Health & Physical

Assessment in Nursing THIRD EDITION

CHAPTER
1
Health Assessment

Dr. Mohammed H. Moreljwab

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Learning objectives

1. Define health and physical

assessment.
2. Differentiate between subjective and
objective data.
3. Use critical thinking technique during
history taking.
4. Identify how to document data at
patient record.
5. Apply nursing process
Copyright © 2016, © 2012, © 2007
Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Health

• Traditional definition
– The absence of disease
• Wellness
– A state of life that is balanced,
personally satisfying, and characterized
by the ability to adapt and participate in
activities that enhance quality of life

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Definitions of Health

• World Health Organization (WHO)

– A state of complete physical, mental,
and social well-being
• Nursing theorists
– Roy and Andrews
● A process and state of being and
becoming whole and integrated in a way
that reflects person and environment
mutuality

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Health Assessment

• A systematic method of collecting data

about a patient
• Scope of focus must be more than
problems presented by patient.

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 The Interview

• Subjective data gathered

– Primary and secondary sources
– Information that the patient
experiences and communicates to the
nurse
– Considered covert data or symptom
when they cannot be observed by
others

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 The Health History

• Purpose of obtaining information about

the patient's health in his or her own
words and based on their perceptions
• Provides cues regarding patient's
health and guides further data
collection
• Most important aspect of data
collection process

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 The Focused Interview

• Enables nurse to clarify points, obtain

missing information, and follow up on
verbal and nonverbal cues
• Nurse applies knowledge and critical
thinking when asking specific and
detailed questions related to
symptoms, feelings, or events.

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Physical Assessment

• Hands-on examination of the patient

• Objective data
– Observed or measured by the
professional nurse
– Accuracy depends on nurse's ability to
avoid reaching conclusions without
substantive evidence.
– Can be constant or variable

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Box 1.1 Standard Abbreviations

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Documentation

• Essential to consistency in health care

• Used to communicate information
between and among health
professionals
• Patient record
– Legal document used to plan care,
monitor care quality

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Documentation

• Accuracy
– Documentation limited to facts or
factual accounts of observations rather
than opinions
– Use of accepted terminology, symbols,
and abbreviations
• Uniform language
– Consistent use of accepted terminology
by all individuals involved

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Table 1.1 Terminology in Relation to Anatomic Planes

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Documentation

• Confidentiality
– Information sharing limited to those
directly involved in patient care
– Protected by Health Insurance
Portability and Accountability Act
(HIPAA)

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Documentation

• Data generally limited to findings

indicating change, progress, or
problems with existing condition
• Should be completed as promptly as
possible

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Documentation

• Narrative notes
– Words, phrases, sentences, paragraphs
• Problem-oriented charting
– SOAP method
● Subjective (data), Objective (data),
Assessment, Planning
– APIE method
● Assessment, Problem, Intervention,
Evaluation

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Documentation

• Flow sheets
– Scales, check sheets, or flowcharts
– Formatted for a specific purpose
• Focus documentation
– Does not limit documentation to
problems and includes patient strengths
– Intended to address one area of focus

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Documentation

• Charting by exception
– Documentation limited to exceptions
from pre-established norms or
significant findings
• Electronic health records (EHRs)
– May include all previous methods
– Decrease time spent deciphering written
findings

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Interpretation of Findings

• Making determinations about all data

collected in the health assessment
process
• Knowledge
– Normal and expected ranges
– Patient's age, gender, race
– Immediate and long-term, health-
related needs

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Interpretation of Findings

• Communication
– Exchange of information, feelings,
thoughts, and ideas
– Verbal and nonverbal means
• Holistic approach
– Considering more than the physiologic
health status of a patient
– All factors that impact a patient's well-
being

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Interpretation of Findings

• Developmental factors
– Age
– Intellect
– Developmental tasks or handicaps
• Psychologic and emotional factors
– Anxiety
– Self-esteem
– Depression
– Grieving

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Interpretation of Findings

• Family factors
– Illness history
– Risk for inheriting disease
– Decision-making processes
• Cultural factors
– Language
– Expression
– Emotional and physical well-being
– Health practices

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Interpretation of Findings

• Environmental factors
– Internal
● Emotional state
● Response to medication and treatment
● Physiologic or anatomic alterations

continued on next slide

Copyright © 2016, © 2012, © 2007
Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Interpretation of Findings

• Environmental factors
– External
● Inhaled toxins such as smoke, chemicals,
and fumes
● Irritants that are inhaled, ingested, or
come in contact with the body

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Nursing Process

• A rational and dynamic process used by

the nurse to plan for and provide
patient care
• Steps of the Nursing Process
– Assessment
– Diagnosis
– Planning
– Implementation
– Evaluation

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
Figure 1.6 The nursing process.

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Assessment

• The collection, organization, and

validation of subjective and objective
data
• Begins when nurse first meets patient

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Diagnosis

• Use of critical thinking and application

of knowledge from the sciences and
other disciplines to analyze and
synthesize data
• Nursing diagnosis
– The basis for planning and
implementing nursing care as described
by the North American Nursing
Diagnosis Association Interantional
(NANDA-I) continued on next slide
Copyright © 2016, © 2012, © 2007
Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Diagnosis

• Nursing diagnosis
– Composed of four components
● Diagnostic label
● Definition
● Defining characteristics
● Risks or related factors
– If problem is actual, three-part
statement; if a risk, two-part
– Can relate to wellness

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Planning

• Priority setting
• Stating patient goals or outcomes
• Selecting nursing interventions

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Implementation

• Putting the nursing interventions into

action
• Promotes patient's achievement of
goals or outcomes

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Evaluation

• Comparing the patient status to the

stated goals or outcomes
• A single nursing diagnosis may
generate more than one patient goal.

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Critical Thinking

• Process of purposeful and creative

thinking about resolutions of problems
or the development of ways to manage
solutions
• Cognitive skill
• Enables nurse to make judgments
about patient care based on careful
collection and interpretation of patient
data
Copyright © 2016, © 2012, © 2007
Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
Figure 1.7 Elements of critical thinking.

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Collection of Information

• Identifying assumptions
• Organizing data collection
• Determining reliability of data
• Identifying relevant versus irrelevant
data
• Identifying inconsistencies in data

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
Figure 1.8 The five skills of the element Collection of Information.

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Analysis of the Situation

• Distinguishing data as normal or

abnormal
• Clustering related data
• Identifying patterns in data
• Identifying missing information
• Drawing valid conclusions

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
Figure 1.9 The five skills of the element Analysis of Situation.

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Generation of Alternatives

• Articulating options
• Establishing priorities

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
Figure 1.10 The two skills of the element Generating Alternatives.

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Selection of Alternatives

• Developing outcomes
• Developing plans
• Includes all actions required by patient
independently or in coordination with
healthcare professionals to achieve
outcomes

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
Figure 1.11 The two skills of the element Selection of Alternatives.

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
 Evaluation

• Determining whether the expected

outcomes have been achieved
• Ensure omissions and
misinterpretations did not occur

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved
Figure 1.12 The two skills of the element Evaluation.

Copyright © 2016, © 2012, © 2007

Health & Physical Assessment in Nursing, Third Edition
by Pearson Education, Inc.
Donita D'Amico | Colleen Barbarito
All Rights Reserved