health assessment

• The purpose of nursing health assessment is to collect subjective & objective data to determine a client’s overall level of functioning in order to make a professional clinical judgement
• The mind, body, and spirit are interdependent factors that affect a person's level of health (Holistic)
• The framework for health assessment in nursing follows the HEAD-TO-TOE framework
• The end result of nursing assessment includes nursing diagnosis (wellness, risk or actual problem) that require nursing care, identification of collaborative problems that require interdisciplinary care, and identification of medical problems that require immediate referral
• The 4 basic types of assessment are:

  • Initial Comprehensive Assessment
  • Ongoing or partial assessment
  • Focused or problem-oriented assessment
  • Emergency Assessment
• The major steps in the assessment phase include:

  • Collection of Subjective Data
  • Collection of Objective Data
  • Validation of Data
  • Documentation of Data
• Preparing for the assessment involves reviewing the client’s medical records, keeping an open mind, educating yourself about the client’s diagnosis, reflecting on your feelings, and organizing materials needed for the assessment
• Subjective data are sensations, symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client
• Objective data are observations and physical assessment findings of the nurse or other healthcare professionals, documented in the client record
• Comparing subjective and objective data:

  • Subjective data are elicited and verified by the client, while objective data are observed through measurement
  • Subjective data are obtained through client interviews, while objective data are obtained through observation and physical examination
• Validating assessment data ensures that the assessment process is not ended before all relevant data have been collected, helping to prevent the documentation of inaccurate data
• Documenting data forms the database for the entire nursing process and provides data for all other members of the healthcare team
• The analysis of assessment data involves identifying abnormal data and strengths, clustering the data, drawing inferences, proposing possible nursing diagnoses, checking for defining characteristics of those diagnoses, and confirming or ruling out nursing diagnoses
• Factors affecting health assessment include culture, family, community, and spirituality
• Nursing diagnosis is a clinical judgement concerning human response to health conditions or life processes, providing a basis for selecting nursing interventions to achieve outcomes for which the nurse is accountable
• Collaborative problems are physiological complications that nurses monitor to detect their onset or changes in status
• Referrals occur because nurses assess the whole client, often identifying problems that require the assistance of other healthcare professionals
• • XII. Hypoglossal: Movement of the tongue
• The cranial nerves and their functions:

  • I. Olfactory: Sense of smell
  • II. Optic: Sense of sight
  • III. Oculomotor: Movement of the eyeball; constriction of pupil in bright light or for near vision
  • IV. Trochlear: Movement of eyeball
  • V. Trigeminal: Sensation in face, scalp, and teeth; contraction of chewing muscles
  • VI. Abducens: Movement of the eyeball
  • VII. Facial: Sense of taste; contraction of facial muscles; secretion of saliva
  • VIII. Vestibulocochlear: Sense of hearing and sense of equilibrium
  • IX. Glossopharyngeal: Sense of taste; sensory for cardiac, respiratory, and blood pressure reflexes; contraction of pharynx; secretion of saliva
  • X. Vagus: Sensory in cardiac, respiratory, and blood pressure reflexes; sensory & motor to larynx; decreases heart rate; contraction of alimentary tube; increases digestive secretions
  • XI. Accessory: Contraction of neck and shoulder muscles; motor to larynx
• Cardiac assessment includes areas like the LV area, RV area, pulmonic area, and aortic area
• The sympathetic and parasympathetic responses in different body parts:

  • Eyes: Dilate pupils (sympathetic), Constrict pupils (parasympathetic)
  • Lungs: Relaxes bronchi (sympathetic), Contract bronchi (parasympathetic)
  • Heart: Accelerates heartbeat (sympathetic), Slows heartbeat (parasympathetic)
  • Stomach/intestine: Inhibits activity (sympathetic), Stimulates activity (parasympathetic)
  • Blood vessels of internal organs: Contracts vessels (sympathetic), Dilates vessels (parasympathetic)
• At a glance, health assessment includes checking body parts like integument, head, eyes, nose and sinuses, mouth, neck, cardiovascular system, respiratory system, gastrointestinal system, urinary system, reproductive system, musculoskeletal system, and neurologic system
• Thank You!!!
• Examples of Aphasia

  • Expressive Aphasia: Inability to speak clearly due to lesion in the motor speech center or Broca's area in the left frontal lobe
  • Receptive Aphasia: Inability to interpret or understand sounds and words due to lesion in the auditory speech center or Wernicke's area in the temporal lobe
  • Global Aphasia: Absence of spontaneous speech and comprehension due to lesions affecting both Broca's area and Wernicke's area
• Speech Disorder

  • Dysphonia: Difficulty in talking with abnormal pitch or volume due to laryngeal disease. Voice sounds hoarse or whispered but articulation and language are intact.
  • Dysarthria: Distorted speech sounds; speech may sound unintelligible; basic language (word choice, grammar, comprehension) intact.
  • Aphasia: True language disturbance with defect in word choice and grammar or comprehension; defect in higher integrative language processing
• Abnormalities of Mood and Affect

  • Flat Affect (Blunted Affect): Lack of emotional response with no expression of feelings; voice monotonous and face immobile
  • Depression: Feeling sad and gloomy, symptoms may occur with specific triggers and fade quickly if temporary
  • Depersonalization: Loss of identity and feeling estranged
  • Elation: Joy, optimism, and overconfidence
  • Euphoria: Excessive well-being and cheerfulness, often inappropriate
  • Anxiety: Feeling worried and uneasy from unknown sources of danger
  • Fear: Feeling worried and uneasy from known sources of danger
  • Irritability: Easily provoked and impatient
  • Rage: Furious with loss of control
  • Ambivalence: Opposing emotions toward an idea, object, or person
  • Lability: Rapid shift of emotions
  • Inappropriate Affect: Affect incongruent with the content of speech
• Abnormalities of Thought Process: Perseveration


  Persistent repeating of verbal or motor response, even with varied stimuli
• Abnormalities of Thought Process: Circumlocution


  Round about expression, substituting a phrase when cannot think name of object
• Abnormalities of Thought Process: Clanging (Clang Association)

  Word choice based on sound, not meaning, includes nonsense rhymes and puns
• Abnormalities of Thought Process: Echolalia

  Imitation, repeats other's words or phrases, often with a mumbling or mocking or mechanical tone
• Abnormalities of Thought Process: Circumstantiality


  Talks with excessive and unnecessary details, delays reaching point. Sentences have a meaningful connection but are irrelevant
• Abnormalities of Thought Process: Word Salad


  Incoherent mixture of words, phrases and sentences; illogical, disconnected, includes neologisms
• Abnormalities of Mood and Affect: Inappropriate Affect

  Affect clearly incongruent with the content of the person's speech. Laughs while being told of his/her diagnosis as cancer
• Abnormalities of Thought Process: Blocking


  Sudden interruption in train of thought, unable to complete sentence, seems related to strong emotion
• Abnormalities of Thought Process: Flight of Ideas


  Abrupt change, rapid shifting from topic to topic, practically continuous flow of accelerated speech; topics usually have unrecognizable associations or are plays on words
• Abnormalities of Thought Process: Confabulation

  Fabricates events to fill in memory gaps. Gives detailed description of his long walk in the hospital patio, although the patient remained in his room all day
• Abnormalities of Mood and Affect: Lability

  Rapid shift of emotions. Person expresses euphoric, tearful, angry feelings in rapid succession
• Abnormalities of Thought Process: Loosening Associations

  Shifting from one topic to an unrelated topic; person seems unaware that topics are unconnected
• Abnormalities of Thought Process: Neologism

  Coining a new word; invented word has no real meaning except for the person
• Strong, persistent, irrational fear of an object or situation; feels driven to avoid it