In The Name of God
(
UNIT I A.
HEALTH ASSESSMENT
INTRODUCTION TO HEALTH ASSESSMENT
CONCEPTS
Tahir Kamal RN.CCN.BA.post rn Bsn
Instructor
ShCollege of Nursing
September 08, 2015
OBJECTIVES
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By the end of the unit, learners will be able
to:
Discuss the need for health assessment in
Shahzad Bashir, NLCON, Karachi.
general nursing practice.
Explain the concepts of health assessment, data
collection, and diagnosis.
Identify types of health assessments.
Document health assessment data using a
problem oriented approach.
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NEED OF HEALTH ASSESSMENT IN
NURSING
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Accurate physical assessment requires an organized and
systematic approach using the techniques of inspection,
palpation, percussion, and auscultation.
Shahzad Bashir, NLCON, Karachi.
It also requires a trusting relationship and rapport between
the nurse and the patient to decrease the stress the patient
may have from being physically exposed and vulnerable.
The patient will be much more relaxed and cooperative if you
explain what will be done and the reason for doing it.
While the findings of a nursing assessment do sometimes
contribute to the identification of a medical diagnosis, the
unique focus of a nursing assessment is on the patient's 3
responses to actual or potential problems.
NURSING ASSESSMENT
Is a major component of nursing care.
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Is a process which includes both physical and
psychological aspect to evaluate client’s condition.
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Enables the nurse to make a judgment about the
client’s health status , ability to manage his/her health
care and need for nursing.
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BASIC CONCEPTS
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Health: (WHO) a state of complete physical, mental &
social Wellbeing, not merely the absence of disease.
Shahzad Bashir, NLCON, Karachi.
Wellness: Level of wellbeing, a person perceives of
being healthy.
Disease: Alteration of structure and function of body.
Disease or discomfort.
Illness: A response a person has to an illness.
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CONT…
The new definition, considers health as a dynamic state
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of well being with different levels of functional abilities
at different point in time. So a diabetic patient no doubt
Shahzad Bashir, NLCON, Karachi.
has a disease, but there are times when the client feels
well and can be called healthy.
Illness is a response to a disease and sickness is the
individual perception of its illness. Thus it is possible
that a person has a disease DM, has hypoglycemia
sometimes, but still feels that he is normal so thus does
not feel sick.
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PHASES OF THE NURSING PROCESS
It is systematic, deliberate, problem solving, decision making
process that nurses use to achieve a certain result.
It consists of A.D.P.I.E steps.
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Diagnosis
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Assessment Planning
Implement 7
Evaluation
ation
CONTI....
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Phase Title Description
I Assessment Collecting subjective and objective data
II Diagnosis Analyzing subjective and objective data to
make a professional nursing judgment
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(nursing diagnosis, collaborative problem,
or referral.
III Planning Determining outcome criteria and
developing a plan
IV Implementati Carry ing out the plan
on
V Evaluation Assessing whether outcome criteria have
been met and revising the plan as
necessary
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COMPONENTS OF HEALTH ASSESSMENT
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Health
Assessment
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Health History Physical Examination
History of present illness Inspection
Past /present Medical history Palpation
Family History, social Hx Percussion
Auscultation 9
FACTS ABOUT PHYSICAL ASSESSMENT:
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a. Physical assessment is an organized systemic process of
collecting objective data based upon a health history and head-
to-toe or general systems examination. A physical assessment
should be adjusted to the patient, based on his needs. It can be
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a complete physical assessment, an assessment of a body
system, or an assessment of a body part.
b. The physical assessment is the first step in the nursing
process. It provides the foundation for he nursing care plan in
which your observations play an integral part in the
assessment, intervention, and evaluation phases.
c. The chances of overlooking important data are greatly
reduced because the physical assessment is performed in an10
organized, systematic manner, instead of a random manner.
PURPOSES OF A PHYSICAL ASSESSMENT:
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A. A comprehensive patient assessment yields both
subjective and objective findings. Subjective findings are
obtained from the health history and body systems
review. Objective findings are collected from the physical
examination.
Shahzad Bashir, NLCON, Karachi.
(1) Subjective data: Are apparent only to the person
affected and can be described or verified only by that
person. Pain, itching, and worrying are examples of
subjective data.
(2) Objective data: Are detectable by an observer or can
be tested by using an accepted standard.
A blood pressure reading, discoloration of the skin, and seeing11
the patient in the act of crying are examples of objective data.
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CONTI….
(3) Objective data are sometimes called signs, and
subjective data are sometimes called symptoms.
(4) Data means more than signs or symptoms; it also
includes demographics, or patient information that is
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not related to a disease process.
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CONTI….
B. The purposes for a physical assessment are:
(1) To obtain baseline physical and mental data on the
patient.
(2) To supplement, confirm, or question data obtained
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in the nursing history.
(3) To obtain data that will help the nurse establish
nursing diagnoses and plan patient care.
(4) To evaluate the appropriateness of the nursing
interventions in resolving the patient's identified
pathophysiology problems
(5) To evaluate the physiological outcome of care.
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IMPORTANCE OF PHYSICAL ASSESSMENT:
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1. To early detect and treat diseases and disorders.
2. To identify actual and potential health problems.
3. To establish a data based from which the subsequent
phases of the nursing evolve.
Shahzad Bashir, NLCON, Karachi.
4. To assess the client’s impact of activity and exercise on
the client’s overall level of health.
5. To assess the client’s routine exercise pattern and
observe how the client’s body system response to
activity and exercise.
6. To establish the client-nurse relationship
7. To obtain information about the client’s health
including, physiologic, psychologic, sociocultural,
cognitive, developmental and spiritual aspects.
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8. To identify the client’s strength and weaknesses.
COMPARING SUBJECTIVE AND OBJECTIVE DATA
Subjective Objective
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Description Data elicited and verified Data directly or indirectly observed
by the client through measurement
Sources •Client Observations and physical
•Family and significant assessment findings of the nurse or
others other health care professionals.
Shahzad Bashir, NLCON, Karachi.
•Client record Documentation of assessments made
•Other health care in client record.
professionals Observations made by the client's
family or significant others.
Methods used •Client interview Observation and physical
to obtain data examination
Skills needed Interview and therapeutic Inspection
to obtain data communication skills Palpation
Caring ability and Percussion
empathy Auscultation
Listening skills
Examples. "I have a headache." Respirations 16 per minute 15
"It frightens me." BP 180/100, apical pulse 80 and
"I am not hungry." irregular
X-ray til in reveals fractured pelvis
TYPES OF ASSESSMENT
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Types of
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Assessment
Initial Focus or
On going
Comprehe Problem Emergency
or Partial
nsive Oriented
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INITIAL COMPREHENSIVE ASSESSMENT
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Also called an admission assessment, it is performed
when client enter health care system.
Involves collection of subjective data about the client's
Shahzad Bashir, NLCON, Karachi.
perception of health of all body parts or systems, past
health history, family history, and lifestyle and health
practices (which includes information related to the client's
overall function) as well as objective data gathered during a
step-by-step physical examination.
The purposes are to evaluates client’s health status, to
identify functional health pattern that are problematic, &
to provide in an- depth, comprehensive data base which is
critical for evaluating changes in the client’s health status
in subsequent assessment. 17
ONGOING OR PARTIAL ASSESSMENT
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Consists of data collection that occurs after the
comprehensive database is established. This consists of a
mini-overview of the client's body systems and holistic health
patterns as a follow-up on his health status.
Shahzad Bashir, NLCON, Karachi.
Any problems that were initially detected in the client's body
system or holistic health patterns are reassessed in less
depth to determine any major changes (deterioration or
improvement) from the baseline data.
This type of assessment is usually performed whenever the
nurse or another health care professional has an encounter
with the client. This type of assessment may be performed in
the hospital, community, or home setting.
For example, a client admitted to the hospital with lung cancer
requires frequent assessment of lung sounds. A total assessment of
skin would be performed less frequently, with the nurse focusing on
the color and temperature of the extremities to determine level of
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oxygenation.
FOCUSED OR PROBLEM-ORIENTED
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ASSESSMENT
It is performed when a comprehensive database exists for a
client and he/she comes to the health care agency with a specific
health concern.
Consists of a thorough assessment of a particular client problem
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and does not cover areas not related to the problem. For
example, if your client, John P.. tells you that he has ear pain,
you would ask him questions about the pain, possible hearing
loss, dizziness, ringing in his ears, and personal ear care. Sexual
functioning & bowel habits would be unnecessary and
inappropriate.
The physical examination should focus on his ears, nose, mouth,
and throat. At this time, it would not be appropriate to repeat all
system examinations such as the heart and neck vessel or 19
abdominal assessment.
EMERGENCY ASSESSMENT
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An emergency assessment is a very rapid assessment
performed in life-threatening situations. In such
situations (choking, cardiac arrest, drowning), an
immediate diagnosis is needed to provide prompt
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treatment.
An example of an emergency assessment is the
evaluation of the client's airway, breathing, and
circulation (known as the ABCs) when cardiac arrest is
suspected.
The major and only concern during this type of
assessment is to determine the status of the client's life-
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sustaining physical functions.
PROBLEM ORIENTED RECORDING (POR)
Type of format for documentation where a data base
leads to a problem list and plan for some
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interventions i.e. diagnostic, therapeutic,
educational.
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S Subjective
O Objective
A Assumption / Diagnosis
P Planning
I Intervention
E Evaluation
R Revision
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DOCUMENTATION OF PE FINDINGS
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Specific – avoid vague terms
Concise – use short simple words
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Complete entry with date & sign
Describe observation clearly
Use standard abbreviations only
Record exact size, position of lesions
Use illustration
Use black pen
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REFERENCES BOOKS
Bickley, L. S., Szilagyi, P. G., & Bates, B. (2007).
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Bates' guide to physical examination and history
taking (11th Edi). Philadelphia: Lippincott Williams &
Shahzad Bashir, NLCON, Karachi.
Wilkins.
Weber, Kelley's. (2007). Health Assessment in Nursing,
3rd Ed: North American Edition. Lippincott Williams
& Wilkins.
Jarvis, Carolyn. (2011). Physical Examination and
Health Assessment - Text + Mosby's Nursing Video
Skills: Physical Examination & Health Assessment 23
Package. W B Saunders Co.
