STEPS OF HEALTH ASSESSMENT

STEPS OF HEALTH ASSESMENT

1. Collection of Subjective Data (Covert Data)
2. Collection of Objective Data (Overt Data)
3. Validation of Data
4. Documentation of Data

1) Collection of Subjective Data (Covert Data)

 Covert Data
 The verbal statements provided by the patient.
 It includes the sensations or symptoms, feelings, perceptions, desires, preferences, beliefs, ideas, values, and
personal information.
 Whatever comes out of the mouth of the patient is considered subjective.
 The verbal statements from our patients.

2) Collection of Objective Data (Overt Data)

 Overt Data
 Directly observed by the examiner.
 Detectable by an observer or can be measured or tested against an accepted standard.
 Ex. You saw your patient bleeding. It is an example of Objective Data.
 You can get the objective data through the chart of the patient.
 What you can observe or what your eyes can see.

3) Validation of Data
 Serves to ensure that the assessment process is not ended before all relevant data have been collected.
 Helps to prevent documentation of inaccurate data.
 The act of "double-checking or verifying data to confirm that it is accurate and factual.
 You have to double check and verify if the data is accurate.

4) Documentation of Data
 Forms the database for the entire nursing process and provides data for all other members of the health care
team.
 An example is the Nurse's Notes.
 It is a type of document where you write all that's happening and what you performed.

SUBJECTIVE DATA VS. OBJECTIVE DATA

SUBJECTIVE DATA OBJECTIVE DATA
Body Temperature - 100° F
Tachycardia – 100 bt/mt
“I have a fever.”
Dull and Tired
Dried Lips
Vomited 100 ml of green tinged fluid
Abdomen firm
“I feel sick to my stomach.”
Slightly distended
Active bowel sounds in all 4 quadrants
RR – 28 br/mt
“I am short of breath.” Tachypnea
Lung Sound diminished in the lower lobe.
Subjective Data
 Data elicited and verified by the client.
 Sources:
 Client  Client's Record
 Family  Other Healthcare Professionals
 Significant Others
 Not just by client alone.
 Methods:
 Client Interview
 Skills:
 Interview and Therapeutic Communicating Skills
 Caring Ability and Empathy
 Listening Skills
 Examples:
 "I have a headache."
 "It frightens me."

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Objective Data
 Data directly or indirectly observed through measurement.
 Sources:
 Observations and physical assessment findings of the nurse or other health care professionals
 Documentation of assessments made in client record
 Observations made by the client's family or significant others
 Skills:
 Inspection
 Palpation
 Percussion
 Auscultation
 Objective Data can be obtained through Observation and Physical Examination.
 Examples:
 RR = 16 breaths/mn
 BP = 180/100 mmHg
 If there is a bulge in the back.
 There is swelling in the eyes.

COLLECTION OF SUBJECTIVE DATA

COLLECTION OF SUBJECTIVE DATA

 Interview and Health History
 Includes the following:
1. Biographic Data
2. Reasons for Seeking Health Care
3. Chief Complaint
4. History of:
a) Present Illness
b) Past Health History
c) Family Health History
d) Review of Body Systems for Current Health Problems
e) Current Medications
f) Lifestyle
g) Developmental Level
h) Psychosocial History
i) ADL

HEALTH HISTORY GUIDELINES

1. Interview
2. Purpose
3. Guidelines of an Effective Interview

INTERVIEWING
 A communication process or conversation with a purpose.
 Consider schedule of tests
 Patient preferences
 Family or visitor presence
 Focuses on:
 Establishing rapport and a trusting relationship with the client.
 Gathering information on the client's developmental, psychological, physiologic, sociocultural, and
spiritual statuses to identify deviations.

PHASES OF INTERVIEW
1. Introductory Phase
2. Working Phase
3. Summary and Closing Phase

1) Introductory Phase
 Nurse introduces self to the client.
 Explains the purpose of the interview.
 Assures confidentiality of information.
 Provide for patient needs before starting.

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2) Working Phase
 Nurse gathers information
 Excellent communication skills
 For example, if you have a patient that is from Cebu, you will not understand each other. Thus, you must
use other language.
 Active listening
 Eye contact
 Must be maintained during interview.
 Critical thinking skills to interpret and validate information
 Open-ended questions

3) Summary and Closing Phase

 Summarizes information and validates problems and goals with the client
 Identifies and discuss possible plans to resolve the problem
 Inform patient when nearing end of interview
 "Ma'am, I have 3 questions left"
 Ensure patient knows what will happen with information
 Offer patient chance to add anything
 You must add option in order to get relevant information

COMMUNICATION
 It can be Non-Verbal Communication or Verbal Communication.

Non-Verbal Communication
 Appearance
 Demeanor
 Facial Expression
 Attitude
 Silence
 Listening

Verbal Communication
 Open-ended Questions
 Closed-ended Questions
 Laundry List
 Rephrasing
 Well-placed Phrase
 Inferring
 Providing Information

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