Foundations of Nursing

Health Assessment

College of Nursing – 2024

By the end of this session you will be able to:

o Describe the nursing role in health assessment.

o Mention the objectives of health assessment

o Identify types of health assessment

o List frequency of health assessment

o Understand the importance of health assessment

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By the end of this session you will be able to:
o Take a comprehensive health history

o Identify the categories of data collection

o Describe the data gathered within each category of the

health history.

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By the end of this session you will be able to:

o Understand the interview

o Apply the correct process of communication during the

interview;
- Internal factors: liking others, empathy and ability to listen.

- External factors (physical setting): ensure privacy, refuse interruptions,

physical environment, dress and accurate documentation (Notes-taking).

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o Describe critical thinking within the following
framework:
o Assessment: collection of subjective and objective data

o Diagnostic reasoning

o Nursing process

o Describe general survey with vital signs.

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o Nurses assess health on many levels, including psychosocial,
physical, emotional, spiritual, and cultural.

o Assessment is the collection of data about the individual health

status from the point of entry to an on going care process.

o From the collected data you make clinical judgment or nursing

diagnosis about individual health state or response to actual or
potential health problem.

o Health behaviors are influenced by a person’s beliefs, culture,

and perceptions.
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o Surveillance of health status, identification of occult disease,
screening, and follow up care.

o The periodic assessment, at regular intervals.

o Increasing client participation in health care.

o Accurately define the health and risk care needs for individuals.

o Health assessment is shared with the client in a clearly and

understandable manner.

o The client must share in decision making for his own care.
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• Complete Assessment: Includes a complete health history and
physical examination and forms a baseline database.

• Focused Assessment: Focuses on a limited or short-term

problem, such as the client’s complains.

• Episodic/ Follow-up Assessment: Focuses on evaluating a

client’s progress.

• Emergency Assessment: Involves the rapid collection of data,

often during the provision of life saving measures.

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• It’s a systematic and continuous collection of data.

• The purpose of the health history is to collect family and

personal histories of risk factors and past issues.

• The nurse relies on data from different sources which can

indicate significant clinical problems (subjective and objective).

• In addition to speaking with the patient (verbal communication),

you also observe the patient’s body position, facial expression,
and eye contact (nonverbal communication).
• Health assessment provides a base line used to plan the clients
care.
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• Frequency varies with the patient’s needs, purpose of data

collection, and health care setting.

• Patients in intensive care settings have vital signs and a

focused assessment hourly, and even more often.

• Patients are seen more frequently in the youngest years to

monitor growth and development, and in later years for

treatment of acute and chronic illnesses.

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Interprofessional communication
• Communication is a complex, ongoing, interactive process
that forms the basis for building interpersonal relationships.
• Communication process focuses on the client's development
of psychological, physiological, sociocultural, and spiritual
responses, that can be treated with nursing & collaborative
interventions.

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 Interprofessional communication

• Therapeutic communication is essential.

• Confidentiality is important, you must
obtain permission from the patient for
other people to be present or leave
during the assessment.
• The nurse must be creative to
communicate with patients who cannot
fully interact verbally or who have
sensory impairments.
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Interprofessional communication

• The team communicates clearly and efficiently to improve patient

health, safety, and wellbeing.
• It is also essential to understand other health care workers’ roles
and responsibilities.
• Interprofessional collaborative practice competency domains
include the following:
➢ Values/ethics for interprofessional practice
➢ Roles/responsibilities
➢ Interprofessional communication
➢ Teams and teamwork
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The Interview
Major purpose:
To obtain health history and to elicit symptoms and the time course
of their development.
The interview conducted before physical examination is done.
Components of nursing interview:
1. Introductory phase.
2. Working phase.
3. Termination phase.

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The Interview
❑ Introductory Phase
✓ Brief introduction: Introduce yourself and explains the purpose of the
interview to the client.
✓ Before asking questions: Let the client to feel comfort, privacy and
confidentiality.

❑ Working Phase
✓ Data gathering phase: Includes your questions to the patient and your
responses to what the patient has said.
✓ There are two types of questions: open-ended and closed (or direct).

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The Interview

❑ Termination or closing phase:

End kindly not abruptly.
✓ The nurse summarizes information
obtained during the working phase.
✓ Making plans to resolve the
problems, nursing diagnosis and
collaborative problems are identified
and discussed with the client.

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 The Interview

❑ With a successful interview, you

✓ Gather complete and accurate data about the person’s health status.

✓ Establish trust so the person feels accepted and thus free to share all relevant
data.
✓ Teach person about health status.

✓ Build report for

- Continuing therapeutic relationship.
✓ Begin teaching for
- Health promotion and disease prevention.

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 The Interview

Communication

▪ Verbal communication is crucial

▪ Nonverbal - more reflective of true feelings
▪ Mutual understanding by the sender and the receiver
▪ Exchanging information
▪ No communication without conveyed meaning
▪ Include all behavior, conscious and unconscious, verbal and nonverbal
▪ Select words carefully without being too formal or casual
▪ Nonverbal demeanor (manner / conduct) is critical
▪ Appearance is the first impression. 21
 The Interview Facilitating Techniques:
▪ Active Listening: Focusing on what is being said.

▪ Facilitation: Encourage client to continue; (mm-hmm, go on, continue).

▪ Clarification: Obtain more info; “What do you mean by...?”

▪ Restatement: Repeating what was said using different words.

▪ Reflection: Repeating what the client just said to encourage elaboration.

▪ Confrontation: Used when inconsistencies appear; use a voice that says

confusion instead of accusation.

▪ Interpretation: Used to share a conclusion drawn from the data.

▪ Summary: Condenses & orders data for sequencing events.

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 The Interview
The followings are essential behaviors in effective interview activities:
Create appropriate physical environment.
▪ Set the room temperature to a comfortable level.
▪ Provide sufficient lighting.
▪ Reduce noise.
▪ Only use professional equipment needed for the examination (remove
distracting objects or unneeded equipment).
▪ Consider the distance between yourself and the patient at about twice your
arm’s length (4-5 feet).
▪ Arrange equal-status seating both should be seated comfortably, at eye level.
▪ Arrange face-to-face position when interviewing the bedridden patient.
✓ Provide privacy.
✓ Greet patient by proper name.
✓ Introduce self.
✓ Refuse interruptions.
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 The Interview

• Wear appropriate attire .The interviewer should be wearing conservative

appropriate clothing.
• Provide clear introduction to interview.
• State time available for interview.
• State the purpose of interview.
• Indicate the role of each participant.
• If patient is adolescent or adult, ask permission for other health providers or
family members to be present.
• Indicate confidentiality of interview and any limitations.
• Indicate any costs that the patient must pay.

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The Interview

• Use verbal responses appropriately.

• Use appropriate nonverbal behavior.

• Respond appropriately to patient’s nonverbal behavior.

• Consider special needs of the patient.

• Provide patient time to respond.

• Use appropriate terminology/language.

• Keep note-taking to a minimum, and try to focus your attention on the patient.

• Close interview with summary or other polite signal that interview is complete.

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The Interview

Nonverbal Skills
❑ Learn to listen with your eyes as well as with your ears.

❑ Nonverbal modes of communication include:-

✓ Physical appearance
✓ Posture
✓ Gestures
✓ Facial expressions
✓ Eye contact
✓ Voice
✓ Touch
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Documentation

• Documentation of both subjective and objective findings is

essential to meet legal requirements and also to communicate
findings to others to ensure safe and efficient delivery of care.
• Confidentiality of documentation is essential, and only
information pertinent to the care of the patient is shared.
• Care of the patient is collaborative, and nurses use an organized
method when communicating with other health care providers.
• You also use an organized method when giving a report between
shifts or when transferring patients to other departments.
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Documentation

• In addition to being a legal document, the medical record is used

for communication among health team members, care planning,
quality assurance, financial reimbursement, education, and
research.
• The patient record can be used in civil or criminal courts to
provide evidence of wrongdoing.

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Complete Health Assessment: History Taking

▪ History taking is both a science and an art. Good history taking

helps establish a communicating and helpful relationship with the

patient, as well as providing the information we need in order to

make a nursing diagnosis, in a time efficient manner.

▪ It’s a systematic collection of subjective and objective data.

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Complete Health Assessment: History Taking

Categories of data gathering during history taking

Categories Data Gathered
Biographical data Name, address, age, birth date, gender, marital
status, race, occupation

Reason for seeking care Brief, spontaneous statement

History of present illness Eight critical characteristics: Location, character
(sharp, burning), severity, timing, setting,
aggravating / relieving factors, associated
factors, etc.

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Complete Health Assessment: History Taking

Categories of data gathering during history taking

Categories Data Gathered
Past medical history Chronic illnesses, injuries, hospitalization,
operations, allergies, immunizations,
obstetrics, last examination, medications
Family history Father, mother, brothers, sisters
Review of Systems All body systems
Psychosocial history, Self esteem, activities, exercise, sleep,
Activities of daily nutrition, elimination, interpersonal
living (ADLs) relationships, spiritual, coping and stress,
habits, alcohol, drugs, partner violence.
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Complete Health Assessment: History Taking

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Critical Thinking in Health Assessment

Assessment: collection of subjective and objective data

❑ Subjective data
- What the person says about themselves

❑ Objective data
- Observe during physical assessment

+
Patient records and laboratory or radiology studies
=
DATA BASE

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Critical Thinking in Health Assessment

Nursing Process

The nursing process includes five phases:

1. Assessment,
2. Diagnosis,
3. Planning,
4. Implementation,
5. Evaluation.

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Critical Thinking in Health Assessment

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Critical Thinking in Health Assessment

❑ 1st level priority problems (ABCS); Airway, Breathing, Circulation, Signs for Vital Sign concerns
❑ 2nd level priority problems: by MAA-U-AR
✓ M- Mental Status
✓ A- Acute Pain
✓ A- Acute urinary elimination problems
✓ U- untreated medical problems required medical attention
✓ A- Abnormal laboratory value
✓ R- Risk for infection
❑ 3rd level priority problems: health problems that don’t fit with the above
categories (lack of knowledge, family coping).

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Critical Thinking in Health Assessment

Four types of data base:-

• Complete (total) data base
This includes a complete health history and a full physical examination.
• Focused / problem centered data base
This is for a limited or short-term problem. Here you collect a “mini” database,
smaller in scope and more targeted than the complete database.
• Follow up data base
The status of any identified problems should be evaluated at regular and
appropriate intervals.
• Emergency data base
This is an urgent, rapid collection of crucial information and often is compiled
concurrently with lifesaving measures.

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Any Questions ?

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 General survey

The general survey is a study of the

whole person, covering the general

health state and any obvious physical

characteristics. Begin building a general

survey from the moment you first

encounter the person.

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 General Survey: Objective Data

Objective Data: Overview

Physical appearance
Body Structure
General survey Mobility
Behavior

Weight
Height
Measurements Body Mass Index (BMI)
Waist-to-Hip Ratio

Temperature
Pulse
Vital signs Respirations
Blood Pressure
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 General Survey: Objective Data

Age; Sex - sexual development

Physical appearance Skin color - even tone, pigmentation, intact skin.
Level of consciousness - Alert, orientated, confused.
Facial feature - symmetric with movement.
Structure – height vs. age, genetic heritage
Nutrition - weight vs. height, body build
Body structure Symmetry - body parts bilaterally same
Posture - sit comfortably, arms relaxed, face examiner
Body build – proportions: arms span = height, body length

Gait (walk / pace)– base = shoulder width, smooth

Mobility well-balanced. symmetric
Range of motion (ROM)– mobility of joints, accurate

Facial expression- maintains eye contact-Expressions are

appropriate to the situation.
Mood and affect—The person is cooperative with the
Behavior examiner.
Speech—Articulation (the ability to form words).
Dress—Clothing is appropriate to the climate, looks clean.
Personal hygiene—The person appears clean 43
 Objective Data :Measurements

Equipment: Scale - standardized balance / electronic

Remove shoes & heavy outer clothing
Weight Sequence of repeated weights: same time of day, same
type of clothing

Equipment: wall-mounted / measuring pole

Position:
Height • Shoeless, stand straight, Look straight ahead
• Feet, shoulders, buttocks in contact with hard surface

Body Mass Index BMI = Weight (kg)

(BMI) Height (m)2

Assess body fat distribution =

indicator of health risks
Waist-to-Hip Ratio WTHR= waist circumference
hip circumference

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 Body Mass Index (BMI)
BMI is a value derived from the mass (weight) and height of an individual.
The BMI is defined as: the body mass divided by the square of the body height,
and is universally expressed in units of kg/m2, resulting from mass in kilograms
and height in meters.

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Objective Data: Vital Signs

Various routes for measurement:

Oral, Axilla, Rectal, Tympanic membrane, etc.
❑ Temperature Influences on temperature:
Diurnal cycle, Menstrual cycle, Exercise, etc.

Rate, Rhythm , Synchronicity,

❑ Pulse Force – three point scale.

Normal: Relaxed, regular, silent

❑ Respiration 30 sec / full 1 min
Infants / children: more fast.

Systolic
Diastolic
❑ Blood Pressure Mean arterial pressure (MAP)
Varies: age, gender, exercise, etc.
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Objective Data: Vital Signs

Blood Pressure (BP) (cont)

Level of BP determined by 5 factors

1. Cardiac output
• ↑ with exercise: to meet body demand for ↑ metabolism
• ↓pump failure: as shock, MI etc
2. Peripheral vascular resistance
• ↑ resistance: vasoconstriction
• ↓ resistance: vasodilation
3. Volume of circulating blood
• ↓ - hemorrhage
• ↑- increased Na+ and H2O retention, intravascular fluid overload
4. Viscosity
• ↑ - polycythemia = ↑ hematocrit (HCT)
5. Elasticity of vessel wall
• ↑ rigidity, hardening – arteriosclerosis – heart pump against ↑
resistance

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 Pain Assessment

Pain is considered as the fifth vital

sign. It could be actual or potential
depends on the patient presentation
and expected outcome.

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 Pain Assessment
• Pain either to be acute or chronic
o Acute pain:-

✓ Short term

✓ Self-limiting

✓ Follows a predictable track

✓ Ends after an injury heals

✓ Acute pain warns the person of actual

or potential tissue damage

i.e. surgery, trauma, or kidney stones.

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 Pain Assessment
o Chronic pain:

• Chronic pain is ongoing and usually lasts longer than six months.

• Divided into malignant and nonmalignant

➢ Malignant or cancer related

➢ Nonmalignant is associated with:

musculoskeletal conditions such as arthritis, low back pain, or fibromyalgia.

• This type of pain can continue even after the injury or illness that caused it
has healed or gone away.

• Pain signals remain active in the nervous system for weeks, months or years.

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 Pain Assessment Developmental Care: Gender Differences

• Women are:

o Two times more likely to experience migraines during

childbearing years.

o More sensitive to pain during the premenstrual period.

o Six times more likely to have fibromyalgia.

• Pain gene exists, that helps to explain why some people feel
more/less pain even with the same stimulus.

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 Pain Assessment Initial pain assessment: Questions

▪ Where is your pain?

▪ When did your pain start?

▪ What does your pain feel like? (i.e burning, throbbing etc)

▪ How much pain do you have now?

▪ What makes your pain better or worse?

▪ How does pain limit your function or activities

▪ How do you usually behave when you are in pain; how would others know
you are in pain

▪ What does this pain mean to you?

▪ Why do you think you are having pain.

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 Pain Assessment Pain assessment tools

▪ Select the pain assessment tool based upon its:

✓ Purpose,
✓ Time involved in administration, and
✓ The patient’s ability to comprehend and complete the tool.
▪ Examples:
✓ Initial Pain Assessment, The Brief Pain Inventory,
✓ McGill Questionnaire.
▪ The Brief Pain Inventory
✓ Asks patient to rate pain within the past 24 hrs
✓ Using graduated scales (0-10)
✓ Focus: impact on mood, walking ability, and sleep.

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 Pain Assessment Pain assessment tools

• The McGill Pain Questionnaire:

✓Asks patient to rank a list of descriptors in terms of intensity.
✓Give an overall intensity rating.
• Pain Rating Scales = unidimensional and are intended to reflect pain intensity.
✓ Numeric rating scales- older adults find this
scale to be abstract & have difficulty responding.
✓ Descriptor scale - lists words to describe
different levels of pain intensity (no pain,
mild pain, moderate pain, and severe pain).

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 Pain Assessment
✓ Verbal Descriptor Scale uses
words to describe the patient’s
feelings and the meaning of the
pain for the person.
✓ Visual Analogue Scale lets the
patient make a mark along a 10-cm
horizontal line from “no pain” to
“worst pain imaginable.”
✓ An alternative is the simple
descriptor scale that lists words
that describe different levels of pain
intensity such as no pain, mild pain,
moderate pain, and severe pain.

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Any Questions ?

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 Review Questions
1. Which of the following is considered as an example of objective data?
A. Alertness
B. Dizziness
C. A sore throat
A
D. Pain
2. The general survey consists of four distinct areas for you to address.
These include:

A. Mental status, speech, behavior, and mood/affect.

C
B. Gait, range of motion, mental status, and behavior.

C. Physical appearance, body structure, mobility, and behavior.

D. Vital signs with pain scale

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 Review Questions
3. The following is considered type of subjective data, Except?
A. Headache
B. Skin rash B
C. Nausea
D. Chest pain
4. The nursing process consists of four main elements. These include:

A. Assessment, planning, implementation and documentation.

B. Assessment, planning, implementation and orientation. D

C. Assessment, planning, implementation and reassessment.

D. Assessment, planning, implementation and evaluation.

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 Review Questions

5. Physical appearance includes statements that compare appearance with:

A. Mood.
B
B. Age.

C. Occupation.

D. Gender

6. The purpose of health assessment is to:

A. Obtain subjective and objective data.

A
B. Intervene to correct Malaria

C. Outline appropriate care.

D. Determine whether interventions are effective

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 Review Questions
7. The nurse documents the following information in a patient’s chart: “Cough and
deep breathe every hour while awake” This is an example of:

A. Evidence-based nursing.

B. Priority setting.
A
C. Comprehensive assessment.

D. Nursing interventions

8. Which of the following processes is the most important when providing nursing
care to an ill patient?

A. Writing outcomes

B. Performing a focused assessment

A
C. Collecting objective data

D. Using critical thinking

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 Review Questions
9. The patient is admitted to a hospital for surgery for colon cancer. What type of
assessment is the nurse most likely to perform on admission?

A. Emergency.

B. Focused.
D
C. Specific.

D. Comprehensive.

10. Which of the following are components of a comprehensive health assessment?

A. Nursing diagnoses

B. Goals and outcomes

C. Collaborative problems D
D. Examination of body systems

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Recap

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