INTRODUCTION TO

HEALTH
ASSESSMENT__________
EDNA U. ROBLES, RN MAN
St. Luke’s College of Nursing
The Lord is my rock and my fortress and my
deliverer, My God, my rock, in whom I take
refuge; My shield and the horn of my
salvation, my stronghold. Psalm 9:9
 OBJECTIVES
1. Describe phases of the Nursing Process
2. Enumerate the purpose of Health
Assessment
3. Give an example of each types of assessment
CRITICAL THINKING AND
HEALTH ASSESSMENT
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 CRITICAL THINKING
• Cognitive process
during which an
individual reviews data
and considers potential
explanations and
outcomes before
forming an opinion or
making a decision

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 CRITICAL THINKING IN NURSING

• NLN*, 2000: “Critical thinking in nursing

practice is a discipline specific, reflective
reasoning process that guides the nurse in
generating, implementing, and evaluating
approaches for dealing with client care and
professional concern.”
*National League of Nurses

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 CRITICAL THINKING IN NURSING
• Essential in making
sound decisions
• How nurses make
decisions on patient
care

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 REMEMBER!

• Decision-making skill separates nurse from

technical or ancillary staff.

• Good problem-solving skills allows nurses to

ask question and look at alternatives.

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 CRITICAL THINKING IN NURSING
• Not a linear step-by-
step process

• Not always a clear

textbook answer

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COMPONENTS OF CRITICAL THINKING

Scientific Knowledge Base

Experience

Competencies

Attitudes

Standards

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 ATTITUDES THAT FOSTER CRITICAL
THINKING

Fair-
Independence Humility
mindedness

Courage to
challenge Integrity Perserverance
status quo

Confidence Curiosity

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HEALTH ASSESSMENT AND THE
NURSING PROCESS
 “the protection, promotion,
and optimization of health and
abilities prevention of illness
WHAT IS and injury, alleviation of
suffering through the diagnosis
NURSING? and treatment of human
responses and advocacy in the
care of individuals, families,
communities and populations”
- ANA,2010
 NURSING PROCESS
• Systematic approach
to gather and
analyze data,
identify client
responses, design
outcomes, take
appropriate action,
then evaluate the
effectiveness of
action
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 NURSING PROCESS

• Involves the use of critical thinking skills

• Common language for nurses to “think

through” clinical problems

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 PHASES OF THE NURSING PROCESS
Assessment

Evaluation Diagnosis

Implementation Planning

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 PHASES OF THE NURSING PROCESS
(ADPIE)
Phase Title Description
I Assessment Collecting subjective and
objective data
II Diagnosis Analyzing subjective and objective data to
make a professional nursing judgment (nursing
diagnosis, collaborative problem, or referral)
III Planning Determining outcome criteria and developing a
plan
IV Implementation Carrying out the plan
V Evaluation Assessing whether outcome criteria have been
met and revising the plan as necessary

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 COLLECTION OF DATA:
Health Assessment
• The collection of data
about an individual’s
health state
• Is the 1st and most
critical phase in the
Nursing Process
• Is ongoing and
continuous
throughout all the
phases of the nursing
process

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 SOURCES OF DATA
• PRIMARY • SECONDARY
– data is directly – Data is gathered
from client’s family
gathered from the
member, significant
client using others, family
interview and member, medical
physical records and other
examination member of the
health care team

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 COLLECTION OF DATA:
Health Assessment
• Step 1 of the Nursing
Process
(ASSESSMENT)
• If data collection is
inadequate or
inaccurate, incorrect
nursing judgments
may be made

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 PURPOSE OF HEALTH ASSESSMENT
To establish data base

To supplement, confirm or question data obtained in the

health history

To obtain data that will help the nurse establish nursing

diagnosis and plan patient care

To evaluate the appropriateness of the nursing interventions in

resolving the patient’s identified pathophysiology problem

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 TYPES OF ASSESSMENT

Initial Ongoing or
Comprehensive Partial

Focused or
Problem- Emergency
Oriented

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 INITIAL COMPREHENSIVE
ASSESSMENT

• Subjective and objective data

• All body parts and systems
• History: past medical and family
• Lifestyle and health practices
• Step by step physical examination

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 ONGOING OR PARTIAL ASSESSMENT
• Occurs after
database established
• Reassessment
• Setting: hospital,
community, home

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 FOCUSED OR PROBLEM ORIENTED
ASSESSMENT
• Does not replace
comprehensive
health assessment
• Performed in
relation to a specific
health concern

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 EMERGENCY ASSESSMENT
• Very rapid
• Performed in life-
threatening
situations
• Ex. CAB’s of CPR

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Thank You!
 ACTIVITY
• Divide the class into 5 groups
– What are the objective data
– What are the subjective data

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