​ HEALTH ASSESSMENT - LECTURE

BS NURSING / FIRST YEAR

MAIN LESSONS
Sessions # 1 to #3

MAIN LESSON ​| ​Session #1

Definition of Health
• Health is a relative state in which a person is able to live to his or her potential and includes the “7 facets”:
• Physical health – how the body works and adapts
• Emotional health – positive outlook and emotions channeled in a healthy manner
• Social well-being – supportive relationships with family and friends
• Cultural influences – favorable connections to promote health
• Spiritual influences – living peacefully, morally, and ethically
• Environmental influences – favorable conditions to promote health
• Developmental level – how one thinks, solves problems, and makes decisions
• Health is a sum of these facets and is not solely defined as the absence of disease or eating right, but rather by
the contribution of all dimensions.

Health Assessment
• The nursing health assessment entails both a comprehensive health history and a complete physical examination,
which are used to evaluate the health and status of a person.
• The nursing health assessment involves a systematic data collection that provides information to facilitate a plan
to deliver the best care for the patient.
• The first part of health assessment is the health history, which also incorporates the “7 facets”.
• The nurse asks pertinent questions to gather data from the patient and/or family. Past medical records may also
be used to collect additional information.
• Learning about the patient’s physical and psychological issues, social and cultural associations, environment,
developmental level, and spiritual beliefs contribute to the history.
• The second component of the health assessment is the physical examination.
• The nurse uses a structured head-to-toe examination to identify changes in the patient’s body systems.
• An unusual or abnormal finding may support the history data or trigger additional questions.
• The purpose of the nursing health assessment is to determine the patient’s health status, risk factors, and need
for education as a basis for developing a nursing plan of care.
• The NURSING PROCESS is the ability of the nurse to extrapolate the findings, prioritize them, and finally
formulate and implement the plan of care is the overall goal.
• The information obtained throughout the health assessment should be documented in a clear, concise manner.
This information is collated in the patient’s medical records.

NURSING PROCESS
• The nurse uses the NURSING PROCESS (a problem-solving process) to identify patient problems; set a goal and
develop an action plan; implement the plan; and evaluate the outcome.
• The NURSING PROCESS steps are:
• Assessment
• Diagnosis
• Planning
• Implementation
• Evaluation
• Assessment ​– it is the first step of the nursing process. It is the subjective and objective data gathered during the
initial health history and physical examination and collected on each patient encounter.

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Education (Department of Nursing)
 • Diagnosis​ has a nursing focus and is based on real or potential health problems or human responses to health
problems. The nurse uses clinical reasoning to formulate diagnoses based on the assessment data and the
patient’s problem list.
• Planning​ is devising the best course of action to address the patient’s diagnosis. During planning, the nurse and
patient select goals for each diagnosis in order to alleviate, decrease, or prevent the problems addressed in the
nursing diagnosis.
• Implementation​ of the interventions can be completed by the patient, the family, or members of the health care
team. The interventions should clearly relate to the nursing diagnosis and the planned goals.
• Evaluation​ is a continuing process to determine if the goals have been attained. The nursing care plan is revised
based on the patient’s condition and whether the goals are realistic or appropriate for the patient.
• During the assessment phase the nurse gathers patient data via the health history and examination of the patient.
• A clinical reasoning process is then used to analyze the patient data and develop hypotheses as the patient’s
problem or problems.
• Once the problems are defined, the nurse develops the plan of care and implements and evaluates it.
• assessment findings and the plan of care in the patient record to communicate the patient’s story and the nurse’s
clinical reasoning and plan to other health care team members.
• Critical thinking is ongoing, as is assessment of the patient.

Types of Health Assessment:

• The admission of a new patient to a clinic, hospital, long-term care facility, or visiting nurse agency usually
requires a ​comprehensive health assessment.​
a. A ​focused or problem-oriented assessment​ is where the nurse focuses on gathering information about the
patient’s problem.

• A follow-up history is a form of a focused assessment.

• An ​emergency history ​is the data collection which focused on the patient’s emergent problem with a systematic
prioritization of need beginning with the ABCs of airway, breathing, and circulation.

MAIN LESSON ​| ​Session #2

Interviewing and Communication

Health History Interview
- a conversation with a purpose within three folds using health history format:
• 1. establish a trusting and supportive relationship
• 2. gather information
• 3. Offer information
Health History Format
• - is a structured framework for organizing patient information in written, electronic, and verbal form to
communicate effectively with other health care providers.
• - patient’s information is concisely organized into three categories:
past
present
family history
Phases of Interview
1. Pre-interview: set the stage for a smooth interview
● Self-Reflection
Self-reflection is a continual part of professional development in clinical work. It brings a deepening
personal awareness to our work with patients, which is one of the most rewarding aspects of patient care.
● Review patient record
● Set interview goals
● Review own clinical behavior and appearance
2. Introduction: put the patient at ease and establish trust
● Greet the patient and establish rapport
● Establish the agenda for the interview
3. Working: obtain patient information
● Invite the patient’s story

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Education (Department of Nursing)
 ● Identify and respond to emotional clues
● Expand and clarify the patient’s story
● Generate and test diagnostic hypotheses
● Negotiate a plan, including further evaluation, treatment, education and self-management support and
prevention

THE SEVEN ATTRIBUTES OF A SYMPTOM

1. Onset. When did (does) it start? Setting in which it occurs, including environmental factors, personal activities,
emotional reactions, or other circumstances that may have contributed to the illness.
2. Location. Where is it? Does it radiate?
3. Duration. How long does it last?
4. Characteristic Symptoms. What is it like? How severe is it? (For pain, ask a rating on a scale of 1 to 10.)
5. Associated Manifestations. Have you noticed anything else that accompanies it?
6. Relieving/Exacerbating Factors. Is there anything that makes it better or worse? 7. Treatment. What have you
done to treat this? Was it effective?
• EXPLORE THE PATIENT ’S PERSPECTIVE (FIFE)
● The patient’s Feelings, including fears or concerns, about the problem
● The patient’s Ideas about the nature and the cause of the problem
● The effect of the problem on the patient’s life and Function
● The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal or
family experiences

4. Termination:
● Summarize important points
● Discuss plan of care
“So, you will take the medicine as we discussed, check your blood glucose daily, and make a follow-up
appointment for 4 weeks. Do you have any questions about this?” Address any related concerns or questions that
the patient raises.

Types of Health Assessment:

1. The admission of a new patient to a clinic, hospital, long-term care facility, or visiting nurse agency usually
requires a comprehensive health assessment. This allows the nurse to obtain a full picture of the patient’s health
status and current problems, as well as provide health promotion and risk reduction education.
2. However, a focused or problem-oriented assessment is appropriate in many situations, especially when the
patient is known to the nurse.
3. A follow-up history is a form of a focused assessment. The patient is returning to have a problem or treatment
plan evaluated, or a second-shift nurse may be following up on a problem identified by a nurse on an earlier shift.
4. An emergency visit generates a fourth type of data collection, the emergency history. The data collection is
focused on the patient’s emergent problem with a systematic prioritization of need beginning with the ABCs of
airway, breathing, and circulation.

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Education (Department of Nursing)
Types of data:
● Subjective data​ are information from the client's point of view (“symptoms”), including feelings, perceptions, and
concerns obtained through interviews.
● Objective data​ are observable and measurable data (“signs”) obtained through observation, physical
examination, and laboratory and diagnostic testing.

History of Present Illness (HPI).​ This section of the history is a complete, clear, and chronologic account of the problems
prompting the patient to seek care. The narrative should include the onset of the problem, the setting in which it has
developed, its manifestations, and any treatments. The HPI should reveal the patient’s responses to the symptoms and
the effect the illness has had on daily living.

Key Elements of the History of Present Illness:

● Seven attributes of each principal symptom
● Self-treatment for the symptom by the patient or family
● Past occurrences of the symptom(s)
● Pertinent positives and/or negatives from the review of systems
● Risk factors or other pertinent information related to the symptom

Seven Attributes of a Symptom

OLD CART​, or ​Onset, Location, Duration, Characteristic Symptoms, Associated Manifestations,

Relieving/Exacerbating Factors, and Treatment

1. Onset. When did (does) it start? Setting in which it occurs, including environmental factors, personal activities,
emotional reactions, or other circumstances that may have contributed to the illness.
2. Location. Where is it? Does it radiate?
3. Duration. How long does it last?
4. Characteristic Symptoms. What is it like? How severe is it? (For pain, ask a rating on a scale of 1 to 10.)
5. Associated Manifestations. Have you noticed anything else that accompanies it?
6. Relieving/Exacerbating Factors. Is there anything that makes it better or worse?
7. Treatment. What have you done to treat this? Was it effective?

Key Elements of the Past History:

Allergies. Allergies, including specific reactions to each medication, such as rash or nausea, must be recorded. Allergies
to foods, insects, or environmental factors along with the patient’s reaction should also be noted.

Medications. Medications, including name, dose/route, and frequency of use, are included. Also list home remedies,
nonprescription drugs, vitamins, mineral or herbal supplements, oral contraceptives, and medicines borrowed from family
members or friends. If the patient is unsure, ask him or her to bring in all medications to see exactly what is taken.

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Education (Department of Nursing)
Childhood illnesses. Childhood illnesses, such as measles, rubella, mumps, whooping cough, chickenpox, rheumatic
fever, scarlet fever, and polio, are included in the Past History. Also included are any chronic childhood illnesses, such as
asthma.

Adult Illnesses. Adult Illnesses in each of the following areas:

● Medical: Illnesses such as diabetes, hypertension, hepatitis, asthma, or HIV; hospitalizations
● Surgical: Dates, reasons for surgery, and types of operations or treatments
● Accidents: type, dates, treatment and residual disability of major accidents
● Psychiatric: Illness and time frame, hospitalizations, and treatments

Health Maintenance
● Immunizations: Ask whether the patient has received vaccines for tetanus, pertussis, diphtheria, polio, measles, mumps
influenza, varicella, hepatitis B, Haemophilus influenzae type B, Neisseria meningitidis meningitis, and pneumococci.
Include the dates of original and booster immunizations.
● Screening Tests: Such as tuberculin tests, cholesterol tests, stool for occult blood, Pap smears, and mammograms.
Include the results and the dates the tests were performed. Alternatively, screening tests may be asked about during and
documented in the Review of Systems.
● Safety Measures: Seat belts in cars, smoke/carbon monoxide detectors, sports helmets or padding, etc.
● Risk Factors:
Tobacco: Do you use or have you ever used tobacco? At what age did you start? How many packs per
day (ppd) do you smoke? How many ppd in the past?
Environmental Hazards: In home or work environment?
Substance Abuse: Do you use or have you ever used marijuana, cocaine, heroin, or other recreational
drugs?
Alcohol: How much alcohol do you drink per sitting and per week?

Family History​. Under Family History, outline or diagram on a genogram the age and health, or age and cause of death,
of each immediate relative, including parents, grandparents, siblings, children, and grandchildren.

Review of Systems​. Understanding and using Review of Systems questions are often challenging for beginning
students. Think about asking a series of questions going from “head to toe.” It is helpful to prepare the patient for the
questions to come by saying, “The next part of the history may feel like a hundred questions, but they are important and I
want to be thorough.” Most Review of Systems questions pertain to symptoms, but on occasion some nurses also include
diseases like pneumonia or tuberculosis.

Health Patterns​. The Health Patterns section provides a guide for gathering personal/social history from the patient and
daily living routines that may influence health and illness.

The Mental Health History​. Cultural constructs of mental and physical illness vary widely, causing marked differences in
acceptance and attitudes. Think how easy it is for patients to talk about diabetes and taking insulin compared with
discussing schizophrenia and using psychotropic medications. Ask open-ended questions initially. “Have you ever had
any problem with emotional or mental illnesses?” Then move to more specific questions such as “Have you ever visited a
counselor or psychotherapist?” “Have you ever been prescribed medication for emotional issues?” “Have you or has
anyone in your family ever been hospitalized for an emotional or mental health problem?”

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Education (Department of Nursing)
MAIN LESSON ​| ​Session #3

Health History Interview

● It is a conversation with a purpose within three folds using health history format:
1. establish a trusting and supportive relationship
2. gather information
3. Offer information

Health History Format

● It is a structured framework for organizing patient information in written, electronic, and verbal form to
communicate effectively with other health care providers.
● The patient’s information is concisely organized into three categories:
o past
o present
o family history
PHASES OF INTERVIEW
1. Pre-interview: set the stage for a smooth interview
Self-Reflection
Self-reflection is a continual part of professional development in clinical work. It brings a deepening personal
awareness to our work with patients, which is one of the most rewarding aspects of patient care.
● Review patient record
● Set interview goals
● Review own clinical behavior and appearance

2. Introduction: put the patient at ease and establish trust

● Greet the patient and establish rapport
● Establish the agenda for the interview

3. Working: obtain patient information

● Invite the patient’s story
● Identify and respond to emotional clues
● Expand and clarify the patient’s story
● Generate and test diagnostic hypotheses
● Negotiate a plan, including further evaluation, treatment, education and self-management support and
prevention
Explore the Patient’s Perspective (FIFE)
● The patient’s Feelings, including fears or concerns, about the problem
● The patient’s Ideas about the nature and the cause of the problem
● The effect of the problem on the patient’s life and Function
● The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal
or family experiences

4. Termination:

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Education (Department of Nursing)
 ● Summarize important points
● Discuss plan of care
“So, you will take the medicine as we discussed, check your blood glucose daily, and make a follow-up
appointment for 4 weeks. Do you have any questions about this?” Address any related concerns or
questions that the patient raises.

THERAPEUTIC COMMUNICATION TECHNIQUES

The Techniques of Skilled Interviewing:
● Active listening
● Guided questioning
● Nonverbal communication
● Empathic responses
● Validation
● Reassurance The first step to effective reassurance is simply identifying and acknowledging the patient’s feelings.
● Summarization
● Transitions
● Empowering the patient

Guided Questioning:
● Moving from open-ended to focused questions
● Using questioning that elicits a graded response
● Asking a series of questions, one at a time
● Offering multiple choices for answers
● Clarifying what the patient means
● Encouraging with continuers
● Using reflection

Nonverbal Communication
● eye contact,
● facial expression,
● posture,
● head position and movement such as shaking or nodding,
● interpersonal distance,
● placement of the arms or legs—crossed, neutral, or open.

Empathic Responses
● To provide empathy, first identify the patient’s feelings.
● Verbal: “I understand,” “That sounds upsetting,” or “You seem sad.”
● Non-verbal: offering a tissue to a crying patient or gently placing your hand on the patient’s arm

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Education (Department of Nursing)
Adapting the Interview for Special Patients
The Silent Patient:
● During periods of silence, watch the patient closely for nonverbal cues, such as difficulty controlling emotions.
● You may need to ask the patient directly, “You seem very quiet. Have I done something to upset you?”
● Patients with depression or dementia may lose their usual spontaneity of expression, give short answers to
questions, and then fall silent.
The Confusing Patient:
● When you suspect a psychiatric or neurological disorder, do not spend too much time gathering a detailed history.
● Shift to the mental status examination, focusing on level of consciousness, orientation, memory, and capacity to
understand.
● You can work in the initial questions smoothly by asking, “When was your last appointment at the clinic? Let’s see .
. . that was about how long ago?” “Your address now is . . . ? . . . and your phone number?”
The Patient with Altered Capacity:
● Determine whether the patient has “decision-making capacity,” or the ability to understand information related to
health, to make health choices based on reason and a consistent set of values and to declare preferences about
treatments.
● The term capacity is preferable to the term “competence,” which is a legal term.
The Talkative Patient:
● Give the patient free rein for the first 5 or 10 minutes, listening closely to the conversation.
● Focus on what seems most important to the patient. Show your interest by asking questions in those areas.
The Crying Patient:
● Usually crying is therapeutic, as is your quiet acceptance of the patient’s distress or pain.
● Offer a tissue and wait for the patient to recover.
● Make a supportive remark like “I am glad you were able to express your feelings.”
The Angry or Disruptive Patient:
● Accept angry feelings from patients. Allow them to express such emotions without getting angry in return.
● Before approaching such patients, alert the security staff—as a nurse, maintaining a safe environment is one of
your responsibilities.
● Stay calm, appear accepting, and avoid being confrontational in return. Keep your posture relaxed and non
threatening and your hands loosely open.
● At first, do not try to make disruptive patients lower their voices or stop if they are haranguing you or the staff.
● Listen carefully. Try to understand what they are saying. Once you have established rapport, gently suggest
moving to a different location that is more private and will cause less disruption.
The Interview Across a Language Barrier:
● If your patient speaks a different language, make every effort to find an interpreter.
● Make your questions clear, short, and simple.
● GUIDELINES FOR WORKING WITH AN INTERPRETER (pls refer to pg.56)
The Patient with Low Literacy:
● Before giving written instructions, assess the patient’s ability to read.
● Lack of reading skill may explain why the patient has not taken medications as prescribed or adhered to
recommended treatments.
● Respond sensitively, and do not confuse the degree of literacy with level of intelligence.
The Patient with Impaired Hearing:
● Find out the patient’s preferred method of communicating.
● If the patient has a hearing aid, make sure the patient is using it and it is working.

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Education (Department of Nursing)
 ● For patients with unilateral hearing loss, sit on the hearing side.
● Eliminate background noise such as television or hallway conversation as much as possible.
● For patients who have partial hearing or can read lips, face them directly, in good light.
● When closing, write out any oral instructions.
The Patient with Impaired Vision:
● When meeting with a blind patient, shake hands to establish contact and explain who you are and why you are
there.
● Orient the patient to the surroundings and report if anyone else is present.
● Encourage visually impaired patients to wear glasses whenever possible. Remember to use words because
postures and gestures are unseen.
The Patient with Cognitive Disabilities:
● Patients with moderate cognitive disability
● pay special attention to the patient’s schooling and ability to function independently
● make a smooth transition to the mental status examination and assess simple calculations, vocabulary, memory,
and abstract thinking
● Patients with severe cognitive disability
● you will have to turn to the family or caregivers to elicit the history. Identify the person who accompanies the
patient, but always show interest in the patient first.
The Patient with Personal Problems:
● Instead of responding, ask about the different approaches the patient has considered and related pros and cons,
others who have provided advice, and what supports are available for different choices.
● Letting the patient talk through the problems is more valuable and therapeutic than any answer you could give.

Sexuality in the Nurse-Patient Relationship:

● Any sexual contact or romantic relationship with patients is unethical; keep your relationship with the patient within
professional bounds.
● Sometimes nurses meet patients who are frankly seductive or make sexual advances. Calmly but firmly, make it
clear that your relationship is professional, not personal. If unwelcome overtures continue, leave the room and find
a chaperone to continue the interview.

Ethics of Interviewing
Ethics & Professionalism
● The principle of confidentiality is of paramount importance in the nurse–patient relationship. The nurse is obligated
to protect patient information.
● Confidentiality is a key quality that fosters the nurse–patient relationship.

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Education (Department of Nursing)