Health Assessment
Assessment
➢ Systematic collection of data to determine
a person's current and past health status,
functional status and determine the
person’s present and coping pattern.
➢ Plan of care that identifies the specific
needs of a person on how needs will be
addressed.
➢ Gathering of information about
physiological, psychological, psychosocial
and spiritual state of a person
➢ Evaluation of holistic well being of a
person.
Health Assessment
➢ Health assessment is an essential nursing
function which provides foundation for
quality nursing care and intervention
➢ It helps to identify the strengths of the
clients in promoting health
➢ Health assessment helps to identify client’s
needs and clinical problems
➢ To evaluate responses of the person to
health problems and intervention.
Purposes of Assessment
● To collect date pertinent to the patient’s
health status – Subjective / Objective
● To identify deviations from normal
● To discover the patient’s strengths,
limitations and coping resources.
● To pinpoint the actual problem.
● To build rapport with a patient and his/her
family.
Assessment Identifies the Client’s Strengths
and Limitation
• It is done continuously throughout the nursing
process
History Taking
• The collection of subjective data that includes
information on both the patient’s past and present
health status.
• It allows positive aspects of health problems,
health teaching needs, and health concerns to be
identified.
• is to obtain information about the patient's health
in his or her own words and based on the patient's
own perceptions.
Components of Comprehensive History
• Identification
• Name, age, sex, informant (reliability of
informant)
• Chief Complaint - The chief reason for seeking
medical treatment. State on patient’s own words
the current problem
• History of Present Illness - Chronological onset
of symptoms, Onset/duration/ frequency.
Associated signs and symptoms, manifestations,
related history/previous treatment for the problem,
Pertinent positives and negatives
• Past Medical History - Current medications,
allergies, surgeries, hospitalizations.
• Family History
• Social History
Psychosocial History
• Psychosocial care is the culturally sensitive
provision of psychological, social, and spiritual
care through therapeutic communication. Current
evidence suggests that effective psychosocial care
improves patients' health outcomes and quality of
life.
Health History Guidelines
Name
Address
Phone
Gender
Provider of history (patient or other)
Birth date
Place of birth
Race or ethnic background
Marital Status Religious or Spiritual
Practices
Educational Level Occupation Significant
others or support persons
(availability