Health Assessment

• Informed consent


  It is crucial during health assessment as it respects the patient's autonomy and right to make decisions regarding their health care
• Nurse's role in obtaining informed consent


  Ensuring the patient understands the purpose and risks of the assessment before proceeding
• Data Privacy Act


  It ensures the confidentiality and protection of patient health information
• Patient's Bill of Rights


  • Right to Appropriate Medical Care and Humane Treatment
  • Right to Informed Consent
  • Right to Privacy and Confidentiality
  • Right to Information
  • Right to Choose Health Care Provider and Facility
  • Right to Self-Determination
  • Right to Religious Belief
  • Right to Medical Records
  • Right to Leave
  • Right to Refuse Participation in Medical Research
  • Right to Correspondence and to Receive Visitors
  • Right to Express Grievances
  • Right to be Informed of His Rights and Obligations as a Patient
• Phases of the interview

  1. Introductory

  2. Working

  3. Summary and closing
• Introductory Phase


  • Introduction
  • Explaining the purpose of the interview
  • Discussing the types of questions that will be asked
  • Explaining the reason for taking notes
  • Assuring the client that confidential information will remain confidential
  • Making sure that the client is comfortable and has privacy
  • Developing trust and rapport using verbal and nonverbal skills
• Working Phase


  • Biographical data
  • Reasons for seeking care
  • History of present health concern
  • Past health history
  • Family history
  • Review of body systems for current health problems
  • Lifestyle and health practices and developmental level
  • Listening, observing cues, and using critical thinking skills to interpret and validate information received from the client
  • Collaborating with the client to identify the client's problems and goals
• Summary and Closing Phase

  • Summarizing information obtained during the working phase
  • Validating problems and goals with the client
  • Identifying and discussing possible plans to resolve the problem with the client
  • Making sure to ask if anything else concerns the client and if there are any further questions
• A client's feelings and perceptions may be recorded as subjective data
• Non-verbal Communication


  • Appearance
  • Demeanor - being quiet
  • Facial expression
  • Attitude
  • Silence
  • Listening
• Non-verbal Communication to avoid

  • Excessive or insufficient eye contact
  • Distraction and distance
  • Standing
• Verbal Communication


  • Open-ended questions
  • Closed-ended questions
  • Laundry list
  • Rephrasing
  • Well-placed phrases
  • Inferring
  • Providing information
• The nurse should use open-ended questions to elicit the client's feelings and perceptions
• Verbal Communication to avoid


  • Biased or leading questions
  • Rushing through the interview
  • Reading the questions
• Special Considerations


  • Gerontologic variations
  • Cultural variations
  • Emotional variations
• Interacting with an Anxious Client

  • Provide the client with simple, organized information in a structured format
  • Explain who you are and your role and purpose
  • Ask simple, concise questions
  • Avoid becoming anxious like the client
  • Do not hurry
  • Decrease any external stimuli
• Interacting with an Angry Client

  • Approach the client in a calm, reassuring, in-control manner
  • Allow the client to vent feelings
  • Avoid any arguments with or touching the client
  • Obtain help from other health care professionals as needed
  • Facilitate personal space so that the client does not feel threatened or cornered
  • Never allow the client to position him or herself between you and the door
• Interacting with a Depressed Client

  • Express interest in and understanding of the client and respond in a neutral manner
  • Take care not to communicate in an upbeat, encouraging manner
• Interacting with a Manipulative Client

  • Provide structure and set limits
  • Differentiate between manipulation and a reasonable request
  • Obtain an objective opinion from other nursing colleagues
• Interacting With a Seductive Client

  • Set firm limits on overt sexual client behavior and avoid responding to subtle seductive behaviors
  • Encourage client to use more appropriate methods of coping in relating to others
  • If the overt sexuality continues, do not interact without a witness
  • Report inappropriate behavior to a supervisor
• Discussing Sensitive Issues


  • Be aware of your own thoughts and feelings regarding dying, spirituality, and sexuality
  • Ask simple questions in a nonjudgmental manner
  • Allow time for ventilation of client's feelings as needed
  • If you do not feel comfortable or competent discussing personal, sensitive topics, you may make referrals as appropriate
• Health History


  • Biographical data
  • Reasons for seeking health care
  • History of present health concern
  • Past health history
  • Family health history
  • Review of systems for current health problems
  • Lifestyle and health practices
  • Developmental level
• Health History—Biographical Data #1

  • Name
  • Address
  • Phone
  • Gender
  • Provider of history (patient or other)
  • Birth date
  • Place of birth
• Health History—Biographical Data #2

  • Race or ethnic background
  • Primary and secondary languages (spoken and read)
  • Marital status
  • Religious or spiritual practices
  • Educational level
  • Occupation
  • Significant others or support persons (availability)
• Lifestyle and Health Practices #1

  • Description of typical day (AM to PM)
  • Nutrition and weight management
  • 24-hour dietary intake (foods and fluids)
  • Who purchases and prepares meals
  • Activity on a typical day and exercise habits and patterns
  • Rest and sleep habits and patterns
  • Medication and substance use
  • Self-concept and self-care responsibilities
• Lifestyle and Health Practices #2

  • Social activities
  • Relationships
  • Values and belief system
  • Past, present and future education and work
  • Type of work, level of job satisfaction, work stressors
  • Stress levels and coping strategies
  • Residency, environment, neighborhood, environmental risks
• Good overhead lighting is sufficient, but sunlight is best when available
• Standard Precautions


  • Hand hygiene
  • Gloves
  • Mask, eye protection, face shield
  • Gown
  • Patient care equipment; patient placement
  • Linen; occupational health (Control environmental Hazards) and blood-borne pathogens
• Gloves must be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms
• Client Approach and Preparation

  • Establish nurse–client relationship
  • Explain the procedure and the physical assessment that will follow, describing the steps of the examination
  • Respect client's requests and desires
  • Explain the importance of the examination
  • Leave room while client changes clothes
  • Provide necessary container in case of need for sample
  • Begin exam with less intrusive procedures
  • Explain procedure being performed
  • Explain to client why position changes are necessary
• Client Positioning


  • Sitting position
  • Supine position
  • Dorsal recumbent position
  • Sims' position
  • Standing position
  • Prone position
  • Knee–chest position
  • Lithotomy position
• Sitting upright on the side of the examination table is a useful position while examining the client as it allows full expansion of the lungs
• Physical Examination: Inspection


  • Room at comfortable temperature
  • Good lighting
  • Look and observe before touching
  • Completely expose part being examined while draping the rest of client as appropriate
  • Note characteristics
  • Compare appearance
• Physical Examination: Palpation #1

  • Light palpation
  • Moderate palpation
  • Deep palpation
  • Bimanual palpation
• Moderate palpation involves depressing the skin surface 1 to 2 cm with the dominant hand and using a circular motion to feel for easily palpable body organs and masses
• Physical Examination: Palpation #2

  • Texture (rough/smooth)
  • Temperature (warm/cold)
  • Moisture (dry/wet)
  • Mobility (fixed/movable/still/vibrating)
  • Consistency (soft/hard/fluid filled)
  • Strength of pulses (strong/weak/thready/bounding)
  • Size (small/medium/large)
  • Shape (well defined/irregular)
  • Degree of tenderness (Pain/Discomfort)
• Physical Examination: Percussion Purposes

  • Eliciting pain
  • Determining location, size, and shape
  • Determining density
  • Detecting abnormal masses
  • Eliciting reflexes
• Physical Examination: Percussion Types

  • Direct
  • Blunt
  • Indirect or mediate
  • Sounds elicited by percussion: Resonance, Hyperresonance, Tympany, Dullness, Flatness
• Blunt percussion is used to detect tenderness over organs by placing one hand flat on the body surface and using the fist of the other hand to strike the back of the hand flat on the body surface
• Physical Examination: Auscultation


  • Eliminate distracting noise
  • Expose the body part being auscultated
  • Diaphragm, high-pitched sounds; bell, low-pitched sounds
  • Place earpieces into outer ear canal
  • Angle binaural down toward nose