NURSE’S ROLE IN

HEALTH ASSESSMENT
INTRODUCTION TO HEALTH
ASSESSMENT IN NURSING
• Define NURSING?

• Where is the emphasis in the

Nursing scope of practice?
DATA COLLECTION
• Collects data in a systematic and ongoing process
• Involves the patient, family, other health care providers, and
environment, as appropriate, in holistic data collection
• Prioritizes data collection activities based on the patient’s
immediate condition, or anticipated needs of the patient or
situation
• Uses appropriate evidence-based assessment techniques and
instruments in collecting pertinent data
• Uses analytical models and problem-solving tools
• Synthesizes available data, information, and knowledge relevant
to the situation to identify patterns and variances
• Documents relevant data in a retrievable format
DATA ANALYSIS
• Derives the diagnosis or issues based on
assessment data
• Validates the diagnoses or issues with the
client, family, and other healthcare providers
when possible and appropriate
• Documents diagnoses or issues in a manner
that facilitates the determination of the
expected outcomes and plan
EVOLUTION OF THE NURSE’S
ROLE IN HEALTH ASSESSMENT
• LATE 1800s–EARLY 1900s
• 1930–1949
• 1950–1969
• 1970–1989
• 1990–PRESENT
Assessment: Step One of the
Nursing Process
 FOCUS OF HEALTH ASSESSMENT
IN NURSING
• The purpose of a nursing health assessment is to
collect holistic subjective and objective data to
determine a client’s overall level of functioning in
order to make a professional clinical judgment.
• The nurse, in particular, focuses on how the client’s
health status affects activities of daily living and how
those activities of daily living affect the client’s health.
• The nurse assesses how clients interact within their
family and community, and how the clients’ health
status affects the family and community.
 FOCUS OF HEALTH ASSESSMENT
IN NURSING
• The nurse also assesses how family and community
affect the individual client’s health status.

• The purpose of a nursing health history and

physical examination differs greatly from that of a
medical or other type of health care examination.
FRAMEWORK FOR HEALTH
ASSESSMENT IN NURSING
• History of Present Health
Concern
• Personal Health History
• Family History
• Lifestyle and Health Practices
TYPES OF HEALTH ASSESSMENT

• Initial comprehensive
assessment
• Ongoing or partial assessment
• Focused or problem-oriented
assessment
• Emergency assessment
STEPS OF HEALTH ASSESSMENT

1. Collection of subjective data

2. Collection of objective data
3. Validation of data
4. Documentation of data
 PREPARING FOR THE
ASSESSMENT
• Reviewing the client’s medical record
• Validate information with the client and be prepared to collect
additional data.
• Educate yourself about the client’s diagnoses or tests performed.
• Take a minute to reflect on your own feelings regarding your initial
encounter with the client.
• Obtain and organize materials that you will need for the assessment.
The materials may be assessment tools such as a guide to interview
questions or forms on which to record data collected during the
health history interview and physical examination.
• Gather any equipment (e.g., stethoscope, thermometer, otoscope)
necessary to perform a nursing health assessment.
 COLLECTING SUBJECTIVE DATA
• SUBJECTIVE DATA - sensations or symptoms (e.g.,
pain, hunger), feelings (e.g., happiness, sadness),
perceptions, desires, preferences, beliefs, ideas,
values, and personal information that can be
elicited and verified only by the client
 COLLECTING SUBJECTIVE DATA
• Biographical information (name, age, religion,
occupation)
• History of present health concern: Physical symptoms
related to each body part or system (e.g., eyes and ears,
abdomen)
• Personal health history
• Family history
• Health and lifestyle practices (e.g., health practices that
put the client at risk, nutrition, activity, relationships,
cultural beliefs or practices, family structure and function,
community environment)
 COLLECTING OBJECTIVE DATA
• This type of data is obtained by general observation
and by using the four physical examination
techniques: IPaPeA
• Another source of objective data is the client’s
medical/health record, which is the document that
contains information about what other health care
professionals (i.e., nurses, physicians, physical
therapists, dietitians, social workers) observed about
the client.
• Objective data may also be observations noted by the
family or significant others about the client.
 COLLECTING OBJECTIVE DATA
• Physical characteristics (e.g., skin color, posture)
• Body functions (e.g., heart rate, respiratory rate)
• Appearance (e.g., dress and hygiene)
• Behavior (e.g., mood, affect)
• Measurements (e.g., blood pressure, temperature,
height, weight)
• Results of laboratory testing (e.g., platelet count, x-
ray findings)
Comparing Subjective and
Objective Data
 VALIDATING ASSESSMENT DATA
• Serves to ensure that the assessment process is not
ended before all relevant data have been collected
• Helps to prevent documentation of inaccurate data

• What types of assessment data should be validated,

the different ways to validate data, and identifying
areas where data are missing
 DOCUMENTING DATA
• forms the database for the entire nursing process

• provides data for all other members of the health

care team.

• Thorough and accurate documentation is vital to

ensure that valid conclusions are made when the
data are analyzed in the second step of the nursing
process.
Analysis of Assessment Data/
Nursing Diagnosis: Step Two
of the Nursing Process
• often called nursing diagnosis
• Analysis of the collected data goes hand in hand
with the rationale for performing a nursing
assessment.
• Purpose of assessment: to arrive at conclusions
about the client’s health
• NURSING DIAGNOSIS - a clinical judgment about
individuals, family or community responses to
actual and potential health problems and life
processes
Analysis of Assessment Data/
Nursing Diagnosis: Step Two
of the Nursing Process
• Collaborative problems - certain “physiological
complications that nurses monitor to detect their
onset or changes in status” (Carpenito, 2012).
• Referrals occur because nurses assess the “whole”
(physical, psychological, social, cultural, and
spiritual) client, often identifying problems that
require the assistance of other health care
professionals.
PROCESS OF DATA ANALYSIS
1. Identify abnormal data and strengths.
2. Cluster the data.
3. Draw inferences and identify problems.
4. Propose possible nursing diagnoses.
5. Check for defining characteristics of those
diagnoses.
6. Confirm or rule out nursing diagnoses.
7. Document conclusions.