Health Assessment

• Health Assessment


  Collecting Objective Data: The Physical Examination
• Preparing for the Examination


  1. Preparing the physical setting

  2. Preparing oneself

  3. Approaching and preparing the client
• Physical Examination Techniques


  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Inspection


  Using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings
• Percussion


  1. Eliciting pain

  2. Determining location, size, and shape

  3. Determining density

  4. Detecting abnormal masses

  5. Eliciting reflexes
• Types of Percussion


  • Direct percussion
  • Blunt percussion
  • Indirect or mediate percussion
• Auscultation


  Using a stethoscope to listen for heart sounds, movement of blood, movement of the bowel, and movement of air through the respiratory tract
• Guidelines for Auscultation


  • Eliminate distracting or competing noises
  • Expose the body part
  • Use the diaphragm for high-pitched sounds
  • Use the bell for low-pitched sounds
• Validation of Data


  The process of confirming or verifying that the subjective and objective data collected are reliable and accurate
• Data Requiring Validation


  • Discrepancies or gaps between subjective and objective data
  • Discrepancies or gaps in what the client says at different times
  • Findings that are highly abnormal or inconsistent with other findings
• Methods of Validation


  • Recheck your own data
  • Clarify data with the client
  • Verify data with another health care professional
  • Compare your objective and subjective findings
• Identification of Areas for which Data are Missing

  Recognizing areas where more information is needed to fully understand the client's condition
• Documentation


  The written legal record of all pertinent interactions with the client
• Purposes of Assessment Documentation

  • Provides a chronologic source of client assessment data
  • Ensures information is accessible to the health care team
  • Establishes a basis for screening or validating proposed diagnoses
  • Offers a basis for determining educational needs
  • Provides a basis for determining eligibility for care and reimbursement
  • Constitutes a permanent legal record
  • Forms a component of client acuity systems
  • Provides access to epidemiologic data
  • Promotes compliance with requirements
• Information Requiring Documentation


  • Subjective Data
  • Objective Data
• Guidelines for Documentation


  • Keep confidential
  • Document legibly
  • Use correct grammar and spelling
  • Avoid wordiness
  • Use phrases instead of sentences
  • Record data findings, not how they were obtained
  • Write entries objectively
  • Record the client's understanding
  • Avoid recording "normal"
  • Record complete information
  • Include additional assessment content
  • Support objective data with observations
• Assessment Forms Used for Documentation

  • Initial Assessment Form
  • Frequent or Ongoing Assessment Form
  • Focused or Specialty Area Assessment Form
• Consequences of Inadequate Documentation

  • Fragmented care
  • Repetition of tasks
  • Delayed Therapy
  • Omitted Therapy
  • Delayed Recovery
• Validation of Data


  The information gathered during the assessment phase must be complete, factual, and accurate because the nursing diagnosis and interventions are based on this information
• Validation


  The act of "double-checking" or verifying data to confirm that it is accurate and factual
• Validation of assessment data is a crucial part of assessment that often occurs along with collection of subjective and objective data
• Validation serves to ensure that the assessment process is not ended before all relevant data have been collected, and helps to prevent documentation of inaccurate data
• Purpose of Validation of Data

  • Ensure that data collection is complete
  • Ensure that subjective and objective data agree, and does not contradict
  • Obtained additional data that may have been overlooked
  • Avoid jumping to conclusion
  • Differentiate cues inferences
• Different Ways to Validate Data

  • Recheck your data via repeat assessment
  • Clarify data with client by asking additional questions
  • Verify data with another health care professional
  • Compare objective findings with subjective findings to uncover discrepancies
• Example situations that require client data to be verified

  • Discrepancies or gaps between the subjective and objective data
  • Discrepancies or gaps between what the client says at one time versus another time
  • Findings that are highly abnormal and/or inconsistent with other findings
• The following are inconsistent with each other: the client has a temperature of 38.9 degree celcius, is resting comfortably, and her skin is not warm to touch and not flushed
• Types of Health Histories

  • Comprehensive health history
  • Problem-based or focused health assessment
  • Episodic or follow-up assessment
• Comprehensive health history


  • May be performed during a hospital admission, with an initial clinic or home visit, or when the patient's reason for seeking care is for relief of generalized symptoms such as weight loss or fatigue
  • Requires more time than other types of histories because a complete database is being established
  • The patient's condition must be considered - a critically ill patient is unable to participate in a comprehensive interview
• Problem-based or focused health assessment

  • Includes data that are limited in scope to a specific problem
  • Must be detailed enough that the nurse is aware of other health-related data that might affect the current problem
• Episodic or follow-up assessment


  • Focuses on the specific problem or problems for which a patient has already been receiving treatment
  • The nurse should assess for changes in the history since the last visit
• Components of the Health History

  • Biographic data
  • Reason for seeking care
  • History of present illness
  • Present health status
  • Past health history
  • Family history
  • Personal and psychosocial history
  • Review of systems
• Biographic data


  Collected at the first visit and updated as changes occur, forming a picture of the patient as a unique individual
• Reason for seeking care

  Also called the chief complaint (CC) or presenting problem, a brief statement of the patient's purpose for requesting the services of a health care provider
• History of present illness

  • When patients seek health care for a specific problem, the nurse documents the present illness or problem and further investigates the history of the present problem through a symptom analysis
• Symptom analysis


  A systematic way to collect data about the history and status of symptoms, including onset of symptoms, location and duration of symptoms, characteristics, aggravating and alleviating factors, related symptoms, attempts at self-treatment, and severity of symptoms
• Present health status


  • Health conditions
  • Medications
  • Allergies
  • Last examinations
  • Obstetric history
• Family history


  Obtained to identify illnesses of genetic, familial, or environmental nature that might affect the patient's current or future health, tracing back at least three generations
• Personal and psychosocial history

  • Personal status
  • Family and social relationships
  • Diet/nutrition
  • Functional ability
  • Tobacco, alcohol, and illicit drug use
• Functional ability


  A person's ability to perform self-care activities and skills needed for independent living
• Tobacco use


  Identified by type of tobacco used and frequency, recorded in pack-years for cigarette smokers