PRELIMS

Liceo de Cagayan University - College of Nursing

Health Assessment In Nursing

Prelims Transes
Transcribed by: Kyla Badong and Juliane Estoque

1ST SESSION NOTE: Nursing process is cyclical, rather than

linear.
Definition of Nursing
Assessment
Emphasis is placed on “diagnosis and treatment of
human responses” based on “accurate client Collect data
assessment”. Organize data
Validate data
Nursing Scope & Standards states that: “The Document data
registered nurse collects comprehensive data
pertinent to the patient’s health of situation”. To In collecting, consider your patient as a WHOLE!
accomplish this pertinent & comprehensive data
(holistically: mind, body, soul)
collection, the nurse:
Collects data in a systematic and ongoing Physiological
process Psychological
Involves the patient, SO, and other health care Sociological
providers and environment, as appropriate in Developmental
holistic data collection. Spiritual
Uses appropriate evidence-based assessment
TYPES OF ASSESSMENT
techniques and instruments in collecting
pertinent data. (a) Initial Comprehensive Assessment
Synthesizes available data to determine the Performed during the first encounter with the
diagnosis or issue. patient.
PHASES OF NURSING PROCESS Baseline data - first data gathered and basis of
comparison for the succeeding data.
1. Assessment - collecting subjective & objective
Initially collected data are reassessed to
data
determine any major changes (deterioration or
2. Diagnosis - analyzing data to make professional
improvement)
judgement
3. Planning - determine outcome and develop a (b) Ongoing or Partial Assessment
plan Mini-overview of the client’s body systems and
4. Implementation - carrying out the plan holistic health patterns as a follow-up on his health
5. Evaluation - assessing whether the outcome status
criteria has been met; revise the plan as
(c) Focused or Problem-oriented Assessment
necessary
A thorough assessment of a particular client problem
and does not cover areas that are not related to the
problem.

Ex. ear pain

A question to ask: Is there a ringing in your ear?
A question NOT to ask: When was your last
menstrual period?
 Liceo de Cagayan University - College of Nursing

health assessment In Nursing

Prelims Transes
Transcribed by: Kyla Badong and Juliane Estoque

(d) Emergency Assessment

Rapid assessment performed in life-threatening
situations.
Assess only the life sustaining functions of the body:
ABC - Airway, Breathing, Circulation
NOTE: END RESULT OF HA = FORMULATION
OF NURSING DIAGNOSIS
Validating
Serves to ensure that the assessment process is not
ended before all relevant data have been collected. It
helps to prevent documentation of inaccurate data

Documenting
PREPARATION FOR THE ASSESSMENT Forms the database
Before meeting the client: Provides data for all other members of the
healthcare team
1. Review the patient’s record if available (for Thorough and accurate documentation - ensures
background check, to verify what you read) valid conclusions are made when data are
analyzed
2. Take a minute or 2 to reflect on your own
EVOLUTION OF THE NURSE’S ROLE IN HA
feelings regarding your initial encounter with the
Our mothers are our first nurses
client.
21st Century Nursing:
ex. Client is a drug addict —> avoid biases,
Forensic nursing
judgment, tendency to project your own feelings on
Nursing Informatics
the client; be objective and open as possible
Acute care nurse
Critical care nurse
3. Obtain & organize materials that you will need
Ambulatory care nurses
for the assessment.
Home health nursing
ex . guide to review questions
Public health nursing
Gather equipment: stethoscope, thermometer,
Hospice nursing
otoscope

SUBJECTIVE DATA VS. OBJECTIVE DATA

SUBJECTIVE OBJECTIVE

Data elicited and verified Data directly or indirectly observed through

by the client. measurement.

Observations and physical assessment findings

Client, Family and SO,
of the nurse or other health care professionals;
Sources Client record, Other
Documentation of assessment made in client
health care professionals
record; Observation made by family and SO.

Interview and therapeutic

communication skills, IPPA - Inspection, Palpation, Percussion, and
Skills needed to obtain data
caring ability & empathy, Auscultation
and listening skills

“I have a headache”“It
Ex. frightens me”“I am RR = 16 bpmBP = 180/100X-ray = fractured ribs
hungry”
 Liceo de Cagayan University - College of Nursing

health assessment In Nursing

Prelims Transes
Transcribed by: Kyla Badong and Juliane Estoque

2ND SESSION (4.) Summary and Closing Phase

Collecting Subjective Data
Subjective data - elicited and verified only by the
client
Provide clues to possible physiologic,
psychologic, and sociologic problems
Obtained through interviewing
Nurse summarizes info obtained during the
working phase and validates problems and goals
with the client
Identifies and discusses possible plans to resolve
the problem
Ask if anything else concerns the client and if
there are any further questions

Interviewing COMMUNICATION during the

INTERVIEW
2 Focuses
1. Verbal Communication - there is use of words
1. Establishing rapport and a trusting relationship to convey messages and information
with the client to elicit accurate and meaningful 2. Nonverbal Communication - there is transfer of
information information throught the use of body language
2. Gather information such as gestures

PHASES OF INTERVIEW (1.) NONVERBAL COMMUNICATION

(1.) Pre-Introductory Phase a. Appearance (neat & clean)

Review the medical record before meeting with b. Demeanor (no shouting and yelling and be
the client professional)
Past health history c. Facial expression (friendly and neutral)
Reasons for seeking healthcare d. Attitude (non-judgmental)
e. Silence (so the client can think)
(2.) Introductory Phase f. Listening (maintain good eye contact)

Introduces
(2.) VERBAL COMMUNICATION
Explains the purpose of the interview
Discusses the questions (1.) Open-ended questions
Explains the reasons for taking notes
Assures the client's confidentiality Used to elicit feelings and perceptions
Comfortable and privacy “How” and “what” (“How have you been feeling
Develop trust and rapport lately?”)
(begin by conveying a sense of priority and Require more than one word response from the
interest in the client) client
Reveal significant information
(3.) Working Phase
(2.) Close-ended questions
Nurse elicits information
Nurse listens, observe cues, and uses critical To obtain facts and to focus on specific info
thinking skills to interpret and validate Client can respond with one or two words
information “When” or “did”
Usefulin keeping the interview on course
To clarify or obtain more data
 Liceo de Cagayan University - College of Nursing

health assessment
Prelims Transes
Transcribed by: Kyla Badong and Juliane Estoque

(3.) Laundry List Nonverbal Communications to Avoid

A choice of words to choose from in describing Excessive or insufficient eye contact
symptoms, conditions or feelings Distraction and distance
Help to obtain specific answers’ Standing
“Is the pain severe, dull, sharp, mild, cutting, or
piercing? Verbal Communications to Avoid
“Does the pain occur once every year, day,
Biased or leading questions (“You don’t feel
month, or hour?”
bad, do you?””
Repeat the choices as necessary
Rushing through the interview
Reading the questions
(4.) Rephrasing
Clarify info ELDERLY
Enables you and the client to reflect on what was
said Hearing
Mr. G tells you that he has been really tired and Speak slowly
nauseatedfor 2 months and that he is scared May be interpreted as mental slowness
because he fears that he has some horrible Speak slowly
disease Face client
Rephrase: “You are thinking that you have a Do not yell
serious illness” Position - on the side with better hearing
Speak clearly
(5.) Well-placed phrases Simple terms
No slang
“Um-hum”
“Yes” COMPLETE HEALTH HISTORY
"I agree”
Excellent way to begin the assessment
(6.) Inferring Lay the groundwork for identifying any
What the client tells you and what you observe problems and provides focus for the physical
Abdominal pain - note where the client places examination (PE)
her hands Provide information hat will assist the examiner
in identifying areas of strength and limitation
(7.) Providing information Provide specific cues to health problems that are
Provide the client wth info as questions and most apparent to the client
concerns arise
8 Sections
Answers questions
Do not know the answer - tell the client that you 1. Biographical Data
will find out 2. Reasons for Seeking Health Care
Knowledgeable - participative 3. History of Present Health Concern
4. Personal Health History
5. Family Health History
6. Review of Body System
7. Lifestyle and Health Practices Profile
8. Developmental Level
 Liceo de Cagayan University - College of Nursing
health assessment
Prelims Transes
Transcribed by: Kyla Badong and Juliane Estoque
(1.) Biographical Data
Information that identifies the client
Sharing the information - delete address and
phone number
- use initials
- privacy
Source of information - to determine accuracy
culture , ethnicity, religion, marital stud etc -
special needs and beliefs that may affect the
client’s health care
Educational level, occupation, working status
- client’s level of understanding
Client’s strengths and weakness, limitations
Who lives with the client - caregiver and support
(2.) Reasons for Seeking Health Care
“What is your major concern or health problem
this time?”
“How do you feel about having to seek health
care?”
“Why are you here?”
“How can I help you?”
(3.) History of Present Health Concern
Detailed description of the concern
Explain the health problem, symptom
(4.) Personal Health History
Earliest beginning to present
Childhood illnesses, immunizations, surgeries,
accidents, allergies, use of prescriptions, ot OTC
drugs
Hospitalizations, pregnancies, births, injuries,
emotional, or psychiatric problems
Pain experiences
Nurse will identify risk factors
(5.) Family Health History
Health problems that seem to run in the family
and that are genetically based
Genetic predisposition
Having grown up in a family and being exposed
- (smoking, exposure, and negative role model)
Maternal, paternal, grandparents, etc.
Generation
(6.) Review of Body System
Each body system is addressed
Asked specific questions to elicit further details
of the current health problems or from the recent
past
To include ONLY the clients subjective
information and not the nurse’s observations
(7.) Lifestyle and Health Practices Profile
Nutritional habits
Activity and exercise patterns
Sleep and rest patterns
Self-concept and self-care activities
Social and community activities
Relationships
Values and belief systems
Education and work
Stress level and coping style
Environment
(8.) Developmental Level
To gather the specific information of the health
concern of patient we will be guided by:
C-O-L-D-S-P-A
Character - Describe the sign or symptom. How
does it feel, look, sound, smell, and so forth?
Onset - When did it begin?
Location - Where is it? Does it radiate?
Duration - How long does it last? Does it recur?
Severity - How bad is it?
Pattern - What makes it better? What makes it
worse?
Associated Factors - What other symptoms
occur with it?
MIDTERMS
 Liceo de Cagayan University - College of Nursing

health assessment
MIDTERMS Transes
Transcribed by: Kyla Badong and Juliane Estoque

Objective Data General Principles

Information about the client that the nurse directly
observes during interaction and the information
elicited through PHYSICAL ASSESSMENT
techniques.
Knowledge on the 3 Basic Areas
1. Types of and operation of equipment needed
2. Preparation of the setting, oneself, and the client
for PA
3. Performance of the 4 assessment techniques
IPPA
Equipment
Collect all the necessary equipment - promotes
organization and prevents the nurse from leaving the
client to search for a piece of equipment
Setting
Hospital room
Outpatient clinic
Physician’s office
School health office
Employee health office
Client’s home
Conditions
Comfortable, warm room temperature -
warm blanket
Private area free of interruptions - close door,
pull curtains
Quiet area free of distractions - turn off radio,
television or other noisy equipment
Adequate lighting - sunlight, portable lamp
Firm examination table or bed at a height that
prevents stooping. Roll-up stool PRN
A bedside table/tray to hold the equipment
needed
Preparing Oneself
Assess your own feelings
Self confidence in performing PA
Wash hands. If possible in the examination room
infront of the client. Wear gloves if necessary —
assures the client that you are concerned about
his/her safety
Wear gloves if you have an open cut or skin
abrasion or if the client has an open or weeping
cut, collecting fluids, handle contaminated
surfaces, or examining mouth, genitalia, vagina
or rectum
If using pin or other sharp objects is used -
discard and use a new one for the next client
Wear mask and protective eye goggles - likely
splash with blood or other body fluids, cough
Standard Precautions
Hand hygiene
Gloves
Mak, eye protection, face shield
Gown
Patient care equipment
Environmetnal control
Linen
Occupational health and bloodborne
pathogens
Patient placement
Approaching and Preparing the Client
N - client relationship — established — to
alleviate tension/anxiety
Explain that PA will follow and describe what
the examination will involve
Change into gown - remove underwear PRN
Respect the client’s desires PRN and requests
related to PA
Explain - importance
Begin with less intrusive procedures
1. v/s, ht and wt
2. allow the client to be comfortable and help ease
the clients anxiety
Through out — continue to explain
Approach from the right side - most examination
techniques are performed with the examiner’s
right hand
 Liceo de Cagayan University - College of Nursing

health assessment
MIDTERMS Transes
Transcribed by: Kyla Badong and Juliane Estoque

PHYSICAL EXAMINATION
Objective Assessment Techniques (4 techniques)
1. Inspection
2. Palpation
3. Percussion
4. Auscultation

INSPECTION
Involves using the senses of vision, smell, and
hearing to observe and detect any normal or
abnormal findings
Precedes palpation, percussion, and auscultation
Use of senses - body senses require special 3 Parts of the Hands
equipment

Guidelines
Make sure the room is in a comfortable
temperature. A too-cold or too-hot room can
alter the normal behavior of the client and the
appearance of the client’s skin
Use good lighting, preferably sunlight.
Fluorescent lights can alter the true color of the
skin. In addition, abnormalities may be
overlooked with dim lighting.
Look and observe before touching
Completely expose the body parts you are
inspecting while draping the rest of the client as
appropriate
Note the following characteristics while
inspecting: color, patterns, size, location,
consistency, symmetry, movement, behavior,
odors, or sounds
Compare the appearance of symmetric body
parts or both sides of any individual body part
PALPATION
Use parts of the hands to touch and feel
Crepitus - grating, crackling popping sound and
sensation experienced under the joint/skin
Fremitus - palpable vibration
Examiner’s fingernails should be short and the
hands should be a comfortable temperature
STANDARD PRECAUTION - if applicable
Light palpation (safest) and the most
comfortable to moderate palpation to deep
palpation
Instructions
LIGHT PALPATION
place your dominant hand lightly on the surface
of the structure
There should be very little or no depression (less
than 1 cm)
Feel the surface structures using a circular
motion
Use to feel pulses, tenderness, surface skin
texture, temperature, and moisture
 Liceo de Cagayan University - College of Nursing

health assessment
MIDTERMS Transes
Transcribed by: Kyla Badong and Juliane Estoque

MODERATE PALPATION
Depress the skin surface 1-2 cm with your
dominant hand and use a circular motion to feel
for easily palpable body organ ad masses
Note size, consistency, and mobility of structure
you palpate

DEEP PALPATION
Place your dominant hand on the skin surface
and your non-dominant hand on top of your
dominant hand to apply pressure
Thigh - flat
Result in surface depression between 2.5-5 cm
Puffed-out cheek - tympanic
Allows you to feel very deep organics or
Air - resonance
structures that are covered by thick muscles
Fluid - dull
BIMANUAL PALPATION
AUSCULTATION
Use two hands, placing one on each side of the
body parts (uterus, breasts, spleen) being Requires the use of a stethoscope to listen
palpated classified according to:
Use the other hand to apply P and the other hand
to feel the structure
Note the size, shape, consistency, and mobility
of structures you palpate

PERCUSSION
Involves tapping the body parts to produce
sound waves
Guidelines
These sound waves or vibrations enable the
examiner to assess underlying structures Eliminate distracting or competing noises from
uses: the environment
1. Eliciting pain Expose - do not auscultate through clothing -
2. Determining location, size, and shape rubbing against the cloth obscures body sound
3. Determining density Diaphragm - listen high pitched sounds - heart,
breath, bowel sounds
3 Types:
Bell - low-pitched sounds - bruits - abnormal
1. DIRECT
loud, blowing, or murmuring heart sounds
Direct with 1 or 2 fingertips
2. BLUNT
Place one hand flat using the fist of the other
hand to strike
3. INDIRECT
Produces sound variation:
Solid tissue - soft tone
Fluid - louder tone
Air - even louder
 Liceo de Cagayan University - College of Nursing

health assessment
MIDTERMS Transes
Transcribed by: Kyla Badong and Juliane Estoque

GENERAL SURVEY
First step in a head to toe assessment
Info will provide clues about the over-all health
status of the client

Includes:
1. Overall impression of the client
2. Mental status
3. Vital signs

OBSERVE OBVIOUS CHARACTERS:

1. Skin color
2. Dress
3. Hygiene
4. Posture
5. Gait
6. Body build
7. Level of Consciousness (LOC)
8. Level of comfort
9. Behavior
10. Body movement
11. Affect
12. Facial expressions
13. Speech
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health assessment In Nursing

Prelims Transes
Transcribed by: Kyla Badong and Juliane Estoque

2ND SESSION
Vital Signs Position:
Standing - slightly higher
Noninvasive
Reclining - lower
Provide data that reflect the status of several
body parts.
Temperature – (first) - puts the client at ease and
remains still for several minutes
Pulse, Respirations, and Blood Pressure - influenced
by anxiety and activity-accurate 1. Dwarfism - decreases height and skeletal
Hypothermia malformations
Below 36.5-degree centigrade 2. Acromegaly - an overgrowth of bones in the
Prolonged exposure to cold face, head, and hands
Hypoglycemia 3. Obesity - having an excessive amount of body
Hypothyroidism fat. It increases the risk of diseases and health
Starvation problems such as heart disease, diabetes, and
high blood pressure.
Hyperthermia
4. Marfan’s Syndrome - elongated fingers
Above 38.0-degree centigrade
5. Cushing’s syndrome - centralized weight gain
Malignancies
Trauma Note: *Obserev gender and sexual development (sexual
Blood, endocrine, immune disorders development is appropriate for gender and age.
Abnormal findings include delayed puberty, a male
Blood Increase - Decrease - client with female characteristics, and female clients
Volume increase BP decrease BP with female characteristics); compare the client’s stated
age with her apparent age and development stage (client
appears to be her stated chronological age. Abnormal
Slow blood No findings may include clients appearing older than their
Blood
flow - resistance -
Viscosity chronological age e.g., due to hard life, manual labor,
Increase BP decrease BP
chronic illness, alcoholism, smoking).*

Pain
Blood Thickened - Thin - Acute - less than 6 months recent injury
Viscosity increase BP decrease BP Chronic - more than 6 months specific/injury,
constant
Cancer pain - compression
BP varies with the ff elements:
Time of day Increase Decrease
Caffeine of nicotine intake
Exercise, emotion, pain, temperature IIR, BP, PVER Cognitive function

Pulse Pressure: systolic and diastolic RR, sputum retention Gastric and intestinal motility
Reflects stroke volume; volume of blood ejected in
ADH, epinephrine, aldosterone, Urinary output
each heartbeat
glucagons, testosterone
 Liceo de Cagayan University - College of Nursing
health assessment In Nursing
Prelims Transes
Transcribed by: Kyla Badong and Juliane Estoque
C-O-L-D-S-P-A
Character Describe the sign or symptom. How
does it feel, look, sound, smell, and so
forth?
Onset When did it start?
Location Where is it? Does it radiate?
Duration How long does it last? Does it recur?
Severity How bad is it?
Pattern What makes it better? What makes it
worse?
Associated What other symptoms occur with it?
Factors
COMPARATIVE PAIN SCALE CHART
Nutritional Assessment
ANTHROPOMETRIC Measurements:
Help evaluate the client’s physical growth,
development, and nutritional status.
First, obtain height and weight, then compare
them to a standard table
General indicators of Nutritional Status:
Good Nutritional Status
Alert, energetic, good endurance, good posture
Good attention span, psychological stability
Weight within range for height, age, body size
Firm, well-developed muscles, healthy reflexes
Skin is glowing, elastic, with good turgor, and
smooth
Eyes are bright and clear without fatigue circles
Hair is shiny, and lustrous, with minimal loss
Mucous membrane: pink-red, gums: pink and
firm, tongue: pink
and moderately smooth, with no swelling
Abdomen, flat
No skeletal changes
Poor Nutritional Status
Withdrawn, apathetic, easily fatigued, stooped posture
Inattentive, irritable
Overweight or underweight
Flaccid muscles, wasted appearance, paresthesias,
diminished reflexes
Skin is dull, pasty, scaly, dry, bruised
The eyes are dull, the conjunctiva is pale, and
discoloration under the eyes
Hair is brittle, dull, and falls out easily
Mucous membranes: pale, gums are red, boggy, and
bleed easily tongue
is bright dark red and swollen
Abdomen flaccid or distended (ascites)
Skeletal malformations
Hydration
Hydration is affected by:
Exposure to excessively high environmental
temperature
Inability to access adequate fluids
Excessive alcohol or diuretic fluids— coffee, sugar-
rich, caffeine-rich soft drinks
Impaired thirst mechanism
Taking diuretics
Severe hyperglycemia
High fever
Conditions
Comfortable, warm room temperature- a warm
blanket
Private area free of interruptions- close door, pull
curtains
Quiet area free of distractions- turn off the radio,
television, or other noisy equipment
Adequate lighting- sunlight, portable lamp
Firm examination table or bed at a height that
prevents stooping. Roll-up stool prn
A bedside table/tray to hold the equipment needed
Prepare the area where the examination takes place
Wash your hands
Explain the procedure to the client
 Liceo de Cagayan University - College of Nursing

health assessment In Nursing

Prelims Transes
Transcribed by: Kyla Badong and Juliane Estoque

General Survey Skin

Observe appearance including: As you perform each part of the head-to-toe assessment,
Overall physical and sexual development. assess skin for color variations, texture, temperature,
Apparent age compared with stated age. turgor, edema, and lesions
Overall skin coloring.
Dress, grooming, and hygiene.
Body build as well as muscle mass and fat
distribution.
Behavior (compare with developmental stage)

Assess the client’s vital signs

Temperature
Pulse
Physical examination of the skin: (procedure)
Respirations
Inspect the skin to evaluate color and pigmentation
Blood pressure
Normal findings:
Pain (as the 5th Vital Sign)
-lighter-pigmented races versus darker-pigmented
Take body measurements races. Hyperpigmentation is a common finding in
Height light-skinned people.
Weight Deviations from normal:
Waist and hip circumference and midarm -suggest compromises in metabolism, circulation,
circumference or oxygenation
Triceps skin fold thickness -pallor, jaundice, cyanosis, erythema

Mental Status Examination

In addition to data collection about the
client’s appearance during the general
survey, observe.
Level of consciousness.
Posture and body movements pallor jaundice
Facial expressions.
Speech
Mood, feelings, and expressions
Thought processes and perceptions
Assess the client’s cognitive abilities (the
Mini-Mental Status Exam (MMSE) may be
used): cyanosis erythema
Orientation to person, time, and place
concentration, ability to focus and follow
directions
A recent memory of happenings today
Remote memory of the past

Acanthosis Nigricans Albinism & Vitiligo

 Liceo de Cagayan University - College of Nursing

health assessment In Nursing

Prelims Transes
Transcribed by: Kyla Badong and Juliane Estoque

Inspect and palpate the skin to evaluate moisture Edema

Normal findings: Edema (if present, grade)
Dry, moisture in skin folds, slightly warm 1+ barely perceptible
Anxiety may cause sweaty palms and perspirations 2+ deeper pit that rebounds in a few seconds
in the axillae, and on the forehead and scalp 3+ deep pit that rebounds in 10-20 seconds
Deviations from normal: 4+ very deep pitting, indentation lasts a long time
Dryness, sweating, or oiliness (not clinically
significant)
- Diaphoresis
- Cold and clammy
- Abnormally dry skin

Palpate the skin to determine the temperature

Normal findings:
Warm, some people have cool skin due to dryness
Deviations from normal:
Extreme: warm skin (local or systemic), or cold skin Note the size of lesion(s); measure the diameter with a
metric ruler

Evaluate skin turgor by lifting a fold of skin between

your thumb and forefinger
Normal findings:
Elastic, rapidly returns to original shape when
grasped between thumb and forefinger
Deviations from normal:
Poor skin turgor - slow to resume its original shape
when pinched. Loss of turgor (dehydration or as a
normal aging process)

This is to track its progression over time, selecting the

These lesions are original lesions arising from
proper treatment modality, surgical planning,
previously normal skin:
determining prognosis, and accurate billing.