HEALTH ASSESSMENT (NCM 101)

•PETER JOHN P. GONO, RN, MAN

• CLINICAL INSTRUCTOR
Week 1
Topic Objectives
• Explain how assessment skills are needed for every situation the nurse
encounters.
• Differentiate between the holistic nursing assessment and a physical
medical assessment.
• Describe how assessment fits into the total nursing process.
• List and describe the steps of nursing process: subjective data collection;
objective data collection; validation of data; documentation of data; and
analysis of data.
• Describe the steps of analysis phase of the nursing process.
 Nursing Process

The nursing
process functions as a
systematic guide to
client-centered care with
5 sequential steps.
 Utilizing the Nursing Process
• Step 1: Data Collection or Assessment
• Step 2: Data Analysis and Organization
• Step 3: Formulating Your Nursing Diagnoses
• Step 4: Setting Priorities
• Step 5: Establishing Client Goals and Desired Outcomes
• Step 6: Selecting Nursing Interventions
• Step 7: Providing Rationale
• Step 8: Evaluation
HEALTH ASSESSMENTIN NURSING
HEALTH ASSESSMENT

A HEALTH ASSESSMENT is a plan of care that identifies the specific

needs of a person and how those needs will be addressed by the
healthcare system or skilled nursing facility.

HEALTH ASSESSMENT is the evaluation of the health status by

performing a physical exam after taking a health history. It is done to
detect diseases early in people that may look and feel well.
Learning About Assessment
• Taking Health History
• Biographical Data
• Chief Complaint
• P- Provocative or Palliative
• Q- Quality or Quantity
• R- Region and Radiation
• S- Severity
• T- Timing
• Medical History
GUIDELINES FOR EFFECTIVE INTERVIEW
• BE PREPARED
• Review the patient, mind cc and hx history
• CREATE A PLEASANT INTERVIEWING ATMOSPHERE
• Quiet, well-lighted, and relax setting (make the patient comfortable)
• ESTABLISH GOOD RAPPORT
• Explain the purpose and show some concern for patient’s condition
• SET THE TONE AND FOCUS
• Encourage the patient to talk, and be professional. Speak clearly and simply.
• CHOOSE WORDS CAREFULLY
• Ask open-ended questions to encourage elaboration of signs and symptoms.
• TAKE NOTES
• Jot down important information.
 Nurse’s Role in Health Assessment: Collecting and Analyzing Data
Term Description

1. Assessment a. Collecting of subjective and objective data.

2. Diagnoses b. Clinical judgment about individual, family, or community responses to actual or potential health problems and life processes.

3. Planning c. Developing a plan of nursing care and outcome criteria.

4. Implementation d. Carrying out the plan of care.

5. Evaluation e. Assessing whether outcome criteria have been met and revising the plan of care if necessary.

6. Nursing Diagnosis f. Analysis of subjective and objective data to make a professional nursing judgment.

7. Subjective Data g. Sensations or symptoms that can be verified only by the client (i.e. pain)

8. Objective Data h. Findings that directly observed or indirectly observed through measurements.

9. Collaborative Problem i. Problems that require assistance of other health care professionals.

10. Referral Problem j. Physiologic complications that nurses monitor to detect their onset or changes in status.
 COLLECTING SUBJECTIVE AND OBJECTIVE DATA

• OBJECTIVE DATA – SIGNS; observable, measurable

• SUBJECTIVE DATA – SYMPTOMS; include the client’s communicated

description, perception, feelings, emotions or concerns

Data collected may include: PHYSICAL, PSYCHOLOGICAL, SOCIAL,

CULTURAL, SPIRITUAL, DEVELOPMENTAL AND COGNITIVE AREAS.
CLASSIFY: SUBJECTIVE OR OBJECTIVE DATA
PAIN PROFUSE SWEATING ATE ½ CUP OF RICE WATER INTAKE: LBM 4X
1000ML

BLOOD PRESSURE INABILITY TO SIT ABDOMINAL ANXIETY VERBALIZED

STILL CRAMPING WEAKNESS

WEIGHT LINITED RANGE OF GRIMACE DISORIENTED TO RAPID RESPIRATION:

MORTION TIME, PLACE, DATE 33 BPM

NAUSEA EXPRESSED TOOTHACHE PROFUSE SWEATING FEELING OF

WEAKNESS CHEST TIGHTNESS

FEAR LACK OF APPETITE URGE TO URINATE FEELING DIZZY WARM TO TOUCH

 IDENTIFYING SUBJECTIVE AND OBJECTIVE DATA
___1. Describes severe right-sided headache.
___2. Reddened, raised, indurated area on deltoid area of left arm.
___3. Cannot eat seeds or uncooked grains without abdominal discomfort.
___4. Passing flatus.
___5. Bowel sounds present in all four quadrants.
___6. Complains of lower back pain on movement.
___7. Pattern of request for pain medication every two hours.
___8. Pale, clammy and diaphoretic.
___9. Feels nauseated and dizzy.
___10. Emesis of 200mL light beige thin liquid.
COLLECTING SUBJECTIVE AND OBJECTIVE DATA
1. During an interview, the nurse collect both subjective and objective data from an adult client. Subjective 6. The nurse is interviewing a client in the clinic for the first time. When the client tells the nurse
data would include the client’s the he smokes “about two packs of cigarettes per day”, the nurse should
a. Perception of pain. a. Look at the client with a frown.
b. Height. b. Teel the client that he is spending a lot of money foolishly.
c. Weight c. Provide the client with as list of dangers associated with smoking.
d. Temperature. d. Encourage the client to quit smoking.

2. During an interview with an adult client, the nurse can keep the interview from going off course by: 7. During a client interview, the nurse uses non-verbal expressions appropriately when the
a. Using open-ended questions. nurse
b. Rephrasing the client’s statements. a. Avoids excessive eye contact with the client.
c. Inferring information. b. Remains expressionless throughout the interview.
d. Using close-ended questions. c. Uses touch in a friendly manner to establish rapport.
d. Displays mental distancing during the interview.
3. The nurse has interviewed a Hispanic client with limited English skills for the first time. The nurse 8. During an interview of an adult client, the nurse should
observes that the client is reluctant to reveal personal information and believes in a hot and cold a. Use leading questions for valid responses
syndrome of disease causation. The nurse should b. Provide client with information as question arise.
a. Indicate acceptance of the client’s cultural differences. c. Read each question carefully from the history form.
b. Request a family member to interpret for the client. d. Complete the interview as quickly as possible.
c. Use slang terms to identify for certain body parts.
d. Remain in a standing position during the interview.

4. For a nurse to be therapeutic with clients when dealing with sensitive issues such as terminal illness 9. While interviewing a client for the first time, the nurse is using a standardized nursing
or sexuality, the nurse should have history form. The nurse should
a. Advance preparation in this area. a. Maintain eye contact while asking the questions from the form.
b. Experience in dealing with these type of clients. b. Read the questions verbatim from the form.
c. Knowledge of his or her own thoughts and feelings about these issues. c. Ask the client to complete the form.
d. Personal experience with death, dying and sexuality. d. Ask leading questions throughout the interview.

5. The nurse is interviewing a client in the clinic for the first time. The client appears to have a very 10. The nurse is interviewing a 78-year -old client for the first time. The nurse should first
limited vocabulary. The nurse should plan to a. Assess the client’s hearing acuity.
a. Use very basic lay terminology. b. Establish rapport with the client.
b. Have a family member present during an interview. c. Obtain biographic data.
c. Use standard medical terminology. d. Use medical terminology appropriately.
d. Show the client pictures of different symptoms, such as faces pain chart.
DATA SOURCES
• A. PRIMARY

A. Subjective
• Patient’s or clients verbal description of their health status or
problems
• ONLY client can provide subjective data
• Subjective data is the MAJOR essential in health history
B. Objective
• Observation or measurements of client’s health status
• Ex: inspection of surgical wound, description of an observed
behavior, measurement of BP
• B. SECONDARY

• Family and significant others

• Incase of infants or children, critically ill patient, mentally unstable
and unconscious
• Healthcare team members
• Medical records
Methods of Data Collection
•Interview
•Nursing History Collection
•Laboratory and Diagnostic Test
Results
PRIMARY AND SECONDARY DATA SOURCES:
SITUATION:
Mr. Magtulis brings his 2-year-old daughter, Lauren to the
emergency department with a fever of 103 deg F. Mr.
Magtulis states that Lauren has had a cough and a runny
nose for the past two days and is not sleeping or eating well.
Lauren is irritable, tugs at her ear, and says “My ear hurts”.
Lauren old records show that she had been treated three
times over the past year for otitis media.
Identify the following:
1. Primary Data Source: ___________________
2. Secondary Data Source: _________________
3. Subjective Data: _______________________
4. Objective Data: _________________________
Prioritizing Problems:
1: Life Threatening
2: Urgent
3: Can Wait
a. BP: 60/40mmHg_______
b. Breathing Difficulty, pulse oximetry 88% on room
air_______
c. Hunger and thirst_______
d. Severe Anxiety_______
e. Temperature 103 deg F______
Documenting Data:
Documentation:
1. Error: draw a line through the ERROR, writing “error” and
initialing.
2. Avoid slang terms or labels unless they are direct quotes.
3. Use only accepted abbreviations and medical terms
4. Procedures not documented on the chart are considered
undone.
5. Chart: Legal Document
6. Data should be in chronological order
III. Assessing Mental Status and Psychosocial Developmental Level
Related Terms:
1. Lethargy: Opens eyes and answers
questions but fall back to sleep.

2. Obtunted: Slow response, opens eyes to

loud voice.

3. Stupor: Awakens to painful stimuli then

goes back to sleep.

4. Coma: Unresponsive to all stimuli.

GLASGOW COMA SCALE:
Assessment:
1. Observe LOC: Ask for name, address and phone number as appropriate. (If no response: Call the name louder; next
shake gently; if still no response, apply painful stimuli.
2. Use GCS for high risk client.
3. Note Posture, gait, and body movements
4. Observe behavior and the client’s affect
5. Note dress, grooming and hygiene.
6. Observe facial expression.
7. Observe speech.
8. Note thought process and perceptions.
9. Observe for any destructive or suicidal tendencies.
10. Observe for the following cognitive abilities:
a. Orientation to time, place, person.
b. Concentration and attentiveness.
c. Recent and remote memory.
d. Memory to learn new information.
e. Abstract reasoning and judgment
f. Visual and constructional abilities.
DISORDERS IN THINKING, PERCEPTION AND THOUGHT PROCESS
DISORDER DEFINITION

1. Concrete thinking a. Inability to abstract

2. Circumstantiality b. Digresses to a topic, never getting to point

3. Word Salad c. Combining words with no meaning

4. Tangentiality d. Excessive, irrelevant detail

5. Clang Associations e. Association of words by sound

6. Echolalia f. Repetition of words

7. Flight of ideas g. Jumps from one topic to the next

8. Illusion h. Misinterpretation of the real external stimuli

9. Delusion i. False belief

10. Hallucination j. False sensory perception

Psychosocial Developmental Level
METHODS OF ASSESSMENT:
AUSCULTATION

• The action of listening

to sounds from the
heart, lungs, or other
organs, typically with a
stethoscope, as a part
of medical diagnosis.