HEALTH ASSESSMENT

• Affective Objectives

  • Inculcate importance of the nursing process in the nursing profession
  • Listen attentively during class discussions
  • Demonstrate tact and respect when challenging other people’s opinions and ideas
  • Accept comments and reactions of classmates on one’s opinions openly and graciously
• Essential Features of Nursing Practice - ANA 1995


  • Full range of human experiences and responses to health and illness w/o restriction to a problem focused orientation
  • Caring relationship that facilitates health and healing
  • Understanding and integration of objective data based on the client’s subjective experience
  • Knowledge (scientific) for diagnosis and treatment
• The nursing process is a systematic problem-solving approach that directs the nurse and the client to determine the need for nursing care, plan and implement the care, and evaluate the result
• Nursing is the diagnosis and treatment of human responses to health and illness - ANA 1995
• The nursing process is a systematic, organized method of planning and providing quality and individualized nursing care
• Health Assessment is a thinking, doing, and feeling process that directs the rest of the nursing process
• Psychomotor Objectives


  • Participate actively during class discussions
  • Confidently express personal opinion and thoughts in front of the class
• Nursing is concerned with the individual’s physical, psychological, sociological, cultural, and spiritual aspects
• Health Assessment involves learning the normal, identifying it, differentiating it from the abnormal, and using it in every area of nursing
• Course Objectives

  • Discuss how nursing assessment skills are needed for every situation the nurse encounters
  • Differentiate between a holistic nursing assessment and a physical medical assessment
  • Describe which phases of the nursing process involve assessment by the nurse
  • List and describe the steps of the nursing process, explaining how some steps overlap and may have to be repeated many times when caring for a client
  • Describe the steps of the “analysis phase” of the nursing process
  • Explain how the nurse’s role in assessment has changed over the past century
• The nursing process combines the most desirable elements of the art of nursing with the most relevant elements of systems theory, using the scientific method
• Health Assessment is the first step of the Nursing Process
• Planning


  1. Involves setting goals and outcomes

  2. Priority setting

  3. Types of goals: Long Term and Short Term

  4. Planning should be specific, measurable, attainable, realistic, time-bound
• Diagnosis

  1. Clinical judgment concerning a human response to health conditions/life processes

  2. Analysis of data to identify the problem

  3. Formulating nursing diagnosis involves identifying and prioritizing actual or potential health problems or responses
• Steps of the Nursing Process (ADPIE)

  • Assessment
  • Diagnosis
  • Planning
  • Intervention
  • Evaluation
• Evaluation


  1. Final step of the nursing process

  2. Crucial to determine if the patient’s condition improved or worsened

  3. Monitoring client’s progress

  4. Alter the plan as indicated
• Nursing Process

  A systematic problem-solving approach for determining the need for nursing care, planning and implementing care, and evaluating the results
• Assessment


  1. Systematic collection of data

  2. Sets the tone for the rest of the process

  3. Identifies patient’s strengths and limitations continuously
• Types of Nursing Diagnosis

  • Problem-focused ND
  • Risk ND
  • Health Promotion ND
  • Syndrome ND
• Nursing Process

  • Goal-oriented
  • Organized
  • Systematic
  • Humanistic care
• Intervention


  1. Any treatment based on clinical judgment to enhance patient outcomes

  2. Putting the plan of care into action

  3. Direct and Indirect care

  4. Types: Independent, Dependent, Collaborative
• The steps of the nursing process are interrelated forming a continuous circle of thought and action that is both dynamic and cyclic
• Purposes of the nursing process

  • To identify a client’s health status; his Actual/Present and potential/possible health problems or needs
  • To establish a plan of care to meet identified needs
  • To provide nursing interventions to meet those needs
  • To provide an individualized, holistic, effective and efficient nursing care
• Creativity and adaptability are very important for nurses
• Definition of Assessment according to Atkinson and Murray (1991): Assessment is a part of each activity the nurse does for and with the patient
• Initial Comprehensive Assessment

  1. Involves collection of subjective and objective data about the client’s health, past health history, family history, lifestyle, and health practices

  2. Total health assessment is needed when the client first enters a health care system and periodically thereafter to establish baseline data

  3. Frequency of comprehensive assessments depends on the client’s age, risk factors, health status, health promotion practices, and lifestyle
• Ongoing or Partial Assessment


  1. Consists of data collection that occurs after the comprehensive database is established

  2. Reassesses any problems initially detected and detects any changes from baseline data

  3. Performed whenever the nurse or another health care professional has an encounter with the client
• Types of Health Assessment

  • Initial comprehensive assessment
  • Ongoing or partial assessment
  • Focused or problem-oriented assessment
  • Emergency assessment
• The nurse must be able to apply some basic abilities on the knowledge of science and theory
• Evaluation


  1. Final step of the nursing process

  2. Crucial to determine if the patient’s condition improved or worsened after application of the first four steps of the nursing process

  3. Monitoring of client’s progress

  4. Alter the plan as indicated

  5. Involves determining the effectiveness of your plan

  6. Assessing the patient’s response based on the criteria set for the outcome
• Definition of Assessment according to Carpenito: deliberate and systematic collection of data to determine a client’s current and past health status and functional status and to determine the client’s present and coping patterns
• Characteristics of the nursing process

  • Dynamic and cyclic
  • Patient centered
  • Goal directed
  • Flexible
  • Problem oriented
  • Cognitive
  • Action oriented
  • Interpersonal
  • Holistic
  • Systematic
• The frequency of this type of assessment is determined by the acuity of the client
• This type of assessment is usually performed whenever the nurse or another health care professional has an encounter with the client
• Baseline data assessment


  Performed to detect any new problems
• Emergency Assessment


  • Immediate assessment needed to provide prompt treatment
• Rapidly evolving roles of nursing

  • Forensic nursing
• The major concern during an emergency assessment is to determine the status of the client's life-sustaining physical functions
• The role of the nurse in assessment and diagnosis is more prevalent today than ever before in the history of nursing
• Nurses in the late 1800s to early 1900s relied on their natural senses; the client's face and body would be observed for changes