2nd Semester

SY 2018-2019
 NCM-101
HEALTH ASSESSMENT

Mila B. Punzalan, RN,MAN

Academic Instructor
HEALTH ASSESSMENT:

This course deals with concepts, principles and techniques of

history taking, head to toe physical examination and psychosocial
assessment using various tools and interpretation of laboratory
findings to arrive at a nursing diagnosis. The learners are
expected to perform holistic nursing assessment of an individual
adult client.
A. Nursing Process Overview

Objectives :
1. Explain ways in which nurses use critical thinking.
2. Identify the steps of the nursing process
3. Discuss the importance of the nursing process as it relates
to client care
4. Relate how nurses implement
each step of the nursing process
What Is the Nursing Process?

Definition:
*systematic problem-solving process that guides all nursing
actions
*an approach used to identify, prevent and treat actual or
potential health problems and promote wellness.
*way to plan, implement and evaluate care for individuals,
families, groups and communities.

Purpose:
To help the nurse provide goal-directed client-centered care
STEPS IN NURSING PROCESS:

1. Assessment
2. Nursing Diagnosis
3. Planning
4. Implementation
5. Evaluation
STEPS IN NURSING PROCESS:
1. Assessment -involves the systemic collection of Patient
data.(collect data, validate data, organize data, document data)
Data Collection
a. subjective & objective data
b. Nursing history( Biographic data, current physical
&emotional complaints, past medical history, past and current
ability to perform ADL’S, socio-economic factors)
c. Physical Assessment.
d. Review of lab &Diagnostic test results.
e. Review other available Health Information.

.
STEPS IN NURSING PROCESS:
Validation of data:
Validation is the act of "double-checking“ or verifying data to
confirm that it is accurate and factual
Organization of data
The nurse uses a written or computerized format that organizes
the assessment data systematically. The format may be modified
according to the clients physical status.
Documenting data:
The nurse records clients data. Accurate documentation is
essential and should include all data collected about the clients
health status. Data are recorded in a factual manner and not
interpreted by the nurse.
STEPS IN NURSING PROCESS: 1. Assessment

.
STEPS IN NURSING PROCESS:
2. Nursing Diagnosis- is a clinical judgment about individual, family, or
community responses to actual or potential health problems/life processes.
Nursing diagnoses provide the basis for selection of nursing interventions to
achieve outcomes for which the nurse is accountable (NANDA, 1997).
Three components:
*Label an actual or potential health problems that Nursing care can affect.
*Related factors- Factors that may precede, contribute to or be associated with the
human response.
*Evidence – Signs symptoms that point to the Nursing Diagnosis.
TYPES OF NURSING DIAGNOSIS
a. Actual Diagnosis: An actual diagnosis is a statement about a health problem
that the client has, and could benefit from nursing care.
b. Risk diagnosis is a statement about a health problem that the client doesnt
have yet, but is at a higher than normal risk of developing in the near future.
STEPS IN NURSING PROCESS:
2.Nursing Diagnosis

***A complete nursing diagnosis is written in the format

problem related to cause of problem as evidenced by symptoms
of problem.

.
STEPS IN NURSING PROCESS:

3.Planning nursing interventions (with collaboration and consultation as

needed)Nursing interventions are treatment, based upon clinical judgment and
knowledge that a nurse performs to enhance patient / client outcomes.

Dependent – a nursing action based on the instruction of another professional.

Independent – requires no supervision
Interdependent – actions carried out by the nurse in collaboration with
another health care professional

.• Nursing interventions must be specifically designed to meet the identified

goal.
• Each intervention should be supported by a scientific rationale.
STEPS IN NURSING PROCESS:
4. IMPLEMENTATION
To implement the care plan successfully, nurses need cognitive, interpersonal,
and technical skills.

Nurses should follow these guidelines:

• Base nursing interventions on scientific knowledge, nursing research, and
professional standards of care whenever possible.
• Adapt activities to the individual client, a client’s beliefs, values; age, health status,
and environment are factors that can affect the success of a nursing action.
• Implement safe care
• Provide teaching, support and comfort to enhance the effectiveness of nursing care
plans.
• Be holistic; view the client as a whole
• Respect the dignity of the client and enhance the client’s self- esteem
• Encourage client to participate actively in implementing the nursing interventions.
STEPS IN NURSING PROCESS:
5. EVALUATION - The last phase of the nursing process, follows
implementation of the plan of care, it’s the judgment of the effectiveness of
nursing care to meet client goals based on the client’s behavioral responses.

When determining whether a goal has been achieved, the nurse can draw one
of the three possible conclusions:
A. The goal was met, that is the client response is the same as the desired
outcomes.

B. The goal was partially met, that is either a short term goal was achieved but
the long term was not, or the desired outcome was only partially attained.

C. The goal was not met.

Components of the Nursing Process
Steps of the Nursing Process
 Task 1

1.Formulate a nursing care plan for a

given scenario and utilize the nursing
process.
2. Present and discuss your NCPs in
class.
B. Health Assessment in Nursing Practice
Health Assessment
Definition:
 A health assessment is a plan of care that identifies the specific needs of
a person and how those needs will be addressed by the healthcare
system or skilled nursing facility.
 Health assessment is the evaluation of the health status by performing a
physical exam after taking a health history. It is done to detect diseases
early in people that may look and feel well.

 Health assessment is the evaluation of the health status of an individual

along the health continuum.
 The purpose of the assessment is to establish where on the health
continuum the individual is because this guides how to approach and
treat the individual
B. Health Assessment in Nursing Practice
B. Health Assessment in Nursing Practice

Concept of Physical Assessment

A physical examination is performed for all age group in health care setting.
Assessing a client is a major component of nursing care. It is the picture of
the client’s physiological functioning ,combined with a health and
psychosocial assessment that forms a data base for decision making.

To ensure a thorough assessment of each system the physical examination

is done in a sequential head to toe fashion. This method decreases changing
of position of both the nurse and the client frequently.
B. Health Assessment in Nursing Practice
Physical Health Assessment
2 Aspects:
1. the health history
2. a physical health examination

performed by the nurse to obtain subjective and objective data that

will be used to formulate a Nursing Diagnosis and Care Plan.
B. Health Assessment in Nursing Practice

Purposes of a health assessment:

1. To establish the client-nurse relationship
2. To obtain information about the client’s health including
physiologic, psychological, socio-cultural, cognitive, developmental,
and spiritual aspects
3. To identify client strengths
4. To identify actual and potential health problems
5. To establish a data base from which the subsequent phases of the
nursing process evolve
B. Health Assessment in Nursing Practice
Health Assessment in Nursing Practice
Health Assessment in Nursing Practice
Health Assessment in Nursing Practice
 C. Nurses’ Role in Health Assessment

“An accurate and thorough Health

Assessment Reflects the KNOWLEDGE &
SKILLS of a PROFESSIONAL NURSE”
-adapted-
 C. Nurses’ Role in Health Assessment

• The primary methods used to assess client’s are :

• 1. Observing
• 2. Interviewing
• 3. Examining
C. Nurses’ Role in Health Assessment
C. Nurses’ Role in Health Assessment
C. Nurses’ Role in Health Assessment
 Steps of Health Assessment
A. Collection of Subjective data through Interview and Health History
Subjective data - elicited and verified only by the client obtained through
interviewing and include the following:
• sensations or symptoms (such as pain, hunger)
• preferences
• feelings (such as happiness or sadness)
• beliefs
• perceptions
• values
• desires
• Ideas
• personal information
Steps of Health Assessment

Skills needed to obtain data :

 Interview and therapeutic communication skills
 Caring ability and empathy
 Listening skills

Helps provide the following data:

 clues to possible physiologic, psychological, and sociological
problems
reveal a client’s risk for a problem as well as areas of strengths for
the client
Complete Health History
(Nurse )Interview
• a communication process that focuses on: establishing
rapport and a trusting relationship with the client to elicit
accurate and meaningful information
• gathering information on the client’s developmental,
psychological, sociocultural, and spiritual statuses to
identify deviations that can be treated with nursing and
collaborative interventions or strengths that can be
enhanced with nurse-client collaboration
Complete Health History
Phases of the interview
• Phase I: Preinteraction
• Phase II: Introductory Phase
• Phase III: Working phase
• Phase IV: Summary and Closing Phase
Complete Health History
I. Preinteraction
 Gather data from medical records, other health
personnel
 Review relevant literature
 Plan the setting and time for the initial interview
Complete Health History
II. Introductory Phase
 Establish a nurse-client relationship/ rapport
 Describe the purpose of the interview
 Assure the client that the confidential data will
remain confidential
 Make sure the client is comfortable (physically and
emotionally) and has privacy
Complete Health History
III. Working phase
 Interview the client about his health history
 Nurse and client collaborate to identify the client’s
problems and goals.
 Use information to plan the physical examination
Complete Health History
IV. Summary and Closing Phase
 Summarize information obtained and validates problems
and goals with the client
 Identify possible plans to resolve the problem(nursing
diagnoses and collaborative problems) with the client.
 Ask if anything else concerns the client and if there are
any further questions
 Document health history data
 Validate the data with secondary sources if necessary
Complete Health History

Communication during interview:

• Nonverbal communication
• Verbal communication
Complete Health History
Communication during interview:
Nonverbal communication –
Appearance:
– Demeanor
– Facial expression
– Attitude
– Silence
– Listening
Complete Health History
Appearance
• ensure that your appearance is professional
• Comfortable, neat clothes
• Hair, nail, jewelry
Demeanor
• Be professional
• Maintain professional distance
Complete Health History
Nonverbal communication
Facial expression
• Keep expression neutral and friendly
• Use right expression at the right time
Attitude
• Nonjudgmental attitude
• Do not preach to the client or impose your own sense
of ethics
Complete Health History
Nonverbal communication
Silence
• Periods of silence allow you and the client to reflect and
organize thoughts, which facilitates more accurate
reporting and data collection
Listening
• Most important skill to learn
• Maintain good eye contact, smile or display open,
appropriate facial expression, maintain open body position
Complete Health History
Verbal communication
• Open-ended questions
• Closed-ended questions
• Laundry list
• Rephrasing
• Well-placed phrases
• Inferring
• Providing information
Complete Health History
Verbal communication
Open-ended questions
 “What”
 “How”
Closed-ended questions
Laundry list
Provide a choice of words to choose from in describing symptoms,
conditions, or feelings – “Is the pain severe, dull, sharp, mild, cutting,
or piercing?” – “Does the pain occur once every year, day, month, or
hour?”
Complete Health History
Verbal communication
Rephrasing
 Helps clarify information stated
 Enables nurse and the client to reflect on what was said
Ex: Mr. G tells you that he has been really tired and nauseated for two
months and that he is really scared because he fears that he has some
horrible disease.
Paraphrase by saying, “You are thinking you have serious illness?”
Complete Health History
Verbal communication
Well-placed phrases
– Ex: “um-hum,” “Yes,” “I agree”
Inferring
Providing information
Complete Health History
Special considerations:
Gerontologic
• Assess hearing acuity – Hearing loss normally occurs in age –
Undetected hearing loss is often misinterpreted as mental slowness or
confusion
• What to do:
– Speak slowly
– Face the client at all times during the interview
– Position yourself so that you are speaking on the side of the client
that has the ear with better acuity
– Do no yell at the client
Complete Health History
Special considerations:
• Do not talk down to the elderly
– being older physically does not mean the client is
slower mentally
• Show respect
• If client is mentally confused or forgetful, it is
important to have SO present to clarify the data
Complete Health History
Special considerations:
Cultural
• Be aware of the possible variations in communication styles
• If difficulty in communication – seek help from “culture broker” or
culture expert.
Emotional
• Anxious
• Angry
• Depressed
• Manipulative
• Seductive
• When discussing sensitive issues
Complete Health History
NURSING HEALTH HISTORY:
a structured interview designed to collect specific health
data and to obtain a detailed health record of the client

Purposes of a nursing health history

• To elicit information about all the variables that may
affect the client’s health status
• To obtain data that will help the nurse understand and
appreciate the client’s life experiences
• To initiate a nonjudgmental, trusting and interpersonal
relationship with the client
Components of a Nursing health history
A complete health history includes:
1. Biographic Data(identifying data and source of history)
2. Reasons for seeking Health Care- Chief Complaint
3. History of:
• Present Illness
• Past Health History
• Family Health History
• Psychosocial History
• Personal and Social history ( lifestyle, psychological data, social
data, patterns of health care)
• Developmental Level
• Current Medications
• Review of body systems (especially for current health problems
Complete Health History
Data Collection, Documentation and Analysis:
A. Data Collection Process
- General Survey
- Interview Techniques
B. Collecting Subjective Data
C. Collecting Objective Data
D. Validation/ Rationalization
E. Documentation of Data
Complete Health History
Data Collection Process:
Primary source:- client himself
The following clients may be unable to provide accurate and reliable
information
1. infants or children
2. clients who are seriously ill, comatose, sedated or in
substantial Pain
3. clients who are developmentally disabled
4. clients disoriented to person, place or time
5. Emotionally disturbed clients
6. clients who cannot speak the common language
7. aphasic clients
Complete Health History
Data Collection Process:
Secondary source- a person or record that provides additional
information about the client
1. parents
2. significant others
> family member,lover,co-habitant, co-worker, close friend, pastor
3. attending physician/ other healthcare personnel
( Whenever possible, the nurse should obtain the client’s permission
before requesting information from another person. This simple act of
courtesy demonstrates respect for the client’s privacy and goes a long
way in establishing a mutual sense of trust)
Complete Health History
Components of the Health History:
I. Biographical Data:
Name Race
Address Ethnic Identity
Age Culture
Date of Birth Religion and
Birthplace Spirituality
Gender Occupation
Marital Status Health Insurance
Source of Information/Reliability
Complete Health History
II. Present Health or Illness
• Reason for seeking care (chief complaint(s)
• Health Beliefs and Practices
• Health Patterns
• Medications: Prescriptions and OTC
• “What is your major health problem or concerns at this time?”
• “How do you feel about having to seek health care?” -encourage
the client to discuss fears or other feelings about having to see
a health care provider.
Complete Health History

Chief Complaint(s)
• one or more symptoms or concerns causing the
patient to seek care.
Complete Health History
History of Present Health concerns
• Mnemonic: COLDSPA
• Character: describe the sign or symptom; how does it feel, look, sound,
smell, and so forth?
• Onset: when did it begin?
• Location: where is it?, does it radiate
• Duration: how long does it last?
• Severity: how bad is it?
• Pattern: what makes it better? what makes it worse?
• Associated Factors: what other symptom occur with it?
Complete Health History
History of Present Health concerns
• Mnemonic: PQRST
P – provocative or palliative
Q – quality or quantity
R – region or radiation
S – severity
T - timing
Complete Health History
History of Present Health concerns
Seven attributes of a symptom
1.Location- where is it? Does it radiate?
2. Quality- What is it like?
3. Quantity or severity- how bad is it? ( for pain- ask for a rating scale of 1-
10)
4. Timing- When does it start? How long does it last? How often does it come?
5. Setting in which it occurs- Include environmental factors, personal activities,
emotional reactions, or other circumstances that may have contributed to the
illness
6. Remitting or exacerbating factors- Does anything make it better or worse
7. Associated manifestations- Have you noticed anything else that accompanies
it?
Complete Health History
III. Past History
Medical Immunizations
Surgical Mental and
Hospitalization Emotional Health
Outpatient care Allergies
Childhood Illnesses Substance use
Complete Health History
IV. Family History
Immediate Family Genogram
Extended Family
• reveals risk factors for certain diseases
(Diabetes, hypertension, cancer, mental illness).
• Use genogram
Complete Health History

V. Psychosocial History
Occupational History Family
Education Social Structure
Financial Background Self concept
Economic concerns
Roles and Relationships
Complete Health History
Lifestyle and health practices profile
Include:
• nutritional habits, activity and exercise patterns
,• sleep and rest patterns
,• use of medications, & substances
• self-concept & self-care activities
• social and community activities,
• relationships,
• values and belief system,
• education and work,
• stress level and coping style, and
• environment.
Complete Health History
Social data
• include family relationships, ethnic and educational
background, economic status, home and neighborhood
conditions.
Psychological data
• information about the client’s emotional state.
Pattern of health care
• includes all health care resources: hospitals, clinics,
health centers, family doctors.
Developmental level