INTRODUCTION TO HEALTH

ASSESSMENT CONCEPTS

By:
SAJID ALI
MSN POST RN BSN DCHN RN
 Objectives
• Discuss the need for health assessment in
general nursing practice.
• Explain the concepts of health, assessment,
data collection, and diagnosis.
• Identify types of health assessments
• Document health assessment data using a
problem oriented approach.
 Objectives
• Explain the purpose, process & principles of interviewing.
• Describe the content and format used to obtain a health
history.
• Discuss the process of investigating positive findings during
the health history.
• Practice obtaining and recording a client health history.
• Practice utilizing therapeutic skills with a learner‟s partner.
• Identify strengths and weaknesses via observation of a
videotaped interaction and self/peer analysis.
• Interview patient in clinical and collect feedback from
colleagues and faculty about use of therapeutic
communication.
 Health
• “Health is a state of complete physical,
mental, and social well-being and not merely
the absence of disease or infirmity.”
 Assessment
• Assessment refers to the full range of
information gathered and synthesized
 Health assessment
• Health assessment helps to identify
the medical need of patients. Patients health is
assessed by conducting physical examination
of patient.
• 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
 Data collection
• Data collection is the process of gathering and
measuring information on variables of
interest, in an established systematic fashion
that enables one to answer and evaluate
outcomes.
 Diagnosis
Identification of the nature of an illness or other
problem by examination of the symptoms.
How you will document this all?
Interview Skills
&
History Taking
 Interview
• A meeting of people face to face, especially
for consultation.
• A conversation in which one person
(the interviewer) elicits information from
another person (the subject or interviewee). A
transcript or account of such a conversation is
also called an interview.
 INTERVIEWING THE CLIENT

"The health assessment

interview is an intentional
process and proceeds in a
goal directed manner."

(Fuller p12, 1994)

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 HISTORY TAKING
• Conversation with a purpose
• Part of data collection
• Important in the beginning to
identify the person's health
strengths and problems
• A bridge to next step in data
collection

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 PURPOSES
 Data collection

 Initiate and maintain a helping relationship. (rapport, trust,

care, and concern)

 Indication of nursing diagnosis

 Identify special concerns and perceptions

 Biomographic and social information

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 INTERVIEWING PROCESS
• Introductory Phase
• Working Phase
• Termination Phase
 Cont….
☼ Introductory Phase:
• Sets the tone, and direction of the interview
• Establishes a mutual understanding
• Prime purposes are meant to establish rapport, to
ensure a comfortable setting, and to state the
purpose of the interview.

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☼ Working Phase:
• Most time consuming.
• Collect data of overall health.
• Prime purposes are meant to
collect biographic data, data
pertinent to the client's health
status, and to identify, and
respond to client's needs.

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☼ Termination Phase:
• Serves to end the interview.
• Should be stated in the beginning (prevents
sense of premature closure at the end).
• Pre summary, summary, and follow-up should
be incorporated.
• Summarize to validate perceptions.

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 Process of
investigating & content
and format?
COMPONENTS OF HISTORY TAKING
• Biographic data
• Chief Complaint
• Present health history
• Past health history
• Family health history
• Lifestyle & health practices

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 COMMUNICATION TECHNIQUES

"Throughout the interview, you must consider

the client's cultural and developmental
background and use appropriate verbal and
nonverbal therapeutic communication skills to
facilitate data collection."
(Fuller p19, 1994)

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 Therapeutic communication
techniques
• Offering Self • General leads
• Exploring • Empathy
• Active listening • Focusing 
• Summarizing • Encouraging
• Encouraging descriptions of • Evaluation
perceptions • Reinforcement
• Seeking clarification
• Reflecting
• Restating
 Non-Therapeutic communication
techniques
• Overloading
• Incongruence
• Underloading
• False reassurance/ agreement
• Focusing on self
•  Changing the subject
• Giving advice
 BARRIERS TO THERAPEUTIC
COMMUNICATION
• Excessive or insufficient eye contact
• Distraction & Distance
• Biased or leading questions
• Using "WHY" questions
• Reading the questions
• Rushing through the interview
• Offering false reassurance
• Using authority
• Using professional jargon
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 Tip of the day

Remember not to predict!!!

"The individual knows everything

about his/her own health state, and
you know nothing. Your skill in
interviewing will glean all the
necessary information as well as
build rapport for a successful
working relationship.
(Jarvis p60, 1996)
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 References
Bates, B. (19910. A guide to physical examination and
history taking(5th ed) Philadelphia: J.B Lippincott.
Chapter 19.
Fullern J. & Schaller – Ayers, J.(1994). Health
Assessment: A Nursing Approach (2nd ed.)
Philadelphia: J.B. Lippincott.
Janet Weber & Jane KL, (2007). Health Assessment in
Nursing (3rd edition) Lippincott Williams & Wilkins.
http://nursingcrib.com/nursing-notes-
reviewer/psychiatric-mental-health-
nursing/therapeutic-and-non-therapeutic-
communication/