NUR 097; CHAPTER 1 Introduction to Health Assessment and Social Determinants of Health

Health 1. Health History

- overall well being of body and mind Biographical Data - Includes personal information
- relative state in which a person strives to meet their such as age, gender, occupation, and address.
potential and includes the areas of wellness with the Chief Complaint or Reason for Seeking Healthcare -
ultimate goal of improving health and includes The primary reason the individual is seeking
“8 dimensions” healthcare services.
1. Physical – how the body works and adapts; Present Health Status - Information about the
involves factors like exercise, nutrition, and individual's current health condition, symptoms, and
proper rest concerns.
2. Emotional – ability to handle life and its Past Medical History - Includes information about
challenges; involves understanding, expressing, previous illnesses, surgeries, hospitalizations, and
coping with feelings in a positive way, and a chronic conditions.
relationship w/ others Family History - Information about the health status of
3. Social – supportive relationships with family close family members.
and friends; involves feeling a sense of Social History - Details about lifestyle factors, habits,
belonging, connection, and satisfaction in your and environmental factors that may influence health.
interaction w/ others
4. Spiritual – living peacefully, morally, and 2. Physical Examination
ethically; involves a person’s sense of values, General Appearance - Observations about the
belief, practices, and experiences related to individual's overall appearance, behavior, and hygiene.
religion. Vital Signs - Measurement of basic physiological
5. Environmental – favorable connections to parameters such as temperature, pulse, respiratory
promote health encompasses the patients rate, and blood pressure.
surroundings Head-to-Toe Assessment or Cephalocaudal Assessment
6. Intellectual – ability to advance knowledge and - A systematic examination of each body system,
is different for each person; state of keeping including inspection, palpation, percussion, and
your mind active, engaged, and continuously auscultation.
seeking new knowledge and challenges
7. Financial – state of having a good and stable 3. Psychosocial Assessment
financial situation and having control over your Evaluating the patient's mental health, emotional
finances; includes budgeting, saving, avoiding well-being, and social support systems.
debt, and planning for long-term goals Identifying any factors that may impact the patient's
8. Occupational – finding satisfaction and mental and emotional health, such as stressors,
fulfillment in your work or chosen activities; coping mechanisms, and social relationships.
involves having a sense of purpose,
accomplishment in your professional life, 4. Functional Assessment
maintaining a healthy work-life balance, Evaluating the patient's ability to perform daily
managing stress related to work, and activities and tasks, including mobility, self-care, and
continuously developing skills to enhance your any limitations they may have.
career
5. Review of Systems (ROS)
Nursing health assessment Inquiry about Symptoms - Systematically examining
- both a comprehensive health history and a complete each body system to identify any signs or symptoms
physical examination, which are used to evaluate the that may be relevant to the patient's overall health.
health status of a person
- help nurses identify health problems, establish a 6. Documentation
baseline for monitoring changes, and provide a basis Recording all assessment findings accurately and
for planning and implementing interventions. comprehensively in the patient's health record.

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NUR 097; CHAPTER 1 Introduction to Health Assessment and Social Determinants of Health
7. Analysis and Interpretation NURSING PROCESS
Synthesizing the collected data to identify patterns, - it is used to identify patient problems; set a goal and
potential health issues, and areas for further develop an action plan; implement the plan; and
investigation. evaluate the outcome

Role of the nurse in assessment NURSING STEPS ARE:

▪ Nurses deliver care across the lifespan in a variety Assessment
of practice arenas Diagnosis
▪ small sample of the groups served are pediatrics, Planning
geriatrics, medical, surgical, mental health, Implementation
maternity, and community health Evaluation
▪ Nurses assess patient needs, develop
interventions, and educate and counsel I. Assessment - Gather comprehensive information
individuals, families, groups, and communities about the patient's health status through
toward higher levels of health and wellness observations, interviews, and examinations.
▪ Nurses view health as the focus with the patient,
the environment, and the nurse all influencing the Subjective data – information provided by the
health status of the patient patient, often based on their feelings, perceptions, or
experiences.
Assessing the patient by using the eight dimensions is Examples: Vital signs (e.g., heart rate, blood
at the forefront of the nurse’s responsibilities The pressure), physical examination findings (e.g.,
nurse conducts a comprehensive assessment covering skin color, respiratory rate), laboratory results,
physical, mental, emotional, developmental, social, and diagnostic imaging.
and spiritual dimensions of the patient.
Objective data – observable and measurable
Physically - signs like changes in vital signs, nausea, or information that can be assessed using the five senses
incontinence are observed. or through diagnostic tests.

Mentally - alterations in consciousness and confusion II. Diagnosis - Identify health issues and their root
may be noted. causes based on the collected data, leading to the
formulation of nursing diagnoses.
Emotionally - the nurse explores mood changes,
considering factors like abuse or financial worries. III. Planning - Develop a tailored care plan by setting
Developing rapport allows the nurse to address priorities, establishing goals, and determining
sensitive issues. specific nursing interventions.

Developmentally - guidance may be needed for IV. Implementation - Execute the care plan by
problem-solving or moral understanding. carrying out nursing interventions, coordinating
care, and providing patient education.
Socially - the patient may be isolated, and the nurse
suggests self-help groups or resources. V. Evaluation - Assess the effectiveness of the care
plan by measuring outcomes, comparing them
Spiritually - the patient's preferences guide with goals, and making necessary adjustments for
interventions, such as connecting with clergy. ongoing care.

Collaborating with the patient ensures partnership in

decision-making - addressing social determinants of
health and promoting long-term healthier lifestyle
outcomes.
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NUR 097; CHAPTER 1 Introduction to Health Assessment and Social Determinants of Health
TYPES OF HEALTH ASSESSMENT
The admission of a new patient to a clinic, hospital,
long-term care facility, or visiting nurse agency usually
requires a comprehensive health assessment

Comprehensive Health Assessment

- A thorough examination of a patient's physical,
psychological, social, and environmental aspects.
-Conducted during initial encounters or periodic
check-ups to provide a holistic view of the patient's
overall health.

Focused or Problem-Oriented Health Assessment

- A follow-up history is a form of a focused assessment
- Targeted and specific, addressing a particular health
concern or set of related issues.
- Performed in response to immediate health
problems, guiding interventions for the specific
identified problem.

Emergency history – is a data collection which focused

on the patient’s emergent problem with a systematic
prioritization of need beginning with the ABCs of
airway, breathing, and circulation

a) Airway - Assess and clear any obstructions.

b) Breathing - Evaluate and provide artificial
ventilation if necessary.
c) Circulation - Check for signs of circulation and
initiate chest compressions if needed. This
sequence is a fundamental guideline for
prioritizing interventions to address life-
threatening issues promptly.

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