HEALTH ASSESSMENT

1. Collection of subjective data

2. Collection of objective data

3. Validation of data

4. Documentation of data

• Initial comprehensive assessment

• Ongoing or partial assessment

• Focused or problem-oriented assessment

• Emergency assessment

STEPS OF HEALTH

ASSESSMENT

TYPES OF HEALTH ASSESSMENT

Biographical information (name, age,

religion, occupation)

History of present health concern:

Physical symptoms

related to each body part or system

(e.g., eyes and ears,

abdomen)

Personal health history

Family history

Health and lifestyle practices

Physical characteristics (e.g., skin color,

posture)
Body functions (e.g., heart rate,

respiratory rate)

Appearance (e.g., dress and hygiene)

Behavior (e.g., mood, affect)

Measurements (e.g., blood pressure,

temperature, height, weight)

Results of laboratory testing (e.g.,

platelet count, x-ray findings)

Subjective data are sensations or symptoms

(e.g., pain, hunger), feelings (e.g., happiness,

sadness), perceptions, desires, preferences,

beliefs, ideas, values, and personal

information that can be elicited and verified

only by the client.

COLLECTING

SUBJECTIVE

DATA

COLLECING

OBJECTIVE

DATA

This type of data is obtained by

general observation and by using

the four physical examination

techniques: inspection, palpation,

percussion, and auscultation.

prone position

The prone position is used primarily

to assess the hip joint. The back can

also be assessed with the client in this

position. Clients with cardiac and

respiratory problems cannot tolerate

this position.

PATIENT POSITIONING

supine position

used for general examination or

physical assessment.

lateral

recumbent (left

or right)

This position makes it

easier to access a

patient's right/left

side..

knee-chest position

Is assumed for a

gynecologic or rectal

examination.

Knee-chest position
can be lateral or

prone.

PATIENT POSITIONING

lithotomy position

Commonly used for

vaginal examinations

and childbirth.

Fowler

s position

Used for patients who

have difficulty

breathing because in

this position, gravity

pulls the diaphragm

downward allowing

greater chest and lung

expansion.

Trendelenburg

position

Patients can benefit

from this position

because it promotes

venous return.

Used to provide

postural drainage of

the basal lung lobes.

PATIENT POSITIONING

HEALTH HISTORY ASSESSMENT "SAMPLE"

S -Symptoms

A -Allergy

M -Medications

P -Past Medical History

L -Last Oral Intake

E -Events leading up to

the illness or injury

patient's chief complaints

seeking to know what type of allergic

reaction they experienced

prescribed, OTC drugs, herbal meds, etc...

seeking to know the previous

state of health and previous

illness

seeking what are the last oral intakes

of the client

events leading up to the

illness or injury.

FAMILY HISTORY ASSESSMENT

"BALD CHASM"

B -Blood pressure

A -Arthritis

L -Lung disease

D -Diabetes

C -Cancers

H -Heart disease

A -Alcoholism

S -Stroke

M -Mental health

disorders

SIGNS vs. SYMPTOMS

sign symptoms
Is objective and discovered

by the healthcare

professional during an

examination.

something I can detect

even if patient is

unconscious.

Is subjective, observed and

experienced by the patient,

and cannot be measured

directly.

sYMptom is something only

hYM jnows about.

PAIN ASSESSMENT

O -Onset

P -Provoking or Palliating factors

Q -Quality

R -Region and Radiation

S -Severity

T -Time&Treatment
U -Understanding&Impact

V -Values

"OPQRSTUV"

CLASSIFICATION OF PAIN

Acute pain

Chronic

nonmalignant

pain:

Cancer pain

according to duration and etiology

usually associated

with a recent injury

usually associated with a

specific cause or injury

and described as a

constant pain that

persists for more than 6

months

often due to the

compression of peripheral

nerves or meninges or

from the damage to these

structures following

surgery, chemotherapy,

radiation, or tumor growth

and infiltration

according to location

Cutaneous pain

(skin or subcutaneous tissue)

Visceral pain

(abdominal cavity, thorax,

cranium)

Deep somatic pain

(ligaments, tendons, bones,

blood vessels, nerves)

according to location whether it is

perceived at the site of the pain

stimuli

Radiating

perceived both at the source and

extending to other tissues

Referred

perceived in body areas away from

the pain source

Phantom pain

can be perceived in nerves left by a

missing, amputated, or paralyzed

body part.
other types of pain

Neuropathic pain

caused by damage or injury to the

nerves that transfer information

between the brain and spinal cord

from the skin, muscles and other

parts of the body.

Intractable pain

A type of pain that can't be

controlled with standard medical

care because of its high resistance

to pain relief.

DIMENSIONS OF PAIN

Physical

effect of anatomic structure and

physiologic functioning on the

experience of pain

Sensory

qualitative and quantitative

descriptions of pain

Behavioral

verbal and nonverbal behaviors

associated with pain

Sociocultural

effect of social and cultural

backgrounds on the experience

of pain

Cognitive

thoughts, beliefs, attitudes,

intentions, and motivations

related to the experience of pain

Affective

feelings and emotions that result

from pain

Spiritual

ultimate meaning and purpose

attributed to pain, self, others,

and the divine

PAIN RATING SCALE

T -Thickening or lump in breast or

elsewhere

WARNING SIGNS OF CANCER

C -Change in bowel or bladder habits

A -A sore that does not heal

O -Obvious change in wart or mole

I -Indigestion or dysphagia

U -Unusual bleeding or discharge

N -Nagging cough or hoarseness

U -Unexplained anemia

S -Sudden & unexplained weight loss

"CAUTION US"

EMERGENCY TRAUMA ASSESSMENT

"ABCDEFGHI"

A -Airway

B -Breathing

C -Circulation

D -Disability

E -Expose & examine

F -Full set of vital signs

G -Give comfort measures

H -History and head-to-toe assessment

I -Inspect posterior surface

NORMAL VITAL SIGNS

PULSE
BLOOD PRESSURE

RESPIRATION

TEMPERATURE

02 SATURATION

60-100 bpm

120/80 mmHg

12-20 breaths per min

95-100%

36.5-37.7 °C (96.0-

99.9 °F)

HEAD-TO-TOE

ASSESSMENT

Knock

Introduce yourself

Wash hands

Ensure privacy

Keep the room

comfortable

Sit/stand at eye level, and

make good eye contact

Verify patient ID and DOB

Explain what you are

doing using non-medical

language

Use open-ended

questions to gather

unbiased information

Before the exam, Orientation

What is your name?

Do you know where you

are?

Do you know what month it

is?

What are you doing here?

A&O X4= Oriented to

Person, Place, Time and

Situation

LEVEL OF CONCIOUSNESS

ASSESSMENT

A -Alert

V -Voice

P -Pain

U -Unresponsive
"AVPU"

Eyes open spontaneously.

Appears aware of and responsive

to the environment.

Follows commands eyes tract

peoples and objects.

Child is active and

responds appropriately to

SO and other external

stimuli.

Eye do not open spontaneously

but open to verbal stimuli.

Able to respond in some

meaningful way when spoken to.

Respond only when his or

her name is called

Does not respond to questions but

moves or cries out in response to

painful stimuli such as pinching

the skin or earlobe.

Patient does not

respond to any
stimuli.

Respond only when

painful stimuli is received

such as pinching the nail

bed.

No response at all.

PHYSICAL ASSESSMENT TECHNIQUES

Inspection

Palpation

Percussion

Auscultation

visual examination of the patient

done when the person doing the assessment

places their fingers on the body to determine

things like swelling, masses, and areas of pain

more superficial and therefore it permits

identification of the superficial organs or

masses, and sometimes it can detect abdominal

wall crepitus.

light palpation
deep palpation

allows examination of organs including the liver,

caecum

tapping the patient's bodily surfaces and hearing

the resulting sounds to determine the presence

of things like air and solid masses affecting

internal organs

listening to an area of the body using a

stethoscope

"IPPA"

Inspect head/scalp/hair

Palpate head/scalp/hair

Face

Inspect

Check for symmetry

Test CN VII

-raise eyebrows

-smile

-frown

-show teeth

-puff out cheeks

-tightly close eyes

Eyes

Inspects external eye

structures
Inspect color of

conjunctiva and sclera

PERRLA

(Pupils Equal, Round,

Reactive to Light, &

Accomodation)

Anterior Chest

Inspect

Palpate: symmetric expansion

Auscultate lung sounds

(anterior and lateral)

-Use of accessory muscles

-AP to transverse diameter

-Sternum configuration

-Note any murmurs,

whooshing, bruits or muffled

heart sounds

Integumentary

Inspect the skin

color

moisture

texture

turgor

lesions

1.
2.

3.

4.

5.

Head & Face

Head

Neck, Chest, & Heart

Neck

Inspect and palpate

Palpate carotid pulse

Check skin turgor under

the clavicle

Posterior Chest

Inspect

Auscultate lung sounds

in posterior and lateral

chest (Noe any crackles

or diminished breath

sounds)

Heart

Auscultate

heart

sounds

(A,P,E,T,M)

w/
diaphragm

and bell

-Note any

murmurs,

whooshing,

bruits, or

muffled

heart

sounds

Inspect and palpate

Note any texture, lesions,

temperature, moisture,

tenderness & swelling

Palpate radial pulses

bilaterally ( +1, +2, +3, +4)

Upper extremities

Spine

Have the patient stand up (if

able)

Inspect the skin on the back

Inspect: spinal curvature

(cervical/thoracic/lumbar)

Palpate spine

Note any lesions, lumps, or

abnormalities

Inspect:
Palpate: Check for edema

(pitting or non-pitting)

Check capillary refill

bilarerally

– Overall skin coloration

– Lesions

– Hair distribution

– Varicosities

– Edema

Abdomen

•Inspect:

Auscultate bowel sounds:

Light palpation: all 4 quadrants

– Skin color

– Contour

– Scars

– Aortic pulsations

all 4 quadrants (start in RLQ and go

clockwise)

Inspect hands, fingers, nails

Palpate hands and finger

joints

Check muscle strength of

hands bilaterally (If both

hands can grip evenly)

Peripherals

Peripherals

Shoulder

Inspect , palpate, assess

Elbows

Inspect , palpate, assess

Hands and Fingers

+1 Diminished

+2 Normal

+3 Full

+4 Bounding, strong

Lower

Extremities

Hips

Inspect & palpate

Knees

Inspect & palpate

Ankles

Inspect and palpate

Post tibial pulse (+1, +2, +3, +4)

Dorsal pedis pulse bilaterally

(+1, +2, +3, +4)

– Check strength bilaterally

-Dorsiflexion flexion against

resistance

ABSENT: Must listen for at least 5 minutes to

chart absent bowel sounds

HYPOACTIVE: One bowel sound every 3-5 mins

NORMOACTIVE: Gurgles 5-30 time per minute

HYPERACTIVE: Can sometimes be heard

without a stethoscope constant bowel sounds,

> 30 sounds per minute

Musculoskeletal

Assess ROM and muscle

strength

Check for + grade and any

edema

Inspect posture and gait

Test deep tendon reflexes

Overall

Positions and drapes patient

appropriately

during exam (gave patient

privacy)

Gave patient

feedback/instructions

Exhibits professional manner

during exam,

treated patient with respect

and dignity
Organized: exam followed a

logical sequence

(order of exam “made sense”)

I can do all things through Christ

who strengthens me.

PHILIPPIANS 4:13

Good luck future RN!

References

Chelsea (2020). Complete Nursing School Bundle. CeceStudyGuides.

May, B. (2017). Verbal Numerical Rating Scale: A Reliable Pediatric Pain Assessment Tool. Clinical

Pain Advisor. Retrieved from https://www.clinicalpainadvisor.com/home/topics/pediatric-pain-

management/verbal-numerical-rating-scale-a-reliable-pediatric-pain-assessment-tool/

Tuttle, K. (2020). The Complete Nursing School Bundle. NurseInTheMaking LLC.

Vera, M. (2018). Nursing Health Assessment Mnemonics & Tips. Nurses Labs. Retrieved from

https://nurseslabs.com/nursing-health-assessment-mnemonics-tips/

Weber, J. & Kelley, J. (2014). Health Assessment in Nursing. Fifth Edition. Lippincott Williams &

Wilkins.

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