Health

Assessment

Nursing Physical Abnormal

History Assessment Lab Results
The nurse should know what to expect of a normal
developmental description at a given age, judge
each person whether he/she is normal for specific level
of development and understand the reason of illness at a
particular age.
A Complete Health Assessment
Physical – identification of cues and
problems related to the basic body
functions like breathing, eating, and
walking.
Psychological – assessment which involves
identification of cues and problems related
to client’s intellect, the value of self-
concept, their emotions and behavior.
Social – assessment which encompasses
the problems or issues in relationships and
interactions among family, friends and co-
workers.
Spiritual – assessment which involves
identification of cues and problems in
belief in a higher being, personal
interpretation of
the meaning of life, and attitude toward
moral decision and conduct.
Nursing Assessment
Deliberate & systematic collection of data to
determine clients current/past health status, present
& coping pattern.
Purposes of Assessment
1. Establish a database for the client’s normal
abilities, risk factors and any alterations.
2. Plan strategies to encourage continuation
of healthy patterns, prevent potential health problems,
and alleviate or manage existing health problems.
3. Provide a holistic view of the client.
4. Formulate a conclusion or a problem
statement such as nursing diagnosis.
5. Provide an essential foundation for the
care of the client
1. Cognitive skills
• Assessment requires thinking and
analysis.
2. Problem – solving skills
3. Psychomotor skills
• Assessment is “doing”.
4. Affective and interpersonal skills
• Assessment is “feeling” trust and
mutual respect.
5. Ethical skills
• Assessment is “being responsible and
accountable” for one’s practice. mutual
respect.
Gathering information
Click to add text
Special Considerations during interview
1. Gerontologic variations
Assess hearing acuity
Speak clearly and use straight forward
language
Presence of SO is necessary
2. Cultural variations
Our culture is a big reflection of our great
and complex history.
Different Cultures Have Different Practices

* “Pasma” concept among Filipinos.

* Taking vitamins could deform the
fetus
* Certain foods can cause the baby to
have skin marks.
* Naming the baby before it is born
or name it after a dead person
causes bad luck
* Eating hot soups during breast
feeding, is believed to promote milk
production
* In order to ward off evil spirits,
garlic, or salt is placed near the
baby's crib.
* “Hilot” to break the knots or nodes
within the body.
3. Emotional variations
During interview, the nurse must also consider the
type of person/client to be interviewed

The nurse considers the verbal and nonverbal

communication of the client.
3. Validating data
Double checking or verifying the data
whether it is factualwhile
Basic considerations or accurate
performing inspection:
Record in factual
* Compare manner
each area NOT
with the opposite
interpretation
side of the body.
* Inspectthe
Recording before touching. as “ate 2 pieces of
breakfast
bread, 1 egg
* Warm andforcup
room of coffee
examination INSTEAD of
of the
“has good
clientappetite”
3. Validating data
Double checking
* Expose body or verifying
parts the data
being observed
whether it is factual or accurate
only.
* Lighting must be sufficient for the
Record in factual manner NOT
nurse to see clearly.
interpretation
* The use of olfactory (smell) and
Recording the(hearing)
auditory breakfastsensesas
to “ate 2 pieces of
bread,observe the condition
1 egg and cup of of variousINSTEAD of
coffee
bodyappetite”
“has good parts is considered inspection.
3. Validating data
Double checking or verifying the data
* Observe for color, size, location,
whether it is factual or accurate
texture, symmetry, odors, and sounds
Record in factual manner NOT
interpretation
Recording the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking or verifying the data
whether
It is theitexamination
is factualofor
theaccurate
body
using sense of touch.
Record in factual manner NOT
interpretation
Recording the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double
Basicchecking orpalpation
principles in verifying the data
whether it is of
* The pads factual or are
the fingers accurate
used since
their concentration makes them highly
Record in factual manner NOT
sensitive to tactile discrimination.
interpretation
* Touch and feel with hands to determine:
Recording
Texturethe breakfast
– use asroughness
fingertips for “ate 2 pieces of
bread, 1 egg and andcup of coffee INSTEAD of
smoothness.
Moisture
“has good – dry, wet or moist.
appetite”
3. Validating data
DoubleTemperature
checking–or
useverifying the
back of hand to data
whether it is factualdetect
or accurate
warm, hot and
cold.
Record in factual manner
Organ location and size NOT
interpretation
Consistency of structure (solid, fluid)
Recording the breakfast
* Examiner’s as “ate
finger nails should 2 pieces of
be cut
bread,short.
1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking or verifying
* Light palpation precedes deep the data
whether it is factual or accurate
palpation.
* Tender
Record areas aremanner
in factual palpated last.
NOT
interpretation
Recording the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double
Typeschecking or verifying the data
of palpation
whether it is factual or accurate
Record in factual manner NOT
interpretation
Recording the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking or verifying the data
whether it is factual or accurate
Record in factual manner NOT
interpretation
Recording the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking or verifying the data
whether it is factual or accurate
Record in factual manner NOT
interpretation
Recording the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking or verifying the data
whether it is factual
The act of striking or accurate
the body
Record surface tomanner NOT
in factual
elicit sounds
interpretation that
can be heard or
that can be
Recording thefeltbreakfast as “ate 2 pieces of
through
bread, vibrations.
1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking
Methods or verifying the data
of Percussion
whether it is factual or accurate
Record in factual manner NOT
interpretation
Recording the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking
Percussion is usedor
to verifying the
determine the sizedata
and shape
whether it is
of internal factual
organs or accurate
by establishing their borders.
Record in factual manner NOT
interpretation Percussion Techniques
https://www.youtube.com/watch?v=Lhe06ZTBV_A

Recording the breakfast as “ate 2 pieces of

bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double
Sound checking
Intensityor verifying
Pitch the data
Duration Quality
whether it is factual or accurate
Tympany
*Distention
Loud High Moderate Drum-like

Record in factual manner NOT

Resonance
*Normal Lung
Moderate to loud Low Hollow Normal sound of a
lung
interpretationVery
Hyper-resonance Very Booming Emphysema
loud low (damaged air sac)

Recording the
Dullness breakfast as “ate 2 pieces of
Soft to moderate
bread, 1 egg and cup High
* Liver
of coffee
Thud like
INSTEAD
Dull-like
of
“has
Flatness
*Muscle
good appetite”
Soft High Short Flat
3. Validating data
Double checking or verifying the data
whether it is factual or accurate
It is the process of
listening
Record intofactual
sounds manner NOT interpretation
produced within the
body using a
Recording
stethoscope.the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking or verifying
Direct or immediate auscultation
the data
whether it is factual or accurate
Application of the ear directly
to the body surface where
Record in factual manner NOT the sound is
most prominent.
interpretation
Mediate auscultation
Recording
The usethe breakfast
of sound as “ate
augmentation 2 pieces of
device
bread, 1 as
such egg and cupinofthecoffee
stethoscope INSTEAD
detection of of
“has body
goodsounds.
appetite”
3. Validating data
Double checking or verifying the data
whether it iscan
Auscultation factual or accurate
be performed in the following
activities:
Record in factual manner
* Listening to body sounds NOT
interpretation
* Movement of air in the lungs
* Blood flow like taking the HR and BP
Recording the breakfast as “ate 2 pieces of
* Fluid and gas movement (bowels)
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking
In abdominal or verifying
assessment: the data
inspection, auscultation,
percussion,
whether itand
is palpation
factualshould be followed instead of
or accurate
the usual inspection, palpation, percussion and
auscultation.
Record in factual manner NOT
interpretation
Changing the order of these assessment techniques
could alterthe
Recording the frequency
breakfast of bowel sounds2and
as “ate make of
pieces
the findings less accurate.
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double
NORMAL checking
BREATH SOUNDS or verifying the data

whether it is factual or accurate

Vesicular Breath Sounds

Record in factual manner NOT

https://www.youtube.com/watch?v=E9iNwFF6R1Y
Bronchovesicular Breath Sounds
interpretation
https://www.youtube.com/watch?v=WfkWMfE9VTY

Recording the breakfast

Bronchial Breath Sounds
https://www.youtube.com/watch?v=p9eWmOHgySE
as “ate 2 pieces of
bread, 1 egg and
Tracheal Breath Sounds
cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double
ABNORMALchecking
BREATH SOUNDS or verifying the data

whether it is factual or accurate

www.youtube.com/watch?v=0fEy-EDHP5Q&t=48s

Abnormal Lung Sounds during Auscultation

Record in factual manner NOT
interpretation
Recording the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking or verifying the data
whether it is factual or accurate
Record in factual manner NOT
Add a little bit of body text
interpretation
Recording the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking or verifying the data
All About
whether it is factual or accurate
Documentation, Different
Client Positions and the
Nursing Process
Record in factual manner NOT
interpretation
Recording the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double
Three checking
general or verifying
types of assessment the data
1.whether
Functional it is factual or accurate
assessment 
Record in factual manner NOT
interpretation
Recording the breakfast as “ate 2 pieces of
bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking
2. Descriptive or verifying the data
Intended to help us determine why a behavior occurs rather than how often
whether
assessment it is afactual
behavior occurs. or accurate

3.Record
Indirect in factual manner
Indirect assessment is NOT
gathering information through means other
than looking at actual samples of student work. These include
interpretation
assessment  surveys, exit interviews, and focus groups (see below).

Recording the breakfast as “ate 2 pieces of

bread, 1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking or verifying
Types of Client to be Assessed
the data
whether it is factual or accurate
1. Silent Client
Record in factual manner NOT
Short periods of silence may be normal.
interpretation
Allow them time to collect their thoughts.
Recording the breakfast as “ate 2 pieces
Consider that the patient may be frightened; or
of
bread, 1 you
perhaps eggfrightened
and cup them
of coffee INSTEAD of
“has good appetite”
3. Validating data
Double checking
Are you orthe
dominating verifying the data
discussion?
whether it is factual or accurate
Have you offended the client?
Record in factual manner NOT
Is there is a physical or mental disorder? Or a lack
interpretation
of understanding?
2.Recording the breakfast
An Overly Talkative Client as “ate 2 pieces of
bread,
Allow 1client
eggtoand
talk.cup of coffee INSTEAD of
“has good
Don’t appetite”
display your impatience
3. Validating data
Double checking
If necessary, orinterrupt
politely verifyingand the
focusdata
the
whether it is factual or accurate
discussion
3.Record in factual
The anxious manner
frightened patient NOT
interpretation
Try to understand the pts. Feelings – “I don’t know
why you are so anxious, would you like to
Recording the breakfast as “ate 2 pieces of talk
about it?”
bread, 1 egg and cup of coffee INSTEAD of
Identify
“has good theappetite”
source of anxiety/fear
3. Validating data
4.Double checking
The angry client or verifying the data
whether it is factual or accurate
Understand the source of these feelings
Record incommon
These are factualfeelings
manner NOT with stress
associated
interpretation
or fear
Be firm but the
Recording let your verbal andas
breakfast body language
“ate 2 pieces of
show that
bread, you care
1 egg and cup of coffee INSTEAD of
“has good appetite”
3. Validating data
5.Double checking
The intoxicated clientor verifying the data
whether it is factual or accurate
These patient may manifest being irrational, at times
violent and
Record abusive, shouting
in factual manner NOT
interpretation
Do not respond back with shouting
6.Recording
Depressed client
the breakfast as “ate 2 pieces of
bread,
Call for1assistance
egg and cup of coffee INSTEAD of
“has good appetite”