HEALTH ASSESSMENT

Jannah Isha Z. Jani

BSN-1B
Brokenshire College
________________________________________________________________________________________________________

TABLE OF CONTENTS Symptoms

I. Health Assessment  Any evidence as to the nature and location of a
- What is Health Assessment? disease noted by the client
- Components of Health Assessment Subjective Symptoms
- Purposes of Health Assessment  When the symptoms are noted by the client
- Definition of Terms themselves (e.g., pain)
I. Health History Objective Symptoms
II. The Nursing Process  When the symptoms are noted by the observer as
- Characteristics of Nursing Process well as the client.
- 5 Steps of Nursing Process
HEALTH HISTORY
III. Data Collection
 A collection of subjective data in detail regarding
- Interviews
clients’ health in a chronological order.
- Observation
- Physical Assessment FACTORS AFFECTING SUBJECTIVE DATA
IV. Validating, Organizing, & Prioritizing Data  Physical setting
V. Documenting Findings  Clients’ personality and behavior
- Documentation Methods  Nurses’ personality and behavior
VI. Handwashing  Communication skill
VII. Gloving  Clients’ skill
VIII. Vital Signs
FORMAT OF HEALTH HISTORY
HEALTH ASSESSMENT I. Biographic data
Health II. Chief complaints
 A state of well-being (WHO) III. History of present illness
Assessment IV. Past health history
 Defined as a systematic, dynamic process by which V. Family history
the nurse interacts with the client/patient, significant VI. Occupational and Environmental history
others, and health care providers, collects and VII. Psychosocial history
analyze data about the client/patient. VIII. Review of systems
Components
 Health history BIOGRAPHIC DATA
 Physical examination  Name, address, gender, age, marital status,
occupation, religion, family income (monthly),
PURPOSES educational qualification, etc.
 To establish a database of patients’ normal abilities,
risk factors that can contribute to dysfunction and CHIEF COMPLAINTS
any current alteration in function.  It is a brief assessment of clients’ problem for which
 To get a clear picture of a client’s health status and clients seeks medical care.
health related problems.  It should be written in clients’ statement.
 To identify the cause and extent of the disease.
 To identify problems at an early stage. H/O PRESENT ILLNESS
 To determine the nature of treatment required for  Onset
the client.  Signs and Symptoms S&S
 To get a holistic view of the client.  Duration
 To contribute in medical research.  Treatment Taken (If Any)
 To identify clients’ strengths, weaknesses,  Other complaints such as loss of appetite,
knowledge, attitude, motivation, support systems, insomnia, disorders of the stomach, etc.
and coping skills.  Clients’ health habits – eating, sleeping, etc.
 To compare clients’ health status with an ideal
status. PAST MEDICAL HISTORY
 Childhood illness – mumps, measles, and so on.
DEFINITION OF TERMS  Allergies
Diagnosis  Medical Disease – HT, DM, Anemia, etc.
 The determination of the nature and extent of the  Surgery – Any H/O surgery
disease.  Hospitalization – Any hospitalization in the past
Prognosis  Obstetric History – Number of live births, abortions,
 The forecast of the course and duration of the mode of delivery
disease.  Family tree (Pedigree chart)
Etiology  Information about family members
 The science of the cause of the disease.  Family history of any illness (Diabetes Mellitus,
Signs Hypertension, etc.)
 The presence of a disease that can be seen or
elicited (e.g., fever) OCCUPATIONAL HISTORY

PADAYON, FUTURE RN! MAKE YOUR MAMA PROUD. 1

HEALTH ASSESSMENT
Jannah Isha Z. Jani
BSN-1B
Brokenshire College
________________________________________________________________________________________________________

 Collecting data regarding clients’ job, nature of job,  Percussion

environment in job, exposure to any hazardous  Auscultation
substances (if any).
STEP 2: NURSING DIAGNOSES
PSYCHOSOCIAL HISTORY  Involves identifying and prioritizing actual or
 Smoking potential health problems or responses
 Food habits and Food fads  Once you collect your data, you need to analyze
 Likes and dislikes them and then identify actual or potential health
 Pattern of sleep problems or responses to life processes and state
 Exercises them as Nursing Diagnoses. (e.g., alteration of
comfort, alteration of body temperature)
REVIEW OF SYSTEMS  Can be actual, potential, possible, or collaborative
 Information is gathered system-wise. problems as well as wellness issues.

THE NURSING PROCESS STEP 3: PLANNING

 Nursing is the diagnosis and treatment of human  Involves setting goals and outcomes
responses to actual or potential health problems.  Once you have prioritized your diagnoses, you are
 Diagnosis and treatment are achieved through a ready to develop an individualized plan of care for
process, called the Nursing Process, that guides your patient.
nursing practice.  First, you establish your goals and determine
 A systematic problem-solving process with 5 steps: measurable outcomes. Next, you identify nursing
assessment, nursing diagnosis, planning, interventions needed to meet the goals and
implementation and evaluation. outcomes. Then, you communicate your plan to
both the patient and all the members involved in the
CHARACTERISTICS OF THE NURSING PROCESS plan of care to maintain continuity of care and
Dynamic and Cyclic ensure success
 It is a cycle from assessment to evaluation
Patient-centered S Specific
 Reduces unnecessary procedures, honors patient M Measurable
preferences, and improves patient health. Patient- A Attainable
centered care is personalized care. R Realistic
Goal directed
T Time-bound
 Setting goals after assessment
Flexible
STEP 4: IMPLEMENTATION
 Flexible enough to do assessment to the patient
 Carrying out a plan based on the problems you
Problem oriented
identified
 Being able to identify the problem
 “Doing” phase (ex. Taking of vital signs)
Cognitive
 Should have a rationale behind the nursing
 Critical-thinking
intervention
Action oriented
 Being able to do nursing interventions
STEP 5: EVALUATION
Interpersonal
 Determining the effectiveness of your plan of care.
 Interact with patients and their watchers, also with
co-healthcare workers
Holistic
 Focus not only on one but all aspects of a patient as
DATA COLLECTION
a whole
A. INTERVIEWS
Systematic
 Structured communication intended to obtain
 Being able to follow the nursing process
subjective data
STEP 1: ASSESSMENT
 Most useful in taking health history
 First phase of the nursing process (and most critical
and important phase)
 Process of collecting, validating, and clustering TYPES OF INTERVIEWS
data. DIRECTIVE NON-DIRECTIVE
 Deliberate and systematic collection of data to  Specific questions  Patient will verbalize
determine clients’ current and past health and  Less time-consuming 
functional status.  Factual data
 Determines clients’ current and past coping patterns
 Ongoing and continuous throughout all the phases TYPES OF INTERVIEW QUESTIONS
of the nursing process. CLOSE-ENDED OPEN-ENDED
QUESTIONS QUESTIONS
SUBJECTIVE DATA OBJECTIVE DATA  Used in directive  Non-directive
 Needs interview  Inspection interview  Invite clients to
 Palpation  Restrictive, generally discover and explore,

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HEALTH ASSESSMENT
Jannah Isha Z. Jani
BSN-1B
Brokenshire College
________________________________________________________________________________________________________

requires a “yes” or “no” elaborate, clarify, and  Validate any inconsistencies

or short factual answer illustrate their thoughts  Realize that multiple problems will lead to varied
giving specific info. and feelings human responses.
 When, where, who,  What, how  Realize that multiple problems will lead to varied
what, do (did, does), is  Non-answerable by human responses.
(are, was) yes or no  Identify problems but also look for strengths.
 Remember that every system is related. So, if you
PHASES OF INTERVIEW identify a problem in one area, realize that this
INTRODUCTOR WORKING TERMINATION problem can affect every after system.
Y PHASE PHASE (BODY) PHASE
(OPENING) (CLOSING) VALIDATING, ORGANIZING, AND PRIORITIZING DATA
 Explain the  Client  Nurse Validation
purpose of communicate terminates  Can occur simultaneously with the assessment
the nursing s what he or the process.
intervention she thinks, interview  Validating every piece of data is unrealistic, but you
 Establish feels, knows, when the do need to validate any time you notice an
rapport and perceives, in needed info inconsistency or unsure of your findings
orient the response to has been Organizing data
interviewee questions obtained, in  After you have validated the assessment data, you
(how long it from the some need to organize them. Begin by identifying
will take) nurse. cases, the pertinent data – any findings that are out of the
 What is  Consistent patient norm and any findings that identify patient
expected of answers are terminates strengths. The pertinent data provide cues that will
the patient, usually the the help you identify any actual or potential problem.
how the truth interview. Prioritizing Data
information  Vital for  Organizing data will assist you in prioritizing the
will be used, maintaining patients’ problems.
and that the rapport and  When prioritizing, consider the root of the problem,
client has the trust for the patients’ perception of the problem, and the
right to facilitating situation at hand.
provide data. future
 Confidential interactions DOCUMENTING YOUR FINDINGS
. Documentation Methods
 Come back A. SOAPIE method
every 4 - Subjective data
hours for - Objective data
vital signs - Assessment / Clinical Judgement (e.g.,
ineffective breathing pattern, related to
B. OBSERVATION incisional pain.)
 Entails deliberate use of your senses of sight, - Plan (e.g., patient will establish breathing
smell, and hearing to collect data. Look at both pattern; patient will experience no signs of
your patient and his or her environment to detect respiratory complications.)
anything out of the ordinary. - Interventions (e.g., encourage coughing and
C. PHYSICAL ASSESSMENT deep breathing; teach patient to splint incision.)
 Provides the objective database. B. DAR METHOD
 Helps you assess your patient’s health status and - Data (e.g., “it hurts to take a deep breath”; pain
identify actual or potential problems. increases with activity and breathing)
- Action (e.g., encourage coughing and deep
ASSESSMENT TIPS breathing; teach patient to splint incision.)
 Involve your patient in planning care. - Response (e.g., patient coughing and deep
 Common problems occur commonly; rare problems, breathing, splinting incision; using incentive
rarely. So, concentrate on common problems. spirometer)
 On the other hand, expect the unexpected and be C. PIE METHOD
open. - Problem (e.g., ineffective breathing patterns
 Determine the onset if it’s acute or chronic related to incisional pain)
 Determine if the problems are life threatening and - Interventions (e.g., encourage coughing and
need immediate attention. deep breathing; teach patient to splint incision)
 Know what is normal before you try to identify - Evaluation (e.g., patient coughing and deep
abnormal. Experience will help you refine your breathing, splinting incision; using incentive
ability to differentiate the two. spirometer; ambulating)
 Look at your patient holistically and identify relevant D. NARRATIVE METHOD
health risk factors. (e.g., a middle-aged, African - F-DAR CHARTING
American male is at risk for hypertension because
F FOCUS
of his biographical data.

PADAYON, FUTURE RN! MAKE YOUR MAMA PROUD. 3

HEALTH ASSESSMENT
Jannah Isha Z. Jani
BSN-1B
Brokenshire College
________________________________________________________________________________________________________

D DATA nursing interventions (calling the doctor,

A ACTION repositioning, administering pain medications, etc.)
R RESPONSE
R (RESPONSE)
WHAT IS F-DAR CHARTING AND WHY IS IT USED?  This is where you write how the patient responded
 It is a method of charting nurses use, along with to your action. Sometimes, you won’t chart the
other disciplines, to help focus on a specific patient response for several minutes or hours later.
problem, concern, and event.
 Geared to save time and decrease duplicate DATE/TIME FOCUS PROGRESS
charting. It is a great charting method for nurses NOTE
who have a lot of patients and is easier to read by 10/27/15 Pain D: Pt called on
other professionals. 11 00 call light
 Giver other professionals a snapshot of what went requesting pain
on during your shift in a concise manner. medication.
 Used not only by nurses but other disciplines such Arrived to room
as nutritionists, occupational therapy, case + found pt
management, etc. Most healthcare settings are grimacing while
requiring disciplines to now document in the F-DAR holding left arm.
format. Pt rates pain 9
 Example: on 1-10 scale in
DATE/TIME FOCUS PROGRESS NOTE left arm. ----------
10/30/2015 Pain D: Patient A: Morphine lmg
08 00 requested IV administered
09 00 medication for in 186 RAC.
incisional pain in Repositioned
right groin. Patient PT onto left
is 1-day status post 11 45 side.
right cath. Rates R: Patient rates
pain 8 on 1-10 pain 2 on 1-10
scale. scale + states “I
feel so much
A: Administered better.”
Lortab 5/325 mg ----------------------
PO. -----------------S.
Page RN
R: Patient now rates
pain 2 on 1-10 CONCLUSION
scale.  F-DAR is a concise and easy way of charting. It
--------------------------- takes some practice to get used to and it is highly
-----------N.Nurse RN encouraged that during clinicals and orientation,
you take ample time to practice charting.
F (FOCUS)
 This is the subject / purpose for the note. The focus
can be:
 Nursing Diagnosis
 Event (admission, transfer, discharge
teaching, etc.)
 Patient event or concern (code blue,
vomiting, coughing)

D (DATA)
 Written in a narrative and contains only subjective
(what the patient says and things that are not
measurable) and objective data (what you
assess/findings, vital signs, and things that are
measurable). This lays the supporting evidence for
why you are writing the note. You are letting the
reader know “this is what the patient is saying and
what I’m seeing”.

A (ACTION)
 This is the “verb” area. In this section, you are going
to write here what you did about the findings you
found in the data part of the note. This includes your

PADAYON, FUTURE RN! MAKE YOUR MAMA PROUD. 4