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NCM 1202
(Health Assessment)

INTRODUCTION TO HEALTH ASSESSMENT

Learning Objectives
1 Discuss how nursing assessment skills are needed for every situation the nurse encounters.
2 Differentiate between a holistic nursing assessment and a physical medical assessment.
3 List and describe the steps of the nursing process
4 Compare and contrast the four basic types of nursing assessment
5 Explain how the nurse’s role in assessment has changed over the past century.

I. OVERVIEW OF NURSING PROCESS

 Nursing Process
 The term nursing process were used by Hall (1955), Johnson (1959), Orlando (1961),
Wiedenbach ( 1963), ANA (1973)
 a systematic ; rational method of planning and providing individualized nursing care.
 organized, systematic, goal oriented, humanistic care (Lydia Hall)
 provides legal framework for nursing practice

 Characteristics of Nursing Process

1. cyclic and dynamic in nature
 data from each phase provide input to the next phase
 regularly repeated event or sequence of events (a cycle)
 continuously changing (dynamic) – not static
2. client-centered
3. Focus: problem solving and decision making
4. different but parallel to process used by physicians
5. Interpersonal and Collaborative Style
6. Universal applicability
7. Use of critical thinking – logic, intuition and creativity

 Critical Thinking
= discipline-specific
= reflective reasoning process

PURPOSE: guides a nurse in generating, implementing, and evaluating approaches for dealing
with client care and professional concerns

 Components of Critical Thinking

 critical analysis
 inductive and deductive reasoning
 making valid inferences
 differentiate facts from opinions
 evaluating the credibility of information
 clarifying concepts
 recognizing assumptions

II. HEALTH ASSESSMENT

 comprehensive assessment of one’s health status
 2 Primary Components
 Nursing Health History
 Physical Assessment

 Purposes of Health Assessment

1. To obtain baseline data
2. To supplement, confirm, or refute data .
3. To establish nursing diagnoses and plans of care.
4. To evaluate physiological outcomes of health care.
5. To make clinical judgments.
6. To identify areas for health promotion and disease prevention.
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 ASSESSMENT
= systematic and continuous collection, organization, validation, and documentation of data
= a continuous process carried out during all phases of the nursing process
= all phases of the nursing process depend on the accurate and complete collection of data

 Purpose: establish a database

 Activities
1. Collecting Data
2. Organizing Data
3. Validating Data
4. Documenting Data

 Collection of Data
 formulation of DATABASE which contains:
= nursing health history
= physical assessment
= primary care provider’s history
= physical examination
= results of laboratory and diagnostic tests

 TYPES OF DATA
A. Subjective data (symptoms)
= itching, pain, and feelings of worry.

B. Objective data (signs)

= BP 120/80, reddish urine.

 SOURCES OF DATA:
 PRIMARY – client
 SECONDARY – family, support persons, other health professionas, medical
 RECORDS AND REPORTS, LABORATORY AND DIAGNOSTIC, RELEVANT LITERATURE

 DATA COLLECTION METHODS

 OBSERVATION - using senses
 INTERVIEW – planned communication or a conversation

2 APPROACHES TO INTERVIEW
A. Directive: nurse establishes the purpose of the interview and controls the interview
 Applicable: Limited Time (i.e. emergency situation)
B. Nondirective or rapport-building

TYPES OF INTERVIEW QUESTIONS

TYPE PURPOSE EXAMPLES
1. Closed-Ended Questions Directive Interview (gather Yes or No Questions
short factual answers) “When” , “Where”
“Who” , “What”
“Do” , “Is”
2. Open-Ended Questions Non-directive; invite clients “What”
to discover and explore, “How”
elaborate, clarify, or
illustrate their thoughts or
feelings
3. Neutral Questions Without direction or
pressure from the nurse
(open-ended and
non-directive
4. Leading Closed, directive interview
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 FACTORS TO BE CONSIDERED DURING INTERVIEW:

 Time
 Place
 seating arrangement
 Distance
 Language

 STAGES OF INTERVIEW:
 Opening or introduction
 Body or development
 Closing

 EXAMINATION
 Physical examination or Physical assessment is a systematic data collection method that
uses observation

 Physical Examination (IPPA TECHNIQUE)

 Inspection
 Palpation
 Percussion
 Auscultation

 Head-to-toe Approach (Cephalocaudal)

 ORGANIZING DATA
= nurse uses a written (or computerized) format that organizes the assessment data
systematically in the form of:
 nursing health history
 nursing assessment
 nursing database form

 Assessment Format
 Conceptual Models/Frameworks
= Gordon’s Functional Health Pattern
= Orem’s Self-Care Model
= Roy’s Adaptation Model.
= Wellness Model
= Non-nursing Models
 Body Systems Model
 Maslow’s Hierarchy of Needs
 Developmental Theories (Freud’s)

 VALIDATION - act of “double-checking” or verifying data to confirm that it is accurate and

factual
 complete
 factual
 accurate

 DOCUMENTING DATA:RECORDING OF DATA

 Accurate
 Factual manner and not as interpreted by the nurse
 Subjective data - virbatim

I. HEALTH ASSESSMENT IN NURSING PRACTICE

 Types
1. Initial Comprehensive Assessment
2. Ongoing or Partial Assessment
3. Focused or Problem Oriented Assessment
4. Emergency Assessment

 INITIAL COMPREHENSIVE ASSESSMENT

 Includes the client’s:
A. Perception of health
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B. Past health history

C. Lifestyle and health practices
D. Objective and subjective data

 ONGOING OR PARTIAL ASSESSMENT

 Data collection that occurs after a comprehensive database is established
 A brief reassessment of the client’s body system is performed to detect any new problems.
 Usually performed whenever the nurse or another health care professional has an
encounter with client

 FOCUSED OR PROBLEM-ORIENTED ASSESSMENT

 Done when a patient came to the health care agency with a specific health concern.
 Thorough assessment of a particular problem and does not cover areas not related to the
problem
 Does not replace the comprehensive HA

 EMERGENCY ASSESSMENT
 Very rapid assessment performed in life-threatening situation
 immediate diagnosis is needed to provide prompt treatment
 Major Concern: determine the status of the client’s life-sustaining physical functions

 Example:
 Evaluation of client’s ABC (Airway, Breathing, Circulation) when cardiac arrest is suspected.

 FRAMEWORKS IN HEALTH ASSESSMENT

 Framework – a basic structure underlying a process, system, concept, or text

Types:
A. Functional Health Framework
B. Cephalocaudal Framework
C. Body Systems Framework

 FUNCTIONAL HEALTH FRAMEWORK

 Evaluates the effects of mind, body and environment in relation to a person’s ability to perform
the ADLs
 Data collection in terms of Gordon’s 11 Functional Health Patterns

 GORDON’S 11 Functional Areas:

1, Health-perception-health management
1. Nutrition-metabolic
2. Activity-exercise
3. Elimination
4. Sleep-rest
5. Cognitive –perceptual
6. Self-perception-self-concept
7. Roles-relationships
8. Sexuality-reproduction
9. Coping-stress tolerance
10. Values-beliefs

 CEPHALOCAUDAL FRAMEWORK
 System data in an organized manner: head to toe
 Used to improve efficiency and expedite the actual physical examination

 BODY SYSTEM FRAMEWORK

 a framework that medical practitioners commonly use as it focuses more on the
pathophysiology involved within specific organ body systems
 maybe used during the focused assessment of an acutely or critically ill client

 CRITICAL THINKING IN HEALTH ASSESSMENT

 a purposeful, goal-directed thinking process that strives to problem solve patient care
issues through the use of clinical reasoning
 It combines logic, intuition, and creativity
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 Clinical Reasoning
 a disciplined, creative and reflective approach used together with critical thinking
Purpose: is to establish potential strategies to assist patients in reaching their desired health
goals

 Components of Critical Thinking

1. Interpretation
2. Analysis
3. Inference
4. Explanation
5. Evaluation
6. Self-regulation

 INTERPRETATION
 decode hidden messages, clarify the meaning of the information, categorize the
information
= (categorization, clarifying meaning)
= Nursing Practice Application: Be systematic in data collection. Look for patterns to categorize
data you are uncertain about.

 ANALYSIS
 ideas and data presented, identifies any discrepancies, and reflects on the reason for the
discrepancies
= Nursing Practice Application: Be open-minded as you look at information about a client. Do
not make careless assumptions. Do the data reveal what you believe is true, or are there other
options? Look for patterns to categorize data you are uncertain about.

 INFERENCE
 speculates, derives, or reasons a specific premise based on information and assumptions
obtained from the patient; can be challenging skill for the novice nurse because a certain level
of knowledge and experience must be possessed in order to draw conclusions and provide
alternatives in any given scenario (examining evidence, speculating or conjecturing alternatives,
making conclusions)

= Nursing Practice Application: Look at the meaning and significance of findings. Are there
relationships between findings? Does the data about the client help you determine that a problem
exists?

 EXPLANATION
 requires that the conclusions drawn from the inferences are cored and can be justified.
 The use of scientific and nursing literature constitutes the basis for clinical justification
= (stating results, justifying procedures)
= Nursing Practice Application: Support your findings and conclusions. Use knowledge to select
strategies you use in the care of clients

 EVALUATION
 examines the validity of the information and hypothesis; this leads to a final conclusion that can
be implemented.
= (assessing results, assessing arguments)

= Nursing Practice Application: Look at all situations objectively. Use criteria (e.g. expected
outcomes, pain characteristics, learning objectives) to determine results of nursing actions. Reflect
on your own behavior.

 SELF REGULATION
 key component to the critical thinking process; the nurse reflects on the critical thinking skills
that were employed and determines which techniques were effective and which were
problematic.
= (self-examination, self-correction)
= Nursing Practice Application: Reflect on your experience. Identify in what way you can improve
your performance. What will make you feel that you have been successful?
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II. NURSES’ ROLE IN HEALTH ASSESSMENT

 Nurses’Role: Dynamic

 Factors Influencing Roles of Nurses

1. Role Expansion – New Roles
2. Computerized Information Systems
3. Education vs Economy: Supply vs Demand
4. Educational Costs and Focus on Primary Care
5. Aging population
6. Mental health issues
7. HMOs

 PAST
 Nurses’ relied on their natural senses - the client’s face and body would be observed for:
“Changes in color, temperature, muscle strength, use of limbs, body output, and degrees of
nutrition, and hydration.” (Nightingale, 1992)

 HEATH ASSESSMENT ACROSS TIME:

 1901: Journal Records : examples of independent nursing practice: inspection, palpation, and
auscultation have been recorded
 1901 – 1938: American Journal of Nursing: RNs doing gastrointestinal palpation, testing
cranial nerve function and examination of children in school systems
 1930s: American Journal of Public Health: routine client and home inspection by PHN
 1970s: provision of primary health services and expansion in conduct of health histories and
physical/psychological assessments
 1980s: Acute care nurses employed the “primary care” method of delivery of care
 1990–PRESENT
= PRIORITIES: downsizing, budget cuts, and restructuring
= 1990s: Critical pathways or care maps
= Demand for documentation emerged
= APNs
= Reimbursement Issues
= Diagnosis-Related Groups (DRGs)
= Health care coverage plans (HMOs)
= Preferred provider organizations (PPOs).
 21st century:
= Emerging Roles and Its Impact on Health Assessment
1. Forensic
2. Acute Care
3. Ambulance Care
4. Critical Care Outreach
5. Ambulatory Care
6. Home Health
7. Public Health
8. School
9. Hospice

Reference: Janet R. Weber & Jane H. Kelly, Health Assessment in Nursing 6th Edition

Prepared by:
Mrs. Robeanna M. Diesto, MN