Introduction to Health Assessment - used to evaluate the health status of a person
HEALTH
- Is a relative state in which a person is able to live
to his or her potential and includes the “7 Facets”
- Additional component that contributes to health:
IRFANEC
◦ individual’s personality and attitude
◦ resilience
◦ family dynamics
◦ access to health care and resources
◦ nutrition
◦ exercise
◦ culture and beliefs
7 Facets PESCSED
-The ability to juggle and align the facets in a
harmonious network leads to a healthy state for an
individual
-Patient’s view and definition of health
Physical health - how the body works and adapts.
Emotional health - positive outlook and emotions
channeled in a healthy manner.
Social well-being - supportive relationships with
family and friends
Cultural influences - favorable connections to
promote health.
Spiritual influences - living peacefully, morally, and
ethically.
Environmental influences - favorable conditions to
promote health.
Developmental level - how one thinks, solve
problems, and make decisions.
HEALTH ASSESSMENT
- Includes a complete health history and physical
examination
- Involves a systematic data collection that provides
information to facilitate a plan to deliver the best
care for the patient.
▪ The ability to ask information, understand the
findings, and apply knowledge can initially be
daunting to the new nurse.
- 1st part
health history which incorporate the “7 facets”
- tasks pertinent questions to gather data from the
patient and/or family
- past medical records
- 2nd part
Physical Examination
- The nurses use structured head to toe examination
to identify changes in the patient’s body system
Purpose of Health Assessment:
▪ To determine a patient’s health status, risk factors,
and need for education as a basis for developing a
nursing care plan.
- The ability of the nurse to extrapolate the findings,
prioritized them, and formulate and implement the
plan of care is the overall goal (Nursing Process)
- The information obtained should be documented
in a clear, concise manner (patient’s medical
records)
▪ Through HA nurses detect areas of concern
requiring immediate attention – as well as health
maintenance or improvement needs
- Health promotion and disease prevention (Health
Education)
Steps in Health Assessment SOVD
▪ Preparing for the Assessment
Before actually meeting the client:
- review the client’s medical record, if available (it
provides background about chronic diseases and
gives clues to how a present illness may impact the
client’s activities of daily living (ADL)
- know the client’s basic biographical data
- keep an open mind and avoid premature
judgments that may alter your ability to collect
accurate data
- take time to educate yourself about the client’s
diagnosis and tests performed
- obtain and organize materials that you will need
for the assessment
1. Collection of subjective data
To elicit accurate subjective data, learn to
use effective interviewing skills with a variety of
clients in different settings.
Major areas of subjective data include:
- biographical information
- history of present health concern
- personal health history
- family history
- health and lifestyle practices
2. Collection of objective data
These includes:
- physical characteristics
- body functions
- appearance
- behavior
- measurements
- results of laboratory testing
3. Validation of data
Occurs along with collection of subjective
and objective data.
To ensure that the assessment process is not
ended before all relevant data have been collected,
and helps to prevent documentation of inaccurate
data.
▪ Prioritizing Data
Assists you in prioritizing the patient’s
problems. When prioritizing, consider the acuity of
the problem, the patient’s perception of the
problems, and the situation at hand.
Top priority or primary problems – such as airway
problems – are life-threatening.
Secondary problems – such as pain – require
prompt attention to prevent further progression or
deterioration in your patient’s condition.
Third level problem – such as teaching needs – do
not require immediate attention and can be
addressed once your patient’s condition has
stabilized.
4. Documentation of data
It forms the database for the entire nursing
process and provides data for all other members of
the health care team.
Pieces to Complete Health Assessment:
▪The review of system is the basis for the
assessment and how to proceed with the PE
▪Listening and understanding a patient is the key…
▪HA assists the nurse to discover a patient’s needs
▪To acquire more details – establish rapport with
patients
▪Once information is collated, actual health risks
emerge, which represents potential health risks
This is a person’s life, and the pieces need to
fit correctly for the person to maintain health and
quality of life.
Acuity of the Patient’s Condition and Site of the Care
(determine the extent of the HA):
EMERGENCY ASSESSMENT- to determine the
patient’s current status who presents with a new
problem of a serious or critical nature.
FOCUSED ASSESSMENT- completed on a patient
who has already had a comprehensive examination
and is being seen for a follow-up visit.
▪ Nursing home admission of a patient with
dementia may require the HA information to be
supplemented from the family, past health care
providers, and/or medical records, based on ability
of the patient to remember information.
Medical focus is on diagnoses and treatment of the
disease.
Nursing Focus is on diagnoses and treatment of the
actual or potential human responses to disease or
life events.
▪ Evaluation continually occurs and reconfiguring
the plan as necessary.
▪ Health care team meets to collaborate on patients
and decide the best overall care.
Types of Health Assessment IOFE
▪ 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.
▪ Ongoing or partial assessment
Consists of mini-overview of the client’s
body systems and holistic health patterns as a
follow-up on health status.
Any problems that were initially detected in
the client’s body system or holistic health patterns
are reassessed to determine any changes.
Usually performed whenever the nurse or
another health care professional has an encounter
with the client.
▪ Focused or problem-oriented assessment
Performed when a comprehensive database
exists for a client who comes to the health care
agency with a specific health concern.
Consists of a thorough assessment of a
particular client problem and does not cover areas
not related to the problem.
▪ Emergency assessment
A very rapid assessment performed in life-
threatening situations to provide prompt treatment.
Role of the Nurse in Assessment
- Nurses delivers care across the lifespan.
- Nurses assess patient needs, develop interventions
and educate and counsels individuals, families,
groups and communities toward higher levels of
health and wellness.
- Nurses are involved in the shaping of public policy
and in social, economic, and workplace decisions/
- They oversee the holistic care of each patient.
- As a nurse, it is vital to sift through all the patient
information and make decisions on what
information will impact patient safety and quality of
care.
Opportunities for nurses with advanced
assessment skills:
- Rising educational costs and focus on primary Care
that affect the numbers and availability of medical
students.
- Increasing complexity of acute care.
- Growing aging population with complex
comorbidities.
- Expanding health care needs of single parents.
- Increasing impact of children and the homeless on
communities.
- Intensifying mental health issues.
- Expanding health service networks.
- Increasing reimbursement for health promotion
and preventive care services.
 PATIENT INTERVIEW
▪ Primary goal of the nurse-patient interview is to
improve the well-being of the patient.
Purpose of conversation with a patient:
- to establish a trusting and supportive relationship
- to gather information
- to offer information
Using techniques that promote trust and convey
respect allows the patient’s story to unfold in its
most full and detailed form.
◦ Health History Format - a structural framework for
organizing patient information in written, electronic,
verbal form to communicate effectively with other
health care providers.
◦ Interviewing Process - generates the health
information, is much more fluids and demands
effective communication and relational skills.
INTERVIEW
- A conversation with the patient where information
related to the patient’s health problems, feelings,
and perceptions is gained which can assist to
provide care.
- Beginning of a trusting nurse-patient relationship
(“rapport”).
- A purposeful, time-limited interaction between the
nurse and the patient.
- Initiated to collect information regarding the
patient’s health status.
- Validation of appropriate health and illness
information.
Patient Interview
Medical Interview- focused on the patient’s physical
or emotional state.
Nursing Interview- holistic in nature and includes
information about the total patient.
Role of the Nurse
- First person from the health care team to interact
with the patient.
- Assumes the role of the intermediary for the
patient
- Assist the patient in effectively utilizing the system.
- Should set the stage for interview.
- Approaching each patient with accepting,
respectful, non-judgmental attitude.
- Facilitator of the interview
- Collaborates with the patient in establishing a
mutually respectful dialogue.
Role of the Patient
- An active and equal participant in the interview
process.
- Should feel free to openly communicate thoughts,
feelings, perceptions and factual information.
- Possess previous knowledge of or experience with
the health care system influencing their current
perceptions and behavior.
- Passivity in health care matters is a norm (in some
cultures).
- Active participation (in today’s health care arena).
- Taking more active role in both their own health
care and in health care decisions.
- Actively seek health care providers who possess
clinical competence and willingness to give care.
Approaches of Interview
▪ Direct Interview – the nurse establishes the
purpose of the interview and controls the interview
by asking closed questions.
▪ Nondirective Interview (rapport-building
interview)
- The nurse allows the client to control the
purpose, subject matter, and pacing.
 - The nurse encourages communication by asking
open-ended questions and providing empathic
responses.
Kinds of Interview Questions
1.) Closed Questions
- directive interview.
- restrictive and generally requires only short
answers giving specific information.
- begin with when, where, who, what, do, is and
sometimes how.
2.) Open-ended Question
- nondirective interview
- lead or invite clients to cover and explore
(elaborate, clarify, or illustrate) their thoughts and
feelings.
- allow clients to talk about what they wish.
- broad, specifies only the topic to be discussed, and
invites answers longer than one or two words.
- useful at the beginning of an interview or to
change topics.
3.) Neutral question
- client can answer without direction or pressure
from the nurse.
Ex: “How do you feel about that?” “Why do you
think you had the operation?”
4.) Leading question
- directs the client’s answer.
- phrasing of the question suggests what answer is
expected.
- It does not give the client an opportunity to decide
whether the answer is true or not.
- It creates problems if the client, in an effort to
please the nurse, gives inaccurate responses.
- This results in inaccurate data collection.
Ex: “You’re stressed about surgery tomorrow, aren’t
you?” “You will take medicine, won’t you?”
Factors that Influence Interview
▪ Time, length and duration
- Nurses need to plan interviews with hospitalized
clients when the client is physically comfortable
and free of pain, and when interruptions are
minimal.
- Enough time must be set aside for the interview.
- Look for the patient’s daily activities then select
a block of time for the interview.
- The time should not conflict with the patient’s
meal time.
- Do not hesitate to ask the patient what
interview times would least disruptive to daily
routine.
- Try to accommodate the patient’s request.
▪ Seating Arrangement
- Seating arrangement in which the parties sit on
two chairs placed at right angles to a desk or
table or a few feet apart, with no table between,
creates a less formal atmosphere, and the nurse
and client tend to feel on equal terms.
▪ Language
- Failure to communicate in language the client
can understand is a form of discrimination.
▪ Approach
- Gather all available information prior to
approaching the patient.
- Admission data and past medical records may
reduce the time needed for interview.
o Introduce yourself before you begin the
interview. Include your name and title.
o Initially call the patient by his or her formal
name and ask how the patient prefers to be
addressed.
o Simple communications utilizing appropriate
names is respectful.
 o Giving recognition helps to lower the patient
anxiety and increase patient comfort level.
o Explain what is to follow and an approximate
time frame for the interview.
▪ Environment
- A well – lighted, well – ventilated, moderate –
sized room that is relatively free from noise,
movements, and interruptions encourages
communication.
- Setting for the interview has a direct influence
on the amount and quality of information
gathered.
- Time and effort spent indicates concern for the
patient and the quality and quantity of
information collected.
- Interview should be conducted in a private
room.
- If private setting is impossible, control the
environment- to minimize distractions and
interruptions.
- Utilize any physical barriers available in the
room to provide privacy.
▪ Confidentiality
- Essential in developing trust between nurse and
patient.
- Patient’s willingness to communicate private
and personal information is indicated.
*Assumption:
The information will be used for the benefit of
the patient.
Reasons for sharing information:
- Patient is a danger to self and others.
- Teaching institution where team approach is
used.
▪ Biases and Preconceptions
- Personal belief and value systems, attitudes,
biases and preconceptions of the nurse and
patient influence the sending and receiving of
messages.
- Cultural and family contexts serve as a lens for
interpreting ethnicity, gender and health care.
- There is an impact on how they respond to
different clinical situations.
- Nurse’s subjective impressions of the patient
may lead to faulty impressions about the patient
abilities or illnesses.
What to do:
To counter faulty assumptions and biases,
continually validate information and personal
impressions and using of careful data gathering and
effective interviewing techniques.
Factors affecting Communication
▪ Distance
- Intimate: 1.5 feet from the patient
- Personal: 1.5 to 4 feet from the patient
- Social: 4 to 12 feet; appropriate for interview
process
- Public: 12 feet or more
▪ Listening
Active listening or the act of perceiving what
is said both verbally and nonverbally.
To decode patient messages in order to
understand the situation or problem as the other
person sees it.
▪ Nonverbal cues
Avoid Traps when Interviewing Patient
◦ Leading the Patient
People will tell you what you want to hear,
so don’t lead the patient. Them describing what is
happening is more helpful.
◦ Blasting Yourself
If you fail to check your biases, you limit your
objectivity during assessment.
◦ Letting family answer for the patient
You will learn a lot by having the patient
describe things in his/her own words.
◦ Asking more than one question at a time
If you do, the patient may not know which
one to answer and get confused.
◦ Not allowing more response time
Give the patient time to think through
his/her answer.
◦ Using medical jargons
Express questions in lay terms for the patient
to understand.
◦ Assuming than clarifying and validating
Assuming can lead to inaccurate
interpretations and incorrect conclusions.
◦ Taking patient’s response personally
Realize that the patient is displacing his/her
feelings on you and using you as a sounding board.
◦ Feeling personally uncomfortable
Often happens at the beginning, it will get
easier with experience.
◦ Using cliché
No one expects you to have all the answers.
If you do not have an answer, tell the patient that
you will try to find one and get back to him/her.
◦ Offering false reassurance
Telling the patient that everything will be
fine is condescending.
◦ Asking persistent or probing questions
Makes the patient uncomfortable. The
patient has a right to not answer a question.
◦ Changing the Subject
You are attending to the patient’s needs, not
your own.
◦ Taking things literally
May lead to misunderstanding. Always
consider the context in which the statement is
made, and clarify if your are still unsure. Recognize
the patient’s feelings and focus on them.
◦ Giving advice
The patient needs to be informed, but can
make his/her own decisions.
◦ Jumping to conclusions
Make sure to have all the facts before
drawing conclusions.
Phases of the Interview
1.) Pre-interview
- Take time for self-reflection – is a continual part
of professional development in clinical work. It
brings a deepening personal awareness to our
work with patients, which is one of the most
rewarding aspects of patient care.
- Review the medical and nursing records.
- Set goals for the interview.
- A nurse must balance these provider-centered
goals with patient-centered goals.
- Review clinical behavior and appearance.
Professionalism requires the nurse maintain
equanimity (calmness under pressure)
-Adjust the environment
-Take notes
2.) Joining or Introductory Phase
- introduce yourself to your patient, put him or
her at ease, and explain the purpose of the
interview and the time frame needed to
complete it.
- Reassure your patient that the information
collected is confidential.
- Choose a distance that facilitates conversation
and allows good eye contact.
- Establish the agenda
Identifying all the concerns at the beginning
of the interview allows the patient and the nurse
to negotiate which concerns are most pressing
 for the visit, and which can be postponed to a
follow-up appointment.
3.) Working Phase
- data collection
- very structured; it is the longest phase
- Invite the patient’s story
◦ avoid biasing patient’s story
◦ do not add new information and do not
interrupt
◦ follow the patient’s lead
◦ use focused questions to explore the patient’s
story in more depth
- Identify and respond to the patient’s emotional
cues
◦ respond immediately when you hear an
emotional cue
◦ responding to emotional cue:
N – Naming
“That sounds like a scary experience”
U – Understanding or legitimization
“It’s understandable that you feel that “way”
R – Respecting
“You’ve done better than most people would
with this”
- Expand and clarify the patient’s story
◦ use patient’s words, making sure you clarify
their meaning
◦ do not use medical jargon
◦ establish the sequence and timing of each
patient symptoms
◦ interview moves back and forth from open-
ended questions to increasingly focused
questions and then on to another open-ended
questions, returning the lead in the interview to
the patient
- Generating and testing diagnostic hypotheses
- Create a shared understanding of the problem
◦ disease/ illness distinction model helps to
understand the full impact on the patient.
Disease is the explanation that the nurse
uses to account for the symptoms. It is the way
that the nurse organizes what is learned from
the patient that leads to a nursing diagnosis
Illness can be defined as how the patient
experiences the disease, including its effects on
relationships, function, and sense of well-being
Learning about the patient’s perception of
illness means asking patient-centered questions
in four domain:
- FEELINGS including fears or concerns, about
the problem.
- IDEAS about the nature and the cause of the
problem.
- The effect of the problem on the patient’s
life and FUNCTION.
- EXPECTATIONS of the disease, of the
clinician, or of health care, often based on
prior personal or family experiences.
- Negotiate a plan
4.) Termination Phase
- The end of the interview.
- Summarize and restate your findings.
- Allow patient to ask questions.