Health Assessment

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 Health Assessment
Health assessment is an essential nursing function which provides foundation
for quality nursing care and interventions.
It helps identify the strength of the clients in promoting health.
Health assessment helps to identify clients needs, clinical problems.
To evaluate response of the person to health
Health assessment is refers to systematic appraisal of all factors relevant to
clients health
Health assessment includes collecting subjective data through interviewing
the client and obtaining data by physically examining the client.

Types of health assessment

1. Initial comprehensive assessment

Also called a triage, the initial assessment's purpose is to determine the origin
and nature of the problem and to use that information to prepare for the next
assessment stages. Due to the fact that the rest of the medical process relies on
the accuracy of this initial assessment, it is the most thorough phase of the
entire process.

It usually consists of getting the patient's medical history and performing a

physical exam on them or, in the case of patients with mental issues, performing
a psychological assessment. Depending on the patient's condition, the initial
assessment may also include recording the patient's vital signs and looking for
subtle symptoms that may be signs of an underlying condition.
 2. Ongoing or partial assessment

After the medical condition is properly diagnosed and a treatment plan is

implemented, the time-lapsed assessment is conducted to evaluate how the
patient reacts to the agreed treatment plan and how their condition is
evolving. Depending on the issue, a time-lapsed assessment can last from a few
hours to a few months. Throughout this time, the patient is constantly
evaluated and their condition is compared to previously recorded parameters
to see if the treatment is effective.

3. Focused or problem-oriented assessment

After the initial assessment, the medical issue is fully exposed and treated in the
focused assessment phase. Given the fact that a patient's condition may rapidly
change, especially in an emergency situation, their vital signs are constantly
monitored throughout all four assessments. The focused assessment also involves
relieving the patient from pain and stabilizing their condition, when needed. Also,
depending on the exact nature of the issue, a long-term treatment plan that
aims to resolve the root cause is implemented during this phase.

4. Emergency assessment

The emergency assessment is performed during emergency procedures, when

it is crucial to evaluate the patient's airway, breathing and circulation, as well
as the exact cause of the problem. Emergency assessments can take place
outside typical healthcare settings and in these situations the registered
nurse must also make sure that no other people are negatively affected by
the emergency rescue process. If the emergency assessment is a success and
the patient's vital signs are stabilized, the next step is usually a focused
assessmen
Key phases of health assessment
1. Collecting data 4. Analyze the data
Subjective data collection 5. Identifying patterns/testing first
Objective data collection impressions
2. Validating (verifying) data 6. Reporting and recording data
3. Organizing data

1. Collection of data

gathering of information about the client, includes physical, psychological,

emotion, socio-cultural, spiritual factors that may affect client’s health
status  includes past health history of client (allergies, past surgeries,
chronic diseases, use of folk healing methods) includes current/present
problems of client (pain, nausea, sleep pattern, religious practices, medication
or treatment the client is taking now)

Type of data

When performing an assessment the nurse gathers subjective and

objective data.

Subjective data

(symptoms or covert data): are the verbal statements provided by the Patient.
Statements about nausea and descriptions of pain and fatigue are examples of
subjective data.
 Includes Complete Health History

Biographical data Family health history

Reasons for seeking health care Review of body systems (especially
History of Present History of Present for current
Health concerns health for current health
Past health history problems)
Lifestyle and health
practices profile
Developmental level

Objective data

(signs or overt data): are detectable by an observer or can be measured or

tested against an accepted standard. They can be seen, heard, felt, or smelt,
and they are obtained by observation or physical examination. For example:
discoloration of the skin

Data include:

physical characteristics
body functions
appearance
behavior
measurement
results of laboratory testing

Objective data are sometimes called signs,

Subjective data are sometimes called symptoms.
 Subjective data:
– States, “I feel like my heart is racing.”

•Objective data:
– Pulse 150 beats, regular, and strong.

The objective data support the subjective data: what you observe confirms
what the person is stating.

The subjective and objective data you identify act as cues.

Cues are data that prompt you to get an initial impression about patterns
of health or illness.
The cues may lead you to infer (suspect).
Inference – the conclusion drawn about the cue: it is how you interpret
or perceive a cue

Cues

subjective or objective data observed by the nurse; it is what the client

says, or what the nurse can see, hear, feel, smell or measure

Inferences

the nurse interpretation or conclusion based on the cues

Example: red, swollen wound = infected

wound; Dry skin = dehydrated
 Source of data
Data can be obtained from primary or secondary sources.

Primary Source Secondary Source

The primary source of data is the
The Secondary sources of data
patient. In most instances the
include family members, significant
patient is considered to be the most
others, medical records, diagnostic
accurate reporter. The alert and
procedures, Members of the
oriented patient can provide
patient's support system may be able
information about past illness and
to furnish information about the
surgeries and present signs,
patient's past health status, current
symptoms, and lifestyle.
illness, allergies, and current

medications.
When the patient is unable to supply

information because of
Other health team professionals are
deterioration of mental status, age,
also helpful secondary sources
or seriousness of illness, secondary
(Physicians, other nurses.)
sources are used.

Data collection methods

1. Observing: to observe is to gather data by using the senses.
2. Interviewing: an interview is a planned communication or conversation
with a purpose.
3. Examining: Performance of a physical examination. The physical
examination is often guided by data provided by the patient. A head-to-
toe approach is frequently used to provide systematic approach that
helps to avoid omitting important data
 2. Validation of data

a crucial part of assessment that often occurs along with collection of

subjective and objective data
the act of “double-checking” or verifying data to confirm that it is
accurate and complete.

Purposes of data validation

ensure that data collection is complete
ensure that objective and subjective data agree
obtain additional data that may have been overlooked
avoid jumping to conclusion
differentiate cues and inferences

Validating (verifying) data

Helps avoid:
Making assumptions
Missing pertinent information
Misunderstanding situations
Jumping to conclusions or focusing in the wrong direction
Making errors in problem identification

Guidelines
Data that can be measured accurately can be accepted as factual (e.g. height,
weight, laboratory study results
Data that someone else observes (indirect data) may or may not be true. When
the information is critical, verify it by directly observing and interviewing the
patient yourself
Validate questionable information by using the following techniques, as appropriate:

Double-check that your equipment is working correctly

Recheck your own data (e.g. take a client’s BP in the opposite arm or 10 min later)
Look for factors that may alter accuracy
Ask someone else, preferably an expert, to collect the same data
Double-check information that is extremely abnormal or inconsistent with patient cues
(e.g. use two scale to check an infant who appears too much heavier or lighter, or
repeat extremely high or low lab result) • Compare subjective and objective data to
see if what the person is stating is congruent with what you observe
Clarify statements and verify your inferences (e.g. “To me, you look tired”)
Compare your impressions with those of other key members of the health care team

3. Organizing (clustering) data

Clustering the data together is a critical thinking principle that enhances

your ability to get a clear picture of the client’s health status

Ways to cluster data:

Clustering data according to a nursing model

helps to identify nursing diagnoses and problems

Henderson’s Components of Nursing Care

Gordon’s Functional Health Patterns
NANDA’s human response patterns
Maslow’s theories

Clustering data according to body systems

– helps to identify data that may indicate medical problems

Note
It is important to do both in order to facilitate recognition of
both possible nursing problems and medical problems.

If you cluster data according to body system only, you are likely to miss
key information that helps you identify nursing diagnoses
If you cluster data according to a nursing model only, you may group
your data in such a way that medical problems may not be obvious

Assessment tools
Gordon’s Functional Health Patterns
Katz Index of Independence
Barthel Index
Newborn – APGAR Scoring System
Infants and Children – MMDST

Gordon’s Functional Health Patterns

Health perception-health management pattern.

Nutritional-metabolic pattern
Elimination pattern
Activity-exercise pattern
Sleep rest pattern
Cognitive-perceptual pattern
Self-perception-concept pattern
Role-relationship pattern
Sexuality-reproductive pattern
Coping-stress tolerance pattern
Value-belief pattern
 4. Analyze data

compare data against standard and identify significant cues.

Standard/norm are generally accepted measurements, model, pattern:

Ex: Normal vital signs, standard Weight and Height, normal laboratory/diagnostic
values, normal growth and development pattern

Identifying patterns/testing first impressions

After clustering data into groups of related information

You get some initial impressions of patterns of human functioning.
But you must test these impressions and decide if the patterns really are as they
appear

Testing first impressions involves

deciding what’s relevant

making tentative decisions about what the data may suggest,
focusing assessment to gain more information to fully understand the
situations at hand

5. Reporting and recording data

Reporting abnormal data in a timely fashion expedites diagnosis and treatment of

urgent problems

Recording data in a timely fashion promotes continuity, accuracy, and critical

thinking
 Documentation of Data
an important step of assessment because it forms the database for the entire
nursing process and provides data for all other members of the health care team

thorough and accurate documentation is vital to ensure valid conclusions are made
when the data are analyzed in the second step of the nursing process

nurse records all data collected about the client’s health

status

data are recorded in a factual manner not as interpreted by

the nurse

record subjective data in client’s word; restating in other

words what client says might change its original meaning

End result of assessment

formulation of nursing diagnoses (wellness, risk, or actual) that

require nursing care,

the identification of collaborative problems that require

interdisciplinary care, and the identification of medical problems that

require immediate referral

 Level of Consciousness
"AVPU"
Eyes open spontaneously. Child is active and

A -Alert Appears aware of and responsive responds appropriately to

to the environment. SO and other external
Follows commands eyes tract stimuli.
peoples and objects

Eye do not open spontaneously

but open to verbal stimuli. Respond only when his or
V -Voice
Able to respond in some her name is called
meaningful way when spoken to

Does not respond to questions but Respond only when

P -Pain moves or cries out in response to painful stimuli is received

painful stimuli such as pinching such as pinching the nail
the skin or earlobe. bed

Patient does not respond

U -Unresponsive No response at all.
to any stimuli.
Physical Assessment Techniques "IPPA"

Inspection visual examination of the patient

done when the person doing the assessment

Palpation
places their fingers on the body to determine
things like swelling, masses, and areas of pain

light palpation
more superficial and therefore it permits
identification of the superficial organs or
masses, and sometimes it can detect
abdominal wall crepitus

deep palpation

allows examination of organs including the

liver, caecum

tapping the patient's bodily surfaces and

Percussion hearing the resulting sounds to determine the

presence of things like air and solid masses
affecting internal organs

listening to an area of the body using a

Auscultation
stethoscope
 Head-to- Toe Assessment
Physical Assessment using head to toe approach

General Mobility and Safe Care

General health status Observe posture
Vital signs and weight Assess gait and balance
Nutrional status Evaluate mobility
Activities of daily living

Head, face and neck Chest

Evaluate cognition
Inspect and palpate breast
LOC
Inspect and auscultate lungs
Orientation
Auscultate heart
Mood
Language and memory
Sensory function
Test vision Inspect and
Abdomen
examine ears Inspect, auscultate, palpate four
Test hearing quadrants
Cranial nerves Palpate and percuss liver, stomach,
Inspect lymph nodes bladder
Inspect neck veins Bowel elimination Urinary
elimination
Skin, hair and nails
Genetalia
Inspect scalp, hair, & nails
Evaluate skin turgor Inspect female client
Observe skin lesion Inspect male client
Assess wounds

Extremeties
Palpate arterial pulses Assess sensory function
Observe capillary refill Assess circulation, movement, &
Evaluate edema sensation
Assess joint mobility Deep tendon reflexes
Measure strength Inspect skin and nails
 Head-to- Toe Assessment
Body system approach

General
Fever, chills, malaise, pain, sleep patterns,
Presentation of fatigability

symptoms:

Diet: Appetite, likes and dislikes, restrictions,

written dairy of food intake

rash or eruption, itching, color or texture

Skin, hair and nails: change, excessive sweating, abnormal nail or
hair growth

Musculoskeletal: joint stiffness, pain, restricted motion, swelling,

redness, heat, deformity

Head and neck:

Eyes: visual acuity, blurring, diplopia, photophobia,
pain, recent change in vision Ears: Hearing loss, pain,
discharge, tinnitus, vertigo

Nose Throat and mouth

Sense of smell, frequency of Hoarseness or change in voice,

colds, obstruction, epistaxis, sinus frequent sore throat, bleeding or
pain, or postnasal discharge swelling of gums, recent tooth
abscesses or extractions, soreness of
tongue or mucosa.
 thyroid enlargement or tenderness, heat or cold
intolerance, unexplained weight change, polyuria,
polydipsia, changes in distribution of facial hair;
Endocrine and
Males: Puberty onset, difficulty with erections, testicular
genital pain, libido, infertility.
reproductive:
Females: Menses {onset, regularity, duration and amount},
Dysmenorrhea, last menstrual period, frequency of
intercourse, age at menopause, pregnancies {number,
miscarriage, abortions} type of delivery, complications,
use of contraceptives; breasts (pain, tenderness,
discharge, lumps)

Pain related to respiration, dyspnea, cyanosis,

Chest and lungs: wheezing, cough, sputum {character, and
quantity}, exposure to tuberculosis (TB), last
chest X-ray

Chest pain or distress, precipitating causes, timing

Heart and blood and duration, relieving factors, dyspnea,
orthopnea, edema, hypertension, exercise
vessels: tolerance

Appetite, digestion, food intolerance, dysphagia,

Gastrointestinal: heartburn, nausea or vomiting, bowel regularity,
change in stool color, or contents, constipation or
diarrhea, flatulence or hemorrhoids

Dysuria, flank or suprapubic pain, urgency,

frequency, nocturia, hematuria, polyuria,
Genitourinary: hesitancy, loss in force of stream, edema, sexually
transmitted disease

Syncope, seizures, weakness or paralysis,

Neurological: abnormalities of sensation or coordination,
tremors, loss of memory
 P a t i e n t
P o s i t i o n i n g

Supine position
used for general examination or
physical assessment Prone position
The prone position is used primarily to
assess the hip joint. The back can also
be assessed with the client in this
position. Clients with cardiac and
lateral recumbent respiratory problems cannot tolerate
(left or right) this position

This position makes it easier to

access a patient's right/left side.

Trendelenburg ’ s
position
Patients can benefit from this position
Fowler ’ s position because it promote venous return.
Used to provide postural drainage of
used for patients who have difficulty
the basal lung lobes
breathing because in this position, gravity
pulls the diaphragm downward allowing
greater chest and lung expansion
 lithotomy position knee-chest position
Commonly used for vaginal Is assumed for a gynecologic or rectal
examinations and childbirth examination. Knee-chest position
can be lateral or prone.

HEALTH HISTORY ASSESSMENT "SAMPLE

S -Symptoms patient's chief complaints
A -Allergy seeking to know what type of allergic reaction they experienced
M -Medications prescribed, OTC drugs, herbal meds, etc...
P -Past Medical History seeking to know the previous
L -Last Oral Intake state of health and previous illness
E -Events leading up to seeking what are the last oral intakes of the client
the illness or injury events leading up to the illness or injury

FAMILY HISTORY ASSESSMENT "BALD CHASM"

B -Blood pressure C -Cancers

A -Arthritis H -Heart disease
L -Lung disease A -Alcoholism
D -Diabetes S -Stroke
M -Mental health
disorders
 CHIEF COMPLAINT
In your patient’s own words, document the chief complaint. The chief complaint may be
elicited by asking one of the following questions:

So, tell me why you have come here today?

Tell me what your biggest complaint is right now?
What is bothering you the most right now?
If we could fix any of your health problems right now, what would it be?
What is giving you the most problems right now?

If your patient has more than one complaint, discuss which one is the most troublesome for
them and document the complaints in order of importance as determined by the patient

PRESENT HEALTH HISTORY

Obtaining information about a patient’s present health status allows the nurse to
investigate current complaints. The mnemonic, PQRST, utilizes a structured format for
information gathering, including evaluation of pain, and provides an efficient
methodology to communicate with other healthcare providers. Use PQRST to assess each
symptom and after any intervention to evaluate any changes or responses to treatment

PQRST
P = Provocative or Palliative What makes the symptom(s) better or worse?

Q = Quality Describe the symptom(s)

R = Region or Radiation Where in the body does the symptom occur? Is there
radiation or extension of the symptom(s) to another area
of the body?

S = Severity On a scale of 1-10, (10 being the worst) how bad is the
symptom(s)? Another visual scale may be appropriate for
patients that are unable to identify with this scale.
T = Timing
Does it occur in association with something else (i.e.
eating, exertion, movement)?
 CLassification of pain
according to duration and etiology

Acute pain: usually associated with a recent injury

usually associated with a specific cause or injury

Chronic nonmalignant pain: and described as a constant pain that persists for
more than 6 months

often due to the compression of peripheral nerves

Cancer pain: or meninges or from the damage to these
structures following surgery, chemotherapy,
radiation, or tumor growth and infiltration

according to location

Cutaneous pain
(skin or subcutaneous tissue)

Visceral pain
(abdominal cavity, thorax, cranium)

Deep somatic pain (ligaments, tendons, bones, blood vessels, nerves)

according to location whether it is perceived at the site of the pain stimuli

Referred Phantom pain

Radiating

perceived both at the perceived in body areas can be perceived in nerves

source and extending to away from left by a missing, amputated,
other tissues the pain source or paralyzed body part.
 other types of pain

caused by damage or injury to the nerves that transfer

Neuropathic pain
information between the brain and spinal cord from the
skin, muscles and other parts of the body.

A type of pain that can't be controlled with standard medical

Intractable pain
care because of its high resistance to pain relief.

Dimensions of pain
effect of anatomic structure and physiologic functioning on the
Physical experience of pain

Behavioral verbal and nonverbal behaviors associated with pain

Cognitive thoughts, beliefs, attitudes, intentions, and motivations

related to the experience of pain

Sensory qualitative and quantitative descriptions of pain

effect of social and cultural backgrounds on the

Sociocultural experience of pain

Affective feelings and emotions that result from pain

ultimate meaning and purpose attributed to pain, self, others,

Spiritual and the divine
 Pain Rating Scale
0 1 2 3 4 5 6 7 8 9 10

Very Worst
No pain Mild Moderate Severe
Severe Pain

WARNING SIGNS OF CANCER "CAUTION US"

C -Change in bowel or bladder habits

A -A sore that does not heal
O -Obvious change in wart or mole
T -Thickening or lump in breast or elsewhere
I -Indigestion or dysphagia
U -Unusual bleeding or discharge
N -Nagging cough or hoarseness
U -Unexplained anemia
S -Sudden & unexplained weight loss

EMERGENCY TRAUMA ASSESSMENT "ABCDEFGHI"

A -Airway
B -Breathing
C -Circulation
D -Disability
E -Expose & examine
F -Full set of vital signs
G -Give comfort measures
H -History and head-to-toe assessment
I -Inspect posterior surface
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1. You agree that this study guides are simply guides and should
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instruction in nursing school

2. These study guides are not intended to be used as medical

advice or clinical practice, they are for education use only

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References:
Chelsea (2020). Complete Nursing School Bundle. CeceStudyGuides.
May, B. (2017). Verbal Numerical Rating Scale: A Reliable Pediatric Pain Assessment
Tool. Clinical
Pain Advisor. Retrieved from
https://www.clinicalpainadvisor.com/home/topics/pediatric-painmanagement/verbal-
numerical-rating-scale-a-reliable-pediatric-pain-assessment-tool/
Tuttle, K. (2020). The Complete Nursing School Bundle. NurseInTheMaking LLC.
Vera, M. (2018). Nursing Health Assessment Mnemonics & Tips. Nurses Labs. Retrieved
from
https://nurseslabs.com/nursing-health-assessment-mnemonics-tips/
Weber, J. & Kelley, J. (2014). Health Assessment in Nursing. Fifth Edition. Lippincott
Williams & Wilkin