UNIT 01

INTRODUCTION TO HEALTH
ASSESSMENT CONCEPTS
DILEEP KUMAR
(RN, PRN BSN, MSN, Dip: CHN,
DIT)
OBJECTIVES
At the end of this presentation learner will be able;
• To Discuss the need for health assessment in general
nursing practice.
• To Explain the concepts of health assessment, data
collection, and diagnosis.
• Identify types of health assessments
• Document health assessment data using a problem
oriented approach.
HEALTH ASSESSMENT
1. Health assessment is an organized systematic assessment
of human body which involves the use of one’s senses to
determine the general physical and mental conditions of
the body by collecting both subjective and objective data.
2. Health assessment is the evaluation of the health status by
performing a physical exam after taking a health history.
It is done to detect diseases early in people that may look
and feel well.
3. It is a systematic method of collecting and analyzing
data for the purpose of planning patient-centered care.
NEED FOR HEALTH ASSESSMENT IN
GENERAL NURSING PRACTICE
• Patient health assessment is essential nursing
responsibilities which provides foundation for quality
nursing care and intervention
• It helps to identify the strengths of the clients in
promoting health
• It helps to evaluate responses of the person to health
problems and intervention
• An accurate and thorough health assessment reflects
the knowledge & skills of a professional nurse
Continue
• It helps to identify client’s needs, clinical problems
• Assessment Is the first step to determine heath status
• Assessment is the deliberate and systematic collection
of data to determine clients current and past health
status, functional status and to determine client’s
present and coping pattern
• Assessment is a part of each activity the nurse does
for and with the patient
CONCEPTS OF HEALTH ASSESSMENT

• Health assessment is a major component of nursing care.

• It is an opportunity to develop a therapeutic relationship
with the patient, optimize communication, promote health,
and provide patient education as necessary.
• Throughout the assessment, be aware of ensuring patient
safety, privacy, and dignity.
• The assessment must always be documented according to
the hospital policy,
• Any unusual findings must be reported comprehensively,
in conjunction with other pertinent findings, to appropriate
members of the health care team.
COMPONENTS OF HEALTH
ASSESSMENT
Components of health assessment are;
• conducting a health history (Subjective data)
• History of present illness, Past /present Medical history, Family
History, social history
• performing a physical examination (objective data)
• Inspection, Palpation Percussion Auscultation
• communicating and documenting the findings
according to hospital policy
 IMPORTANCE OF HEALTH ASSESSMENT
• Systematic and continuous collection of data focused on client’s
health problems.
• The nurse carefully examine the client’s body parts to determine
any abnormalities.
• The nurse relies on data from different sources which can indicate
significant clinical problems.
• Health assessment provides a base line used to plan the clients
care.
• Health assessment helps the nurse to diagnose client’s problem &
the intervention.
• Complete health assessment involves a more detailed review of
client’s condition.
• Health assessment influence the choice of therapies & client's
responses. 
PURPOSES OF HEALTH
ASSESSMENT
• To gather baseline data about the patient’s health
status.
• To confirm or refuse data obtained in the health
history.
• To identify nursing diagnoses.
• To make clinical judgments about client's changing
health status.
• To evaluate bio-psycho-social & spiritual outcomes of
care.
 CONCEPTS OF DATA COLLECTION
• A comprehensive patient assessment yields both subjective
and objective findings.
• Subjective findings are obtained from the health history and
body systems review.
• Objective findings are collected from the physical
examination.
• Subjective data are apparent only to the person affected and
can be described or verified only by that person. Pain, itching,
and worrying are examples of subjective data.
• Objective data are detectable by an observer or can be tested
by using an accepted standard.
CONCEPTS OF DATA COLLECTION
• The complete health history is performed to collect
as much subjective data about a client as possible.
• It consists of eight sections:
1. biographic data
2. reasons for seeking health care
3. history of present health concern
4. past health history
5. family health history
6. review of body systems (ROS) for current health problems
7. lifestyle and health practices
8. developmental level
TYPES OF ASSESSMENT

Four basic types of assessment are

• Initial comprehensive assessment

• Ongoing or partial assessment

• Focused or problem-oriented assessment

• Emergency assessment
INITIAL COMPREHENSIVE
ASSESSMENT
• Also called an admission assessment, it is performed when
client enter health care system.
• Involves collection of subjective data about the client's
perception of health of all body parts or systems, past health
history, family history, and lifestyle and health practices (which
includes information related to the client's overall function) as
well as objective data gathered during a step-by-step physical
examination.
•  The purposes are to evaluates client’s health status, to identify
functional health pattern that are problematic, & to provide in an-
depth, comprehensive data base which is critical for evaluating
changes in the client’s health status in subsequent assessment.
 ONGOING OR PARTIAL ASSESSMENT
• Consists of data collection that occurs after the comprehensive
database is established. This consists of a mini-overview of the client's
body systems and holistic health patterns as a follow-up on his health
status. 
• Any problems that were initially detected in the client's body system
or holistic health patterns are reassessed in less depth to determine any
major changes (deterioration or improvement) from the baseline data.
•  This type of assessment is usually performed whenever the nurse or
another health care professional has an encounter with the client. This
type of assessment may be performed in the hospital, community, or
home setting.
• For example, a client admitted to the hospital with lung cancer requires frequent
assessment of lung sounds. A total assessment of skin would be performed less
frequently, with the nurse focusing on the color and temperature of the extremities
to determine level of oxygenation.
PROBLEM- BASED / FOCUSED
ASSESSMENT
• It involves a history and examination that are limited to a
specific problem or complaint.
• This assessment focuses on specific health problems. For
example, if the client is suffering from pneumonia, the
assessment will focus on the assessment of the whole
respiratory system.
• This type of assessment is most commonly used in a walk in
clinic or emergency department and out patient departments.
 EMERGENCY ASSESSMENT
• An emergency assessment is a very rapid assessment
performed in life-threatening situations. In such situations
(choking, cardiac arrest, drowning), an immediate
diagnosis is needed to provide prompt treatment.
•  An example of an emergency assessment is the
evaluation of the client's airway, breathing, and
circulation (known as the ABCs) when cardiac arrest is
suspected.
•  The major and only concern during this type of
assessment is to determine the status of the client's life
sustaining physical functions.
WHAT HAPPENS DURING A HEALTH
ASSESSMENT BETWEEN A PATIENT &
NURSE?

• Establish the nurse-patient relationship

• Gather data-physiological, psychological, cognitive,

socio-cultural, developmental, spiritual

• Identify patient strengths

• Identify actual and potential health problems

• Establish a base for the nursing process (Assessment)

PROBLEM ORIENTED RECORDING
(POR)
• Type of format for documentation where a data base
leads to a problem list and plan for some
interventions i.e. diagnostic, therapeutic,
educational.
S Subjective
O Objective
A Assumption / Diagnosis
P Planning
I Intervention
E Evaluation
R Revision
DOCUMENTATION OF PE FINDINGS
Specific – avoid vague terms
Concise – use short simple words
Complete entry with date & sign
Describe observation clearly
Use standard abbreviations only
 Record exact size, position of lesions
Use illustration
 Use black pen
NURSING AND MEDICAL DIAGNOSIS

There is a big Difference between both because:

 Nursing diagnose is independent role of the nurse
 Nursing diagnoses depends on the client's
problems/response associated with specific disorder
 Any problem in nursing diagnosis must notice from a
holistic view e.g. bio-psycho-social and spiritual
relations
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 MEDICAL DIAGNOSES
Depends on clinical picture and laboratory findings

The specialist doctor has a right to diagnose not else

Example:

- DM is medical diagnoses (hypo or hyperglycemia)

- Nursing diagnoses in this case e.g. Impaired skin integrity R/T poor
circulation, Knowledge deficit about the effects of exercise on needs
of insulin.

The difference between medical diagnosis, a collaborative problem,

and nursing diagnosis is explained with the next table:-
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 HEALTH, WELLNESS & WELL
BEING
• HEALTH is a state of complete physical, mental, and
social well-being, and not merely the absence of
disease or infirmity”
• WELLNESS is a dynamic process that is ever
changing. The well person usually has some degree of
illness and the ill person usually has some degree of
wellness
• The World Health Organization defines WELLBEING
as a state in which an individual can [1] realize their
own potential, [2] cope with normal stresses, [3] work
productively, [4] and contribute to their community.
 DISEASE, ILLNESS, & SICKNESS
DISEASE

Alteration of structure and function of body

ILLNESS

A response a person has to a disease

 SICKNESS
It is the individual perception of its illness
Thus it is possible that a person has a disease DM, has
hypoglycemia sometimes, but still feels that he is normal so thus
does not feel sick