Health Assessment

• Types of Health Assessment

  • Initial Comprehensive Assessment
  • Ongoing or Partial Assessment
  • Focused or problem-oriented assessment
  • Emergency Assessment
• Initial Comprehensive Assessment


  Involves collection of subjective data about the client's perception of his or her health of all body parts or systems, past health history, family history, and lifestyle and health practices as well as objective data gathered during a step-by-step physical examination
• Ongoing or Partial Assessment


  Consists of data collection that occurs after the comprehensive database is established, and consists of a mini-overview of the client's body systems and holistic health patterns as a follow-up on health status
• Focused or problem-oriented assessment


  Does not replace the comprehensive health assessment, it is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern
• Emergency Assessment


  Very rapid assessment performed in life-threatening situations to determine the status of the client's life-sustaining physical functions
• Steps of Health Assessment

  1. Collection of Subjective Data

  2. Collection of Objective Data

  3. Validation of Data

  4. Documentation of Data
• Subjective Data


  Sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and personal information that can be elicited and verified only by the client
• Objective Data


  Data that the examiner directly observes, including physical characteristics, body functions, appearance, behavior, measurements, and results of laboratory testing
• Validation of Data


  A crucial part of assessment that often occurs along with collection of subjective and objective data, involving determining what types of assessment data should be validated, the different ways to validate data, and identifying areas where data are missing
• Documentation of Data


  An important step of assessment because it forms the database for the entire nursing professionals
• Collection of Subjective Data

  • Biographic Data
  • Reasons for seeking healthcare
  • Chief complaint
  • History of: Present Illness, Past Health History, Family Health History, Current Medications, Lifestyle, Developmental level
• Interviewing


  Focuses on establishing rapport and a trusting relationship with the client to elicit accurate and meaningful information, and gathering information on the client's developmental, psychological, physiologic, sociocultural, and spiritual statuses
• Phases of the Interview

  • Preintroductory Phase
  • Introductory Phase
  • Working Phase
  • Summary and Closing Phase
• Communication During Interview


  • Non-verbal: Appearance, Demeanor, Facial Expression, Attitude, Silence, Listening
  • Verbal: Open-ended questions, Closed-ended questions, Laundry list, Rephrasing, Well-phased phrases, Interferring, Providing information
• Special Considerations During the Interview

  • Gerontologic
  • Cultural
  • Emotional
• Eight Sections of Health History

  • Biographic Data
  • History of Present Health Concern
  • Family Health History
  • Lifestyle and practices
  • Reasons for Seeking Health Care
  • Personal Health History
  • Review of Systems
  • Developmental Level
• History of Present Illness

  Encourage the client to explain the health problem or symptom in detail, ask about onset, progression, duration, signs and symptoms, related problems, what makes it worse/better, treatments tried, effect on daily life, expectations, and self-care ability
• Past Health History/Personal Health History


  Focuses on questions related to the client's personal history, from the earliest beginnings to the present, including childhood illnesses and immunizations, adult illnesses, surgeries, accidents, allergies, and medication use
• Family Health History


  Includes as many genetic relatives as the client can recall, such as maternal and paternal grandparents, aunts and uncles, parents, siblings, and children
• Review of Systems


  • Skin, hair, and nails
  • Head and neck
  • Eyes
  • Ears
  • Mouth, throat, nose, and sinuses
  • Thorax and lungs
  • Breasts and regional lymphatics
  • Heart and neck vessels
  • Peripheral vascular
  • Abdomen
  • Male genitalia
  • Female genitalia
  • Anus, rectum, and prostate
  • Musculoskeletal
  • Neurologic
• Lifestyle and Health Practices


  • Description of Typical Day
  • Nutrition and Weight Management
  • Activity Level and Exercise
  • Sleep and Rest
  • Substance Use
  • Self-Concept and Self-Care Responsibilities
  • Social Activities
  • Relationships
  • Values and Belief System
  • Education and Work
  • Stress Levels and Coping Styles
  • Environment
  • Psychosexual History
• Freud's Theory of Psychosexual Development


  Consciousness, Preconsciousness, Unconsciousness
• Revised - Three basic structures in the anatomy of personality

  Id, Ego, Superego
• Collecting Objective Data


  Includes information about the client that the nurse directly observes during interaction with the client and information elicited through physical assessment (examination) techniques
• Areas of knowledge for physical assessment


  • Types and operation of equipment needed
  • Preparation of the setting, oneself, and the client
  • Performance of the four assessment techniques: inspection, palpation, percussion, and auscultation
• Preparing the Physical Setting

  • Comfortable, warm room temperature
  • Private area free of interruptions
  • Quiet area free of distractions
  • Adequate lighting
  • Firm examination table or bed at a height that prevents stooping
  • A bedside table/tray to hold the equipment needed
• Preparing oneself


  Wash your hands before beginning the examination, immediately after accidental direct contact with blood or other body fluids, and after completing the examination
• Preparation for the Examination
• Preparing the Physical Setting

  1. Ensure the examination setting meets the following conditions:

  2. Comfortable, warm room temperature

  3. Private area free of interruptions from others

  4. Quiet area free of distractions

  5. Adequate lighting

  6. Firm examination table or bed at a height that prevents stooping

  7. A bedside table/tray to hold the equipment needed for the examination
• Preparing oneself


  1. Wash your hands before beginning the examination, immediately after accidental direct contact with blood or other body fluids, and after completing the physical examination or after removing gloves

  2. Always wear gloves if there is a chance that you will come in direct contact with blood or other body fluids

  3. If a pin or other sharp object is used to assess sensory perception, discard the pin and use a new one for your next client

  4. Wear a mask and protective eye goggles if you are performing an examination in which you are likely to be splashed with blood or other body fluid droplets
• Approaching and Preparing the Client

  1. Establish the nurse–client relationship during the client interview before the physical examination takes place

  2. Explain to the client that the physical assessment will follow and describe what the examination will involve

  3. Respect the client's desires and requests related to the physical examination
• Physical Examination Techniques


  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• Positions


  • Sitting Position
  • Supine Position
  • Dorsal Recumbent Position
  • Sims' Position
  • Standing Position
  • Prone Position
  • Knee Chest Position
  • Lithotomy Position
• Inspection


  • Using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings
  • Some body systems require the use of special equipment (e.g., ophthalmoscope for the eye inspection, otoscope for the ear inspection)
• General Considerations for Examining Older Adults

  • Some positions may be very difficult or impossible for the older client to assume or maintain
  • Allow rest periods for the older adult, if needed
  • Older clients may process information at a slower rate, so explain the procedure and integrate teaching in a clear and slow manner
• Inspection


  • Make sure the room is a comfortable temperature
  • Use good lighting, preferably sunlight
  • Look and observe before touching
  • Completely expose the body part you are inspecting while draping the rest of the client as appropriate
  • Note the following characteristics while inspecting the client: color, patterns, size, location, consistency, symmetry, movement, behavior, odors, or sounds
  • Compare the appearance of symmetric body parts
• Palpation


  Using parts of the hand to touch and feel for characteristics such as texture, temperature, moisture, mobility, consistency, strength of pulses, size, shape, and degree of tenderness
• Parts of Hand to use when Palpating

  • Light Palpation
  • Moderate Palpation
  • Deep Palpation
  • Bimanual Palpation
• Percussion


  Tapping body parts to produce sound waves that enable the examiner to assess underlying structures
• Uses of Percussion


  • Eliciting pain
  • Determining location, size, and shape
  • Determining density
  • Detecting abnormal masses
  • Eliciting reflexes