nursing assessment

• Nursing Process (ADPIE): This five (5) stage ensuring essential, systematic and individualized patient care


  • A-ssessment
  • D-iagnosis
  • P-lanning
  • I-mplementation
  • E-valuation
• Health Assessment is the first and most crucial phase of the nursing process
• Health Assessment in Nursing Practice

  • Systematic and continuous collection of data
  • Sorting, analyzing, and organizing that data
  • Documentation and communication of the data collected
• Health Assessment


  Holistic approach that helps to think about an individual's physical health, mental health and other needs, as well as the broader social and environmental factors that influence their lives and care
• Types of Health Assessment

  • Initial Comprehensive Assessment
  • On-going or Partial Assessment
  • Focused or Problem-Oriented Assessment
  • Emergency Assessment
• Initial Comprehensive Assessment


  Involves collection of subjective and objective data about the client's perception on their health, past health history, family history, lifestyle and health practices, Objective data gathered during step-by-step physical examination. * Usually done at OPD or during admission
• On-going or Partial Assessment


  Consists of data collection that occurs after the initial or comprehensive database, including a mini overview of the client's body system and holistic health patterns (deterioration or improvements) *Usually done after admission and reassessment based on admitting diagnosis
• Focused or Problem-Oriented Assessment


  Consists of a thorough assessment of a particular problem, does not replace the comprehensive health assessment
• Emergency Assessment


  A very rapid assessment performed in life-threatening situations to provide prompt treatment (choking, cardiac & pulmonary arrest, drowning, congestion). Immediate assessment is needed to provide prompt treatment.(ABCs)
• Nurses' Role in Health Assessment

  • Making sound judgement based on observations and data collection
  • Assessing patients, family and community
  • Using senses to assess patients
  • Protecting patient rights
• Steps of Health Assessment

  • Preparing for Assessment
  • Collection of Subjective Data
  • Collection of Objective Data
  • Validation of Data
  • Documentation of Data
• Collection of Subjective Data

  Includes biographical information, history of present illness/condition, personal health history (Lifestyle, health practices, immunization, nutrition, beliefs, other practices and review of system),family history
• Collection of Objective Data

  Includes physical characteristics, body functions, appearance, behavior, measurements, results of laboratory testing
• Validation of Data


  Serves to ensure the assessment process and prevent inaccurate data, including validating with another health care provider
• Documentation of Data


  Serves as database for the entire nursing process and provides data for all other members of the health care team.Thorough and accurate documentation is vital to ensure valid conclusion.
• Factors Affecting Health Assessment

  • Knowledge
  • Health Practices/Beliefs/Culture/Traditions
  • Family
  • Community
  • Psychosocial Nursing
• Positioning the Client


  • Sitting Position
  • Supine Position
  • Dorsal Recumbent Position
  • Prone Position
  • Sims Position
  • Standing Position
  • Knee-Chest Position
  • Lithotomy
  • Trendelenburg Position
  • Reverse Trendelenburg Position
• Equipment for Assessment


  • Examination Equipment
  • Vital Signs Equipment
  • Nutritional Status Exam Equipment
  • Skin, Hair, and Nail Examination Equipment
  • Head and Neck Examination Equipment
  • Eye Examination Equipment
  • Ear Examination Equipment
  • Mouth, Throat, Sinus Examination Equipment
  • Thoracic and Lung Examination Equipment
  • Heart and Neck Vessel Examination Equipment
  • Peripheral Vascular Exam Equipment
  • Abdominal Exam Equipment
  • Musculoskeletal Examination Equipment
  • Neurologic Exam Equipment
  • Male Genitalia and Rectum Examination Equipment
  • Female Genitalia and Rectum Examination Equipment
• Sample Common Chief Complaints

  • Fever
  • Chills
  • Pain
  • Swelling
  • Dizziness
  • Wound
  • Rash
  • Numbness
  • Loose bowel movement
  • Nausea and Vomiting
  • Colds
  • Cough
  • Blurring of vision
  • Shortness of Breath
  • Bleeding
  • Weakness
  • Convulsion
  • Blood in the stool/urine
  • Jaundice
  • High blood pressure
  • Epistaxis
  • Hemoptysis
  • Hematemesis
  • Hematochezia
  • Melena
• Proper patient positioning provides optimal exposure to the surgical/treatment site and maintenance of the patient’s dignity by controlling unnecessary exposure. In most settings, proper positioning of patients provides airway management and ventilation, maintains body alignment, and provides physiologic safety.
• This position good to evaluate the head, neck, lungs, chest, back, breast, axilla, heart, vital signs and upper extremities.

  sitting position
• This position allows the abdominal muscle to relax and provides easy Access to peripheral pulse sites, & all extremities.

  supine position
• like supine but the knees bent, and the legs separated and the feet flat on the table or bed

  dorsal recumbent position
• The patient lies down on the abdomen with the head to the side. This position is used primarily to assess the hip joint and back. Patients with cardiac and respiratory problems cannot tolerate this position.

  prone positioning
• The patient lies on the right or left side with lower arm placed behind the body and the upper arm flexed at he shoulder and the elbow. This position is useful for rectal and vaginal areas.

  sims position
• Thelevel of the feet and legs are abovethe level of the heart. This position is helpful to aid the blood flow from the lower extremities to our central circulation. Shock, lower abdomenandgynecological surgery

  trendelenburg position
• To relieve gastroesophageal reflux and intracranial pressure. In surgery, it is used to reduce blood loss during neck and head procedures.

  reverse trendelendurg position