Introduction To Health assessment

• BY
• Razia Cheema
• College of Nursing
• Allama Iqbal Medical College Lahore
OBJECTIVES

• By the end of the unit, learners will be able to:

• Define the basic terms of health assessment
• Explain the purpose, indication of health assessment
• Describe the principles of health assessment, and legal issues in health
assessment.
• Identify types of health assessments.
• Examine the frequency and importance of health assessment in
nursing
Introduction to Health Assessment

• Definition of Health:

• Health is a state of complete physical, mental, and social well-being

and not merely the absence of disease or infirmity (WHO, 1948).
WHO recently added, the ability to lead a “socially and economically
productive life”.
Introduction to Health Assessment

• Definition of Assessment

• The action of assessing someone or something.

• The act of judging or deciding the amount, value, quality, or

importance of something
Introduction to Health Assessment

• Health is a state of wellbeing. (WHO)

• Assessment is defined as a systematic , dynamic process by which the

nurse through interaction with client, significant others and health care
providers, collects and analyze data about the client. (ANA).
 Introduction to Health Assessment
• Definition of health assessment

• The process of collecting, validating, and clustering data about the health

• 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.
Introduction to Health Assessment
• Definition of Nursing assessment
Nursing Assessment means the systematic collection of data about an
individual client for the purpose of judging that person’s health/illness
status and actual or potential healthcare needs. Nursing assessment
involves collecting information about the whole person including the
physical, psychological, social, cultural, and spiritual aspects of the
person.
Introduction to Health Assessment
• Nursing assessment
• Nursing assessment includes taking a nursing history and an appraisal
of the person’s health/illness through the interview, physical
examination and information from family/significant others, and
pertinent information from the person’s past health / medical record.
The data collected during the nursing assessment process provides the
basis for a diagnosis(es), plan for intervention, and evaluation.
Introduction to Health Assessment
• Medical Assessment
• Medical assessment means focus primarily on the client's
physiological changes (diagnosis& treatment).
Introduction to Health Assessment
• BASIC CONCEPTS:
Health: (WHO) a state of complete physical, mental &social Wellbeing,
not merely the absence of disease.

Wellness: Level of wellbeing, a person perceives of being healthy.

Disease: Alteration of structure and function of body. Disease or

discomfort.

Illness: A response a person has to an illness.

Introduction to Health Assessment
• Illness : It is a response to a disease and sickness is the
individual perception of its illness.
Thus, it is possible that a person has a disease DM, has hypoglycemia
sometimes, but still feels that he is normal so thus does not feel sick.
Introduction to Health Assessment
• Components of health assessment

• History taking

• Physical examination of various systems

• Nutritional assessment

• Related investigations and diagnostic

Introduction to Health Assessment
• Purposes of health assessment:

• To establish a data base of client’s normal abilities, risk factors that can
contribute to dysfunction and any current alteration in function.

• To get a clear picture of a client’s health status and health related problems.

• To identify cause and extent of disease.

• To identify the problems at early stage.

Introduction to Health Assessment
• Purposes of health assessment:
• To determine the nature of treatment required for the client.
• To get a holistic view of the client.
• To contribute to medical research.
• To identify client’s strength, weakness, knowledge, attitude, motivation,
support systems and coping skills.
• To compare client's health status with an ideal status.
Introduction to Health Assessment

• Purposes of health assessment:

• To identify the needs of health teaching

• To identify the client's strengths

• To identify the health problems

• To determine client’s normal function

• To build rapport with patient and family

Indication of health assessment

• On admission

• On discharge

• On follow up

• Health camps

• Before and after diagnostic and therapeutic procedure.

Principles of Health Assessment
• An accurate and timely health assessment provides foundation for
nursing care & intervention.

• Go for comprehensive assessment.

• The health assessment process should include data collection,

documentation and evaluation of the client’s health status.

• All documents should be objective, accurate, clear, concise, specific

and current.
Principles of Health Assessment

• It should be practiced in all settings whenever there is nurse-client

interaction.

• Information gathered should be communicated to other health care

professional.

• Keep the confidentiality

Legal Issues in health assessment
• In today’s litigious (debatable) society, you must be ever vigilant
(attentive) when engaging in nursing practice. Documentation issues
have previously been addressed. Equally important is how you execute
the nursing assessment. Establishing a trusting and caring relationship
is the primary element in avoiding malpractice (misconduct) claims.
Legal Issues in health assessment
• While performing each step in the physical assessment process, you need to
inform the patient of what to expect, where to expect it, and how it will feel.
Protests by the patient need to be addressed prior to continuing the
examination. Otherwise, the patient may claim insufficient informed
consent, sexual abuse, or physical harassment.

• All assessments and procedures, including any injury that was caused during
the physical assessment, must be completely documented. The institutional
policy regarding patient injury in the workplace must be followed.
TERMINOLOGY

• Diagnosis – It is the determination of the nature and extent of a disease.

• Prognosis – It is the forecast of the course and duration of a disease.

• Etiology – It is the science of the cause of a disease.

• Signs – The presence of a disease that can been seen or elicited E.g., Fever.

• Symptoms – Any evidence as to the nature and location of a diseases noted

by the client.
TERMINOLOGY Cont…

• Subjective Symptoms – When the symptoms are note by the client

himself. E.g., Pain.

• Objective Symptoms – When the symptoms are noted by the observer

as well as by the client. E.g., Jaundice.
HEALTH HISTORY

• It is a collection of subjective data in detail regarding client’s health in

a chronological order.
Difference between subjective &objective
data
subjective data Objective Data
Information perceived only by the Observable and measurable data
affected person that can be seen, heard, or felt by
someone other than the person
experiencing them.
For example, pain experience, For example, elevated temperature,
feeling dizzy, feeling anxious skin moisture, vomiting
Factors Affecting The Collection of
Subjective Data
• Physical setting

• Client’s Personality and Behavior

• Nurses’ Personality and Behavior

• Communication Skill

• Patient’s Problem
STEPS OF HEALTH ASSESSMENT

The assessment phase of the nursing process has four major

steps:

1. Collection of subjective data

2. Collection of objective data

3. Validation of data

4. Documentation of data
Types of assessment

• The type of health assessment dependents on several factors like

context of care, the patient’s needs and the nurse’s experience.

• Initial comprehensive assessment

• Ongoing or partial assessment

• Focused or problem-oriented assessment

• Emergency assessment
Initial Comprehensive Assessment

• An initial comprehensive assessment involves collection of subjective

data about the client’s perception of her health of all body parts or
systems, past health history, family history, and lifestyle and health
practices (which includes information related to the client’s overall
function) as well as objective data gathered during a step-by-step
physical examination.
Ongoing or Partial Assessment
• An ongoing or partial assessment of the client consists of data collection
that occurs after the comprehensive database is established. This consists
of a mini-overview of the client’s body systems and holistic health
patterns as a follow-up on his health status. Any problems that were
initially detected in the client’s body system or holistic health patterns are
reassessed in less depth to determine any major changes (deterioration or
improvement) from the baseline data. In addition, a brief reassessment of
the client’s normal body system or holistic health patterns is performed to
detect any new problems.
Focused or Problem-Oriented Assessment

• A focused or problem-oriented assessment does not take the place of

the comprehensive health assessment. It is performed when a
comprehensive database exists for a client who comes to the health
care agency with a specific health concern. A focused assessment
consists of a thorough assessment of a particular client problem and
does not cover areas not related to the problem.
Emergency Assessment
• An emergency assessment is a very rapid assessment performed in life-
threatening situations. In such situations (choking (‫)دم گھٹنا‬, cardiac arrest,
drowning), an immediate diagnosis is needed to provide prompt
treatment. An example of an emergency assessment is the evaluation of
the client’s airway, breathing, and circulation (known as the ABCs) when
cardiac arrest is suspected. The major and only concern during this type
of assessment is to determine the status of the client’s life-sustaining
physical functions.
Time- lapsed assessment

• Time lapsed assessment involves assessment several days after first

initial assessment.

• Purpose: To compare the client’s current status to baseline data

previously obtained.

• E.g., reassessment of client's functional health patterns in a home.

Major Types of assessment

Comprehensive assessment: is usually the initial assessment it very

thorough and includes detailed health history and physical examination and
examine the client's overall health status.
Focused assessment : is problem oriented and may be the initial assessment
or an ongoing assessment.
Frequency of assessment

• The persons under (35) years every (4-5) years.

• The persons from (35-45) every (2-3) years.

• Persons from (45-55) years of age undergo a thorough health

assessment every year.

• Persons over (55) years may need assessment every 6 months or less.
Importance of nursing health assessment

Systematic and continuous collection of client data.

It focus on client responses to health problem

The nurse carefully examine the client’s body parts to determine any
abnormalities.

The nurse relies on data from different sources which can indicate
significant clinical problems.

• Health assessment provides a base line used to plan the client's care
Importance of nursing health assessment

• Health assessment helps the nurse to diagnose client’s problem & the
intervention.

• Complete health assessment involves a more detailed review of

client’s condition.

• Health assessment influence the choice of therapies & client's

responses.
Nursing and medical diagnosis

• There is a big Difference between both because:

• Nursing diagnose is independent role of the nurse.

• Nursing diagnoses depends on the client's problems/response

associated with specific disorder.

• Any problem in nursing diagnosis must notice from a holistic view

e.g., bio-psycho-social and spiritual relations.
Medical diagnosis

• Depends on clinical picture and laboratory findings.

• The specialist doctor has a right to diagnose not else.

• Example: DM is medical diagnoses (hypo or hyperglycemia).

• Nursing diagnoses in this case e.g., Impaired skin integrity R/T poor
circulation, Knowledge deficit about the effects of exercise on needs
of insulin.
 References
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Williams & Wilkins, .
References

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• Massey, D., & Meredith, T. (2011). Respiratory assessment 1: Why do

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References

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