HEALTH ASSESMENT LECTURE

Nursing process is a critical thinking process that professional nurses use to apply the best
available evidence to caregiving and promoting human functions and responses to health
and illness. (American Nurses Association, 2010).
• Nursing process is a systematic method of providing care to clients.
• The nursing process is a systematic method of planning and providing individualized
nursing care.
Purposes of nursing process
• To identify a client’s health status and actual or potential health care problems or
needs.
• To establish plans to meet the identified needs.
• To deliver specific nursing interventions to meet those needs.
Components of nursing process
• It involves assessment (data collection), nursing diagnosis, planning, implementation, and
evaluation. 
 
Characteristics of Nursing Process
• Cyclic
• Dynamic nature,
• Client centeredness
• Focus on problem solving and decision making
• Interpersonal and collaborative style
• Universal applicability
• Use of critical thinking and clinical reasoning.

ASSESSMENT
Assessment is the systematic and continuous collection, organization, validation, and
documentation of data (information). 
Assessing
 Collect Data
 Organize Data
 Validate Data
 Document Data
Types of assessment
The four different types of assessments are;
1. Initial nursing assessment: Performed within specified time after admission. To
establish a complete database for problem identification.
Eg: Nursing admission assessment
2. Problem-focused assessment: To determine the status of a specific problem
identified in an earlier assessment.
Eg: hourly checking of vital signs of fever patient
3. Emergency assessment: During emergency situation to identify any life threatening
situation.
Eg: Rapid assessment of an individual’s airway, breathing status, and circulation during a
cardiac arrest.
4. Time-lapsed reassessment: Several months after initial assessment. To compare the
client’s current health status with the data previously obtained.
Collection of data
Data collection is the process of gathering information about a client’s health status. It
includes the health history, physical examination, results of laboratory and diagnostic tests,
and material contributed by other health personnel.
Types of Data
Two types: subjective data and objective data.
1. Subjective data, also referred to as symptoms or covert data, are clear only to the
person affected and can be described only by that person. Itching, pain, and feelings of
worry are examples of subjective data.
2. Objective data, also referred to as signs or overt data, are detectable by an observer
or can be measured or tested against an accepted standard. They can be seen, heard, felt,
or smelled, and they are obtained by observation or physical examination.
For example, a discoloration of the skin or a blood pressure reading is objective data.
Sources of Data
Sources of data are primary or secondary.
1. Primary: It is the direct source of information. The client is the primary source of
data.
2. Secondary: It is the indirect source of information. All sources other than the client
are considered secondary sources. Family members, health professionals, records and
reports, laboratory and diagnostic results are secondary sources.
Methods of data collection
• The methods used to collect data are observation, interview and examination.
Observation: It is gathering data by using the senses. Vision, Smell and Hearing are used.
Interview: An interview is a planned communication or a conversation with a purpose.
• There are two approaches to interviewing: directive and nondirective.
• The directive interview is highly structured and directly ask the questions. And the
nurse controls the interview.
• A nondirective interview, or rapport building interview and the nurse allows the
client to control the interview.
STAGES OF AN INTERVIEW
An interview has three major stages:
1. The opening or introduction
2. The body or development
3. The closing
Examination: The physical examination is a systematic data collection method to detect
health problems. To conduct the examination, the nurse uses techniques of inspection,
palpation, percussion and auscultation. 
Organization of data
The nurse uses a format that organizes the assessment data systematically. This is often
referred to as nursing health history or nursing assessment form.
Validation of data
The information gathered during the assessment is “double-checked” or verified to confirm
that it is accurate and complete. 
Documentation of data
To complete the assessment phase, the nurse records client data. Accurate documentation
is essential and should include all data collected about the client’s health status.

DIAGNOSIS
• Diagnosis is the second phase of the nursing process. In this phase, nurses use
critical thinking skills to interpret assessment data to identify client problems.
• North American Nursing Diagnosis Association (NANDA) define or refine nursing
diagnosis.
Definition
• The official NANDA definition of a nursing diagnosis is:
“a clinical judgment concerning a human response to health conditions/life processes, or a
vulnerability for that response, by an individual, family, group, or community.”
Diagnosis
 Analyze Data
 Identify health problems, risks, and strengths
 Formulate Diagnostic Statements
Status of the Nursing Diagnosis
The status of nursing diagnosis are actual, health promotion and risk.
1. An actual diagnosis is a client problem that is present at the time of the nursing
assessment.
2. A health promotion diagnosis relates to clients’ preparedness to improve their
health condition.
3. A risk nursing diagnosis is a clinical judgement that a problem does not exist, but
the presence of risk factors indicates that a problem may develop if adequate care is not
given.
Components of a NANDA Nursing Diagnosis
A nursing diagnosis has three components:
(1) The problem and its definition
(2) The etiology
(3) The defining characteristics.
1. The problem statement describes the client’s health problem.
2. The etiology component of a nursing diagnosis identifies causes of the health
problem.
3. Defining characteristics are the cluster of signs and symptoms that indicate the
presence of health problem.
Formulating Diagnostic Statements
The basic three-part nursing diagnosis statement is called the PES format and includes the
following:
1. Problem (P): statement of the client’s health problem (NANDA label)
2. Etiology (E): causes of the health problem
3. Signs and symptoms (S): defining characteristics manifested by the client.

Acute pain related to abdominal surgery as evidenced by patient discomfort and pain scale.
Problem Etiology Sign and Symptoms
Pain Surgery of abdomen Pain scale and discomfort of
patient
Differentiating Nursing Diagnosis from Medical Diagnosis
Nursing Diagnosis Medical Diagnosis

A nursing diagnosis is a statement of A medical diagnosis is made by a physician.

nursing judgment that made by nurse, by
their education, experience, and expertise,
are licensed to treat.
Nursing diagnoses describe the human Medical diagnoses refer to disease
response to an illness or a health problem. processes.

Nursing diagnoses may change as the A client’s medical diagnosis remains the
client’s responses change. same for as long as the disease is present.

Nursing Diagnosis Medical Diagnosis

Ineffective breathing pattern Asthma
Activity intolerance Cerebrovascular accident
Acute pain Appendicitis
Disturbed body image Amputation

PLANNING
• Planning involves decision making and problem solving.
• It is the process of formulating client goals and designing the nursing interventions
required to prevent, reduce, or eliminate the client’s health problems.
Planning
 Prioritize problems/disgnoses
 Formulate goals/desired outcomes
 Select Nursing Interventions
 Write Nursing Interventions

TYPES OF PLANNING
1. Initial Planning: Planning which is done after the initial assessment.
2. Ongoing Planning: It is a continuous planning.
3. Discharge Planning: Planning for needs after discharge 
Planning process
Planning includes;
• Setting priorities
• Establishing client goals/desired outcomes
• Selecting nursing interventions and activities
• Writing individualized nursing
interventions on care plans.
Setting priorities
• The nurse begin planning by deciding
which nursing diagnosis requires attention
first, which second, and so on.
• Nurses frequently use Maslow’s hierarchy
of needs when setting priorities.

Establishing client goals/desired outcomes

• After establishing priorities, the nurse set goals for each nursing diagnosis. Goals may be
short term or long term. 
Nursing interventions
• A nursing intervention is any treatment, that a nurse performs to improve patient’s
health. 
TYPES OF NURSING INTERVENTIONS
1. Independent interventions are those activities that nurses are licensed to initiate on
the basis of their knowledge and skills.
2. Dependent interventions are activities carried out under the orders or supervision of
a licensed physician.
3. Collaborative interventions are actions the nurse carries out in collaboration with
other health team members
Writing Individualized Nursing Interventions
• After choosing the appropriate nursing interventions, the nurse writes them on the
care plan.
• Nursing care plan is a written or computerized information about the client’s care.
IMPLEMENTATION
• Implementation consists of doing and documenting the activities. 
The process of implementation includes;
• Implementing the nursing interventions
• Documenting nursing activities 
EVALUATION
• Evaluation is a planned, ongoing, purposeful activity in which the nurse determines
(a)the client’s progress toward achievement of goals/outcomes and
(b)the effectiveness of the nursing care plan.
The evaluation includes;
• Comparing the data with desired outcomes
• Continuing, modifying, or terminating the nursing care plan.
Guidelines of an Effective Interview and History Taking

Phases of Interview
1. Preparatory 2. Introduction Phase 3. Working Phase 4. Termination
Types of Communication
1. Verbal Communication
OPEN-ENDED QUESTION
• Used to elicit the client’s feelings and perceptions.
• They typically begin with the words “how” or “what”. An example of this type of
question is “How have you been feeling lately?”
• These types of questions are important because they require more than a one-word
response from the client, and therefore, encourage description.
• Asking open-ended questions may help to reveal significant data about the client’s
health status.
LAUNDRY LIST
• Another way to ask questions is to provide the client with a choice of words to
choose from in describing symptoms, conditions, or feelings.
• This laundry list approach helps you to obtain specific answers and reduces the
likelihood of the client’s perceiving or providing an expected answer.
REPHRASING
• Rephrasing information the client has provided is an effective way to communicate
during the interview.
• This technique helps you to clarify information the client has started; it also enables
you and the client to reflect on what was said.
• For example, your client Mr. M, tells you that he has been really tired and nauseated
for 2 months and that he is scared because he fears that he has some horrible
disease. You might rephrase the information by saying, “ You are thinking that you
have a serious illness?”
WELL-PLACED INTERVIEWS
• Client verbalization can be encouraged by well-placed phrases from the nurse.
• If the client is in the middle of explaining a symptom or feeling and believes that you
are not paying attention, you may fail to get all the necessary information.
• Listen closely to the client during his or her description and use phrases such as”um-
hum,” “yes”, or “I agree” to encourage the client to continue.
INFERRING
• Inferring information from what the client tells you and what you observe in the
client’s behavior may elicit more data or verify existing data.
 • Be careful not to lead the client to answers that are not true.
• An example of inferring information follows: Your client, Mrs. J, tells you that she has
bad pain. You ask where the pain is and she says, “My stomach”. You notice the
client has a hand on the right side of her lower abdomen and seems to favor her
entire right side. You say, “It seems that you have more difficulty with the right side
of your stomach”. (use the word “stomach” because this is the term the client used
to describe the abdomen.) This technique, if used properly, helps to elicit the most
accurate data from the client.
PROVIDING INFORMATION
• Another important thing to consider throughout the interview is to provide the client
with information as questions and concerns arise.
• Make sure you answer every question as well as you can. If you do not know the
answer, explain that you will find out for the client.
• The more clients know about their own health, the more likely they are to become
equal participants in caring for their health.

2. Nonverbal Communication
APPEARANCE
• Ensure that your appearance is professional.
• The client expects to see a health professional; therefore, you should look the part.
• Wear comfortable, neat clothes and a laboratory coat or a uniform.
• Be sure your name tag, including credentials, is clearly visible.
• Your hair should be neat and not in any extreme style; some nurses like to wear long
hair pulled back.
• Fingernails should be short and neat.
• Jewelry should be minimal.
DEMEANOR
• Your demeanor should be professional.
• When you enter a room to interview a client, display poise.
• Focus on the client and the upcoming interview and assessment.
• Do not enter the room laughing aloud, yelling to a coworker, or muttering under
your breath. This appears unprofessional to the client and will have an effect on the
entire interview process.
• Greet the client calmly and focus your full attention on him/her.
FACIAL EXPRESSION
• Facial expression are often an overlooked aspect of communication.
 • Facial expression often shows what you are truly thinking (regardless of what you are
saying), keep a close check on your facial expression.
• No matter what you think about a client or what kind of day you are having, keep
your expression neutral and friendly.
• Portraying a neutral expression does not mean that your face lacks expression. It
means using the right expression at the right time.
SILENCE
• Another nonverbal technique to use during interview process is silence.
• Periods of silence allow you and the client to reflect and organize thoughts, which
facilitates more accurate reporting and data collection.
ATTITUDE
• One of the most important nonverbal skills to develop as a health care professional
is a nonjudgmental attitude.
• All clients should be accepted, regardless of beliefs, ethnicity, lifestyle and health
care practices.
• Do not act superior to the client who appear shocked, disgusted, or surprised at
what you are told. These attitudes will cause the client to feel uncomfortable
opening up to you and important data concerning his or her health status could be
withheld.
• Being nonjudgmental involves not “preaching” to the client or imposing your own
sense of ethics or morality on him.
• Focus on health care and how you can best help the client to achieve the highest
possible level of health.
LISTENING
• Listening is the most important skill to learn and develop fully in order to collect
complete and valid data from the client.
• Maintain good eye contact, smile or display an open, appropriate facial expression,
maintain an open body position (open arms and hands and lean forward).
• Avoid preconceived ideas or biases about your client.
• Keep an open mind. Avoid crossing your arms, sitting back, tilting your head away
from the client, thinking about other things, or looking blank or inattentive.
SPECIAL CONSIDERATIONS RELATED TO AGE, CULTURAL AND EMOTIONAL VARIATIONS

Gerontologic Variations
Age affects and commonly slows all body systems in varying degrees. However, normal
aspects of aging do not necessarily equate with a health problem.
Older clients have the potential to be as healthy as younger clients.
• When interviewing an elderly client, you must first assess the hearing acuity.
• If you detect hearing loss, speak slowly.
• Face the client at all times during the interview, and position yourself so that you are
speaking on the side of the client that has the ear with better acuity.
Do not yell at the client.
• Many times, older clients with health problems feel vulnerable and scared.
• Establishing and maintaining trust, privacy, and partnership with the older client is
particularly important.
• It is not unusual for elderly clients to be taken for granted and their health
complaints ignored, causing them to become fearful of complaining.
• Speak clearly and use straightforward language.
• Ask questions in simple terms.
• Avoid medical jargon and modern slang.
• Showing respect is very important.
• If the client is mentally confused or forgetful, it is important to have a significant
other present during the interview to provide or clarify data.
CULTURAL VARIATIONS IN COMMUNICATION
• Ethnic/cultural variations in communication and self-disclosure styles may
significantly affect the information obtained.
• Be aware of possible variations in communication styles of yourself and the client.
• If misunderstanding or difficulty in communicating is evident, seek help from an
expert. This is someone who is thoroughly familiar not only with the client’s
language, culture, and related health practices but also with the health care setting
and system of the dominant culture.
• Keep in mind that communicating through the use of pictures may be helpful when
working with some clients.
• Frequently noted variations in communication styles include:
• Reluctance to reveal personal information to strangers for various culturally based
reasons.
 • Variation in willingness to openly express emotional distress or pain.
• Variation in ability to receive information (listen).
• Variation in meaning conveyed by language.
• For example, a client who does not speak the predominant language may not know
what a certain medical term or phrase means and, therefore, will not know how to
answer your question.
• Use of slang with non-native speakers is discouraged.
• Keep in mind that it is hard enough to learn proper language, let alone the idiom
vernacular. The non-native speaker will likely have no idea what you are trying to
convey.
• Variations in disease/illness perception: Culture specific syndromes or disorders are
accepted by some groups.
• Variation in past, present, or future time orientation. (e.g. the dominant U.S. culture
is future oriented; other cultures may focus more on the past or present)
• Variations in the family’s role in the decision-making process: A person other than
the client or the client’s parent may be the major decision maker about
appointments, treatments, or follow-up care for the client.
• Variations in use and meaning of nonverbal communication: eye contact, stance,
gestures, demeanor.
• For example, direct eye contact may be perceived as rude, aggressive, or immodest
by some cultures but lack of eye contact may be perceived as evasive, insecure, or
inattentive by some other cultures.
• A slightly bowed stance may indicate respect in some groups; size of personal space
affects one’s comfortable interpersonal distance; touch may be perceived as
comforting or threatening.
EMOTIONAL VARIATIONS IN COMMUNICATION
• Not every client you encounter will be calm, friendly, and eager to participate in the
interview process. Clients’ emotions vary for a number of reasons.
• They may be scared or anxious about their health or about disclosing personal
information.
• They may be angry that they are sick or about having to have an examination.
• They may be depressed about their health or other life events.
• They may have an ultimate motive for having an assessment performed.
• Clients may also have some sensitive issues with which they are grappling and may
turn to you for help.
METHODS OF PHYSICAL EXAMINATION

DEFINITION OF PHYSICAL EXAMINATION

 Physical Examination is defined as a complete Assessment of a patient’s physical and
mental status.
 Physical assessment is a systematic collection of objective information that is
directly observed or elicited through examination technique.

PURPOSE OF PHYSICAL EXAMINATION

• To understand the physical and mental well-being of the patient.
• To detect disease in its early stage
• To determine the cause and the extend of disease
• To understand any changes in the condition of disease, any improvement or regression.
• To determine the nature of the treatment or nursing care needed for the patient

METHODS OF PHYSICAL EXAMINATION

 INSPECTION
It is a deliberate, purposeful, and systematic collection of data from the client through the
visual examination (that is, assessing by using the sense of sight)
GUIDELINES OF INSPECTION
• Make sure that adequate lighting is available, either direct or tangential.
• Uses direct light sources (eg., a penlight or lamp) to inspect body cavities.
• Inspect each area for size, shape, color, symmetry, position, and abnormality.
• Position and expose body parts as needed so all surfaces can be viewed but privacy can be
maintained.
• When possible, check for side-to-side symmetry by comparing each area with its match on
the opposite side of the body.

 PALPATION
Is the process of using one's hands to check the body, especially while perceiving
/diagnosing a disease or illness.
PURPOSE OF PALPATION
• Examination of the body surface (skin, smoothness, dryness, irregularities etc…)
• Examination of internal organs (shape, size, consistency etc…)
• To look for abnormal resistances.
• Detection of painful areas
• To feel movement of fluids within the body.
PRINCIPLES OF PALPATION
• Prepare for palpation by warming hands, keeping fingernails short, and using a gentle
approach.
• Palpation proceeds slowly, gently, and deliberately.
• Encourage the patient continue to breath normally throughout the palpation.
• Ask the patient to point to more sensitive areas.
• Ask the patient to point to more sensitive areas.
• Watching for nonverbal signs of discomfort.
• If the pain is experienced during palpation discontinue the palpation immediately.

TYPES OF PALPATION
• LIGHT PALPATION A method of determining the outlines of organs or masses by
lightly palpating the surface with the tip of a finger for 1 to 2 centimeters.
• DEEP PALPATION Deep palpation is used to feel internal organs and masses, usually
pressing down 4-5 centimeters.

 PERCUSSION
Is a method of tapping the skin with the fingertips to vibrate underlying tissues and organs,
to determine the structure.
TYPES OF PERCUSSION
• Direct percussion: It involve tapping lightly with the pad of the fingers directly on the
client skin.
• Indirect percussion: It can be performed by using two finger left middle finger
[Pleximeter finger] is placed over the area and its middle phalanx is tapped with the
tip of the right middle finger or index finger [percussing finger]
• Fist percussion: It involve placing one hand flat against the body surface and striking
the back of the hand with a clenched fist of the other hand.
  AUSCULTATION
Is listening to the internal sounds of the body, usually using a stethoscope.
PURPOSE OF AUSCULATION
• Auscultation is performed for the purposes of examining the circulatory and respiratory
systems, as well as the gastrointestinal system.
• It helps to listening for body sounds typically from organs and tissues to assess their
functions.
TYPES OF AUSCULTATION
• DIRECT AUSCULTION It involve listening to the client body sound without using any
assistive instrument [eg wheezing, chest congestion]
• INDIRECT AUSCULTION Involve listening to the client body sound with the use of a
stethoscope

 OLFACTION
Another skill that used during assessment, certain alteration is body function create
characteristic body odors, smelling can detect abnormalities that unrecognized by other
means.
ASSESSMENT OF CHARACTERISTIC ODOR
• Alcohol odor from oral cavity means ingestion of alcohol.
• Ammonia from urine means urinary tract infection.
• Body odor from skin, particularly in areas where body parts rub together means poor
hygiene, excess perspiration (bromidrosis).
• Feces odor from wound site means wound abscess, but if this odor from vomitus this
means bowel obstruction, and if the odor from rectal area this means fecal incontinence.
• Foul–smelling stools in infant from stool means mal absorption syndrome.
• Halitosis from oral cavity means poor dental and oral hygiene, gum disease. Assessment of
characteristic odors • Halitosis from oral cavity means poor dental and oral hygiene, gum
disease.
• Sweet, fruity ketone from oral cavity may be from diabetic acidosis.
• Musty odor from casted body part means infection inside cast.
• Fetid odor from tracheostomy or mucous secretions means infection of bronchial tree
(pseudomonas bacteria)