

 To assess for tenderness, temperature, moisture,

pulsations, and masses

Apr-24 139
 Palpation …
 Deep palpation:- which is done after light palpation is used
to detect abdominal masses and the skin is depressed about
4-5 cm.
 To asses internal organs and masses for size, shape,
tenderness, symmetry, and mobility
 Bimanual palpation:- involves using both hands to trap a
structure between them.
 This technique can be used to evaluate the spleen, Kidney
and uterus.
Apr-24 140
 Palpation …
Techniques of palpation

• Should be slow and systematic

• Warm your hands

• Palpate tender areas last

• Start with light palpation to detect surface characteristics

and accustom the person to be touched

• Bimanual palpation requires the use of both hands to

capture certain organs such as kidneys, uterus
Apr-24 141
 Percussion
• The technique of examining part of the body by tapping it
with short, sharp stroke in order to assess the underlying
structures

• The strokes yield a palpable vibration and a characteristics

sound that show the location, size and density of the
underlying organ

Apr-24 142
 Percussion …
Characteristics of normal percussion notes:

o Dull : relatively dense organ ( e.g. Liver or spleen, full

bladder ,pregnant uterus)

o Resonant : over lung tissue

o Hyper resonance: normal over child’s lung; abnormal in

adult’s over lungs ( Emphysema-abnormal amount of air)

o Tympanic: over air filled stomach or intestine

Apr-24 143
 Percussion …
Methods of percussion
 Direct percussion: Tapping or hammering the body part directly by using
striking (dominant) hand.
 The striking hand directly contacts the body wall as in infant’s thorax or the
adult’s sinus areas.
 Indirect percussion
 Putting non dominant hand on the body surface and taping the middle finger
of the non dominant hand with the middle finger of the dominant hand to
elicit sound.
 Blunt percussion/fist percussion
 Hit with the ulnar surface of your fist against body surface.
 Causes the tissue to vibrate instead of producing sound for tenderness
Apr-24 144
 Auscultation
• The skill of listening to body sounds created in the lungs, heart,
blood vessel, and abdominal viscera by the help of a stethoscope.

• It is usually the last technique used during the examination.

• Choose a stethoscope with two-end pieces: a diaphragm and a

bell
• Bell : best for the soft, low pitched sounds such as extra
heart sounds or murmurs.
• Diaphragm : is used mostly, because its flat edge is best
for high pitched sounds: breath, bowel and normal heart
sounds.
Apr-24 145
Apr-24 146
 P/E

Apr-24 147
 PE…

Apr-24 148
Apr-24 149