Course: Health Assessment

Unit Title: Introduction to Health Assessment

LaBette Luecht RN, MSN

Developed: June 2018 Copyright Nurses International 2018
 Module Goals
Learner Outcome:
• At the completion of the Health Assessment modules the learner will
demonstrate knowledge and skills to perform a complete health
assessment of an individual.
Module Objectives
• Discuss the purpose and content of a health assessment
• Explain the legal and ethical consideration in performing a health
assessment
• Explore the main components of the comprehensive health
assessment process
• Contrast the nursing health assessment with the medical examination.
Content Outline based on the Objectives
1. Discuss the purpose and content of a health assessment
● Holistic approach to serve the health, wellness and needs of the 3. Explore the main components of a comprehensive a health assessment process
patient ● Be aware of normal physiological changes with aging
● Gather and analyze data about the patient in a respectful and culturally ● Privacy: Expose only areas of the body that need to be assessed
sensitive, non-judgmental manner ● Listen to the patient, permitting time for the patient to answer health inquiry
● Health assessment has 6 key parts: Biographic data, Reason for
questions
seeking care, Present health or HPI, Past medical history, Social history,
Family history, Review of symptoms, cancer screening, domestic ● Be aware of cultural differences
violence screening, Health promotion and education, physical exam ● Respectful of patient
● Throughout the patient health assessment interaction, the nurse uses ● Adapt assessment techniques to accommodate patient (hard of hearing, limited
critical thinking to prioritize findings according to “ABC’s” and V for mobility, developmental stages, illness, disease processes, etc.)
vital sign abnormalities ● 4 steps of a basic physical exam: Inspect, auscultate, percuss, and palpate
▪ Airway
▪ Breathing
▪ Circulation 4. Contrast the nursing health assessment with the medical examination.
▪ Vital sign abnormality (i.e. fever) ● Medical exam will focus on disease diagnosis and pathophysiology
● Nursing assessment will focus on human response to potential health problems and quality
2. Explain the legal and ethical consideration in performing a health of life
assessment
● Ensure that the patient receives evidenced based, competent, safe care
● Accurate charting
● Know your scope of practice and maintain clinical competency of skills
▪ Maintain sobriety (No drugs or alcohol, be careful with
prescription medications that may affect nursing judgment)
▪ Follow EBP guidelines to protect the patient, hospital, and your
nursing license
▪ Follow hospital/clinic policies and procedures
● Maintain Patient confidentiality
● Act as patient advocate
● Communicate findings with physician/advanced practice nurse/patient
care team
Purpose of a Comprehensive Health Assessment

The purpose of a comprehensive health assessment is to gather information about an

individual to determine his/her state of health

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Holistic Approach

The World Health Organization defines human health as “a state of complete physical,
mental and social well-being and not merely the absence of disease or infirmity” (
www.who.int).
Gathering Data

Respectful – show kindness, courtesy, politeness

Culturally Sensitive – be aware that there are differences and similarities

between people and realize each person is unique related to his/her
experiences, beliefs and values.

Non-judgmental – avoid judging others rather try to accept others for who
they are
Cultural Considerations
You are meeting with an elderly female for her initial comprehensive
assessment, how will you gather assessment information in a respectful,
culturally sensitive and non-judgmental manner?

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Key Parts to an Assessment
1. Physical
2. Social
3. Environmental
4. Emotional
5. Spiritual
6. Intellectual/Mental
ABCDE’s

Airway

Breathing

Circulation
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Disability, Exposure
What would the nurse do?

A 101 year old woman is at her local health clinic and indicates to the nurse
she is having knee pain. What should the nurse do? Select the most
appropriate response:
• Explain to the woman as you age you will start having pain, especially in
your large joints
• Inform the woman that she likely has arthritis and discuss options to treat
arthritis, such cold/hot therapy, over the counter medications and
physical therapy
• Ask open ended questions to obtain more information about the pain
Legal and Ethical Considerations
The nurse will need to ensure the patient receives evidence based, competent and
safe care.

1. Evidence Based
2. Competent
3. Safe
Accurate Charting
• Carrying out professional responsibility
• Establishing accountability
• Communicating among health professionals
• Educating staff
• Providing information for research
• Satisfying legal and practice standards
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• Ensuring reimbursement
What would the nurse do?

Which of the following are basic purposes for maintaining accurate and complete patient
documentation? (select all that apply)

A. Sometimes used by government agencies to evaluate patient care

B. It is a permanent record for accountability

C. It is a legal record of care

D. They are perfect sources for business and marketing

E. Can be used for research, teaching and data collection

Know Your Scope of Practice
According to the American Nurses Association the scope of practice for registered
nurses is as follows:

Scope of practice describes the services that a qualified health professional is deemed
competent to perform, and permitted to undertake – in keeping with the terms of
their professional license.
Legal and Ethical Considerations Continued
• Maintain patient confidentiality

• Act as a patient advocate

• Communicate changes to physician/care team

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CC BY-SA
What would the nurse do?

Which of the following actions is/are required of the nurse practicing advocacy?
(Select all that apply.)

A. Speak up for patient care issues even when others may disagree.
B. Contribute money toward the patient's health care costs if the patient is indigent.
C. Assess the patient's point of view and prepare to articulate it.
D. Document all clinical changes in the medical record in a timely and legible way.
E. Become an active member of professional nursing organizations.
Main Components of a Comprehensive Assessment
• Be aware of normal physiological changes with aging
• Privacy: Expose only the areas of the body that need to be assessed
• Listen to the patient, permitting time for the patient to answer health inquiry
questions
• Be aware of cultural differences
• Respectful of patient
Main Components of a Comprehensive Assessment

• Adapt assessment techniques to accommodate your patient (hard of hearing,

limited mobility, developmental stages, illness, disease processes, etc.)

• 4 steps of a basic physical exam:

1. Inspect
2. Auscultate
3. Percuss
4. Palpate

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What would the nurse do?

A nurse is beginning the initial comprehensive assessment in the ER of a

5 year old child. What are adaptations that may assist with the physical
examination?
Nursing Assessment Versus Medical Assessment
Nursing Assessment Medical Assessment

• Focus on patient response to disease, • Focus on disease

pathophysiology or stressors
• Emphasis on cure and repair
• Holistic approach
• Pathology
• Seeks solutions to problems caused by
disease
Glossary
• Accountability: required or • Cultural Sensitivity: being
expected to justify actions or aware that cultural
decisions differences and similarities
• Competent: having the between people exist
necessary ability, knowledge or without assigning them a
skill to do something positive or negative value
successfully
• Confidential: entrusted with
private or restricted
information
Glossary
• Evidence Based Nursing: approach
to making quality decisions and
providing nursing care based upon
personal clinical expertise in
combination with the most current,
relevant research available on the
topic.
• Holistic: treatment of the whole
person, taking into account mental
and social factors, rather than just
the physical symptoms of a disease
• Professional Responsibility:
ethical and moral obligations
permeating the nursing
profession. These standards
relate to patient care,
collaboration with other
medical professionals,
integrity, morals and the
responsibility to effectuate
social change
Additional learning resources
Brooker, C. & Waugh A. (2013). Foundations of nursing practice: Fundamentals of
holistic care (2nd ed.). Edinburgh: Mosby Elsevier.

Jarvis, C. (2016). Physical health examination and health assessment

(7th ed.). St. Louis: Elsevier.

Lockwood, W. (2017). Documentation: Accurate and legal.

Retrieved from http://www.rn.org/courses/coursematerial-66.pdf

Mitchell, P. H. (2008). Patient safety and quality: An evidence-based handbook for

nurses. R.G. Hughs (Ed.). Rockville, MD: Agency for Healthcare Research and
Quality (US). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK2681/
Additional learning resources
Purnell, L. D. (2013). Transcultural health care: A culturally competent approach (4th
ed.). Philadelphia, PA: F. A. Davis Company.

Troels, T., Krarup, N. H, V., Grove, E. L. Rohde, V., & Lofgren, B. (2012). Initial
assessment and treatment with the airway, breathing, circulation, disability, exposure
(ABCDE) approach. International Journal of General Medicine, 5, 117- 121. Retrieved
from www.ncbi.nlm.nih.gov/pmc/articles/PMC3273374/#__ffn_sectitle

Weber, J. R. & Kelley, J. H. (2013). Health assessment in nursing (5th ed.).

Philadelphia: Wolters Kluwer.
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