STEPS IN HEALTH ASSESSMENT

 At the end of the discussion, students will be able to :

1. Identify the necessary steps in health assessment

2. Differentiate subjective and objective data collection
3. Discuss the means by which data is validated
4. Analyze the importance of documentation in the nursing profession and
nursing practice.
 KEY STEPS IN HEALTH ASSESSMENT
C.O.V. D.

Data Collection
Data Organization
Data Validation
Data Documentation
 DATA COLLECTION

 Process of GATHERING INFORMATION about patient’s health status

 SYSTEMATIC AND CONTINUOUS to prevent omission of significant data and

can reflect patient’s changing health status

 A DATA BASE contains all information about the patient ( nursing health history,
physical assessment, primary care provider’s history and physical examination,
results of laboratory examinations and diagnostic tests and materials contribute
by other health personnel
 SOURCES OF INFORMATION

 PRIMARY SOURCE ( Patient )

 SECONDARY SOURCES ( Family Members or Support Persons, Other Health professionals, records
and reports, laboratory and diagnostic analysis, relevant literature )

 All sources other than the patient is considered SECONDARY.

 All data from secondary sources should be VERIFIED, CLARIFIED AND VALIDATED if possible.

 COMPLETE DATA BASE = BASELINE for comparison of patient’s responses to nursing and medical
interventions
 TYPES OF DATA
SUBJECTIVE
 SYMPTOM OR COVERT DATA
 Can ONLY be described and verified by
the patient affected
 Examples : Itching , Pain, Feelings of
Worry
 Includes patient’s sensations, feelings,
values, beliefs attitudes and perception of
personal health status or life situation
OBJECTIVE
 SIGNS OR OVERT DATA
 Detectable by an observer or can be measured or tested
against an acceptable standard
 OBERVABLE, MEASURABLE and OBTAIN through
physical examination and diagnostic test
 This can be SEEN, HEARD, FELT or SMELLED
 Example : Blood Pressure, Level of Pain/ Pain Scale, Age
 OBSERVATION

INTERVIEW

EXAMINATION

DATA COLLECTION METHODS

( OIE )
 DATA COLLECTION  When the nurse IN CONTACT WITH PATIENT
METHODS

 Gather patient’s data using the SENSES

OBSERVATION
 A conscious, deliberate skill that is developed through effort and
with an organized approach

 Distinguishing data in a meaningful manner

 Nursing observations must be organized so that significant data is

not missed.

 Most nurses develop a sequence in observing events

?????????
What do nurses observe upon  Example : Nurse entering the patient’s room
entering the patient’s room ?
 DATA COLLECTION
METHOD

TYPES OF INTERVIEW
INTERVIEW
 DIRECTIVE INTERVIEW : Highly structured and elicit specific
information, gathering information during limited time
( emergency situation )
PLANNED COMMUNICATION OR
CONVERSATION with PURPOSE
 NON DIRECTIVE OR RAPPORT BUILDING INTERVIEW
1. Get Information
Allows patient to control the purpose , subject matter
2. Identify problems of mutual
concern and pacing

3. Evaluate change
Rapport : understanding between 2 or more people
4. Teach or Health Education
5. Provide Counselling or Therapy
A combination of both directive and non directive
Example : Nursing Health History
approaches is most appropriate during information
gathering interview.
 DATA COLLECTION
METHODS

INTERVIEW

 CLOSED QUESTIONS ( Direct Interview ) : Restricted / Yes or No Answers

Questions begin with who, what, where, when

 OPEN ENDED QUESTIONS ( Non Directive Interview inviting patients to discover or explore, elaborate, clarify and
illustrate their thoughts
Questions may begin with what or how

 NEUTRAL QUESTIONS patient can answer without direction or pressure from the nurse
 DATA METHOD COLLECTION

EXAMINATION

Physical examination is a systematic data

collection method that uses observation
( sense of sight, hearing touch and smell )  To conduct physical examination, the nurse uses techniques of
to detect health problems. INSPECTION, AUSCULTATION, PALPATION AND
PERCUSSION
 Can be carried out systematically from HEAD TO TOE
 ORGANIZING DATA
 Nurses use a written or electronic format that organizes the assessment data systematically

 Referred to as NURSING HEALTH HISTORY, NURSING ASSESSMENT OR NURSING DATA BASE

FORM

 Modified according to the patient’s physical status

 Utilized NURSING JUDGMENT on data reporting

 Data reflecting a SIGNIFICANT DEVIATION FROM NORMAL would need to be REPORTED as

well as RECORDED.
 VALIDATING DATA
 Act of “ double checking or verifying data” to confirm that it is ACCURATE and FACTUAL.
 Information gathered must be COMPLETE, FACTUAL AND ACCURATE since nursing diagnosis
and interventions are based on this information.
 Validating data helps the nurse complete the following tasks :
1. Ensure that assessment information is complete.
2. Ensure that the objective and subjective data agree
3. Obtain additional information that may have been overlooked
4. Differentiate cues and inferences

CUES : Subjective or Objective data directly observed by the nurse ( What the patient says or what
the nurse can see, hear or measure )

INFERENCES : Are the nurse’s interpretation or conclusions made based on the cues
 DOCUMENTATION

 Aims to describe the collected data to make it easier to use relieved or manage

 Accurate documentation is essential that includes all data collected about patient’s health condition

 Data should be collected in factual manner and not as interpreted by the nurse

 Example : Nurse records the patient’s breakfast intake ( objective data ) as “ tea 200 ml,
water 100 ml, 1 piece of egg and 1 toasted bread “ rather than saying “
Appetite is good.
 COLLECTION OF SUBJECTIVE DATA
THROUGH
INTERVIEW AND HEALTH HISTORY

 Biographic Data  Family Health History

 Reasons for Seeking Care  Current Medications
 Chief Complaint  Lifestyle
 History Taking  Developmental Level
 Present Illness  Psychosocial History
 Past Illness
  Identifies the patient ( name, address, phone
number, gender and who provided the
information ) whether it’s the patient or
significant other

 Collected data ( address and phoen numbers )

BIOGRAPHIC DATA should be deleted. Use initials for patient’s
name to provide privacy.

 Culture, ethnicity, or subculture may be

collected that helps the nurse to examine
special needs and beliefs that may affect the
family or family’s health care.

COLLECTION OF SUBJECTIVE DATA

 Gathering information about the patient’s
THROUGH INTERVIEW AND HEALTH educational level, occupation and working
HISTORY status will assist the nurse to tailor questions
according to the level of understanding of the
patient.
  What is your current major health
problem ?

 Assist patient to focus on his/her most

significant health concern and answers the

REASONS question
 Physician calls this Client’s CHIEF

FOR COMPLAINT ( CC )

SEEKING CARE
 How do you feel about having to seek care ?

COLLECTION OF SUBJECTIVE DATA  Encourage the patient to discuss fears or

THROUGH INTERVIEW AND HEALTH other feelings about having to see a health
HISTORY care provider.
 Questions may draw out descriptions of
previous experiences both positive and
negative.
  Detailed description of health
concern

HISTORY OF  Nurse encourages patient to explain

PRESENT ILLNESS
COLLECTION OF SUBJECTIVE DATA
THROUGH INTERVIEW AND HEALTH
HISTORY
the health problem or symptoms
focusing on the onset, progression
and duration of the problem; signs
and symptoms and related problems
and what the patient perceives as
causing the problem.
  Questions about birth, growth

PAST HEALTH development, childhood diseases,

immunizations, allergies, previous health
problems, surgeries, pregnancies, previous
HISTORY accidents, injuries, pain experiences and
emotional or psychiatric problems.

 Assists nurse to identify the risk factors to

the patient as well as significant others.

COLLECTION OF SUBJECTIVE DATA

THROUGH INTERVIEW AND HEALTH
HISTORY
 FAMILY HEALTH  Genetic relatives that the
patient can recall
HISTORY
 It includes the maternal and
paternal grandparents, aunts
and uncles on both sides,
CURRENT MEDICATIONS parents, siblings and patient’s
children

COLLECTION OF SUBJECTIVE DATA

THROUGH INTERVIEW AND HEALTH  Gathering information of the
HISTORY medications patient has taken.
  Deals with patient responses ( nutritional
habits, activity and exercise, sleep and rest
patterns, use of medications and substances,
LIFESTYLE self concept and self care activities, social and
community activities, relationships, values
and beliefs, education and work stress level
and coping styles and environment )

COLLECTION OF SUBJECTIVE DATA

THROUGH INTERVIEW AND HEALTH
HISTORY
  Determining the patient’s developmental
level is essential to complete the patient’s
portrait
 Nurse will group and analyze the data
obtained during the health history and
DEVELOPMENTAL LEVEL compare them with the normal
developmental parameters

 Example : Height, weight Erickson’s

PSYCHOSOCIAL HISTORY Psychosocial Developmental stage

 Psychosocial History covers many aspect

of the patient’s life.
COLLECTION OF SUBJECTIVE DATA THROUGH
INTERVIEW AND HEALTH HISTORY
 Areas include psychological or mental
health, social history and many factors
such as health, finances, employment,
education, religion, stress and support
system ( friends and family )
 COLLECTION OF SUBJECTIVE DATA THROUGH
INTERVIEW AND HEALTH HISTORY
( SUMMARY )

 Collecting Subjective Data is a key step to nursing assessment.

 Subjective Data consists of information elicited and verified only by the patient.

 Interviewing is the means by which subjective data is gathered.

 Complete health history is performed to collect as much subjective data about the
patient is possible.
 COLLECTION OF OBJECTIVE DATA

 PHYSICAL EXAMINATION ( Preparation, Positioning and Techiniques )

 DIAGNOSTIC TESTS AND PROCEDURES

 Other Source ( Patient’s Chart )

 COLLECTION OF OBJECTIVE DATA

 Complete Nursing Assessment = Subjective Data + Objective Data

 Information about the patient that the nurse can directly observe during INTERACTION

 Information elicited through PHYSICAL EXAMINATION TECHNIQUES

 To become proficient with Physical Assessment, the nurse must have basic knowledge in 3
areas ( Preparation, Positioning and Techniques )
 PATIENT PREPARATION

 Most patient need an EXPLANATION of Physical Examination

 Patient often anxious about what the nurse will find during the physical assessment
 Nurse should explain when and where the examination will take place, why it is important and what
will happen
 Informed the patient that all data findings and documentation will be CONFIDENTIAL.
 Health examinations are painless, the nurse need to know in advance the positions that are
contraindicated for the patient.
 Nurse assist the patient as needed to undress and put on a gown.
 Patients should empty one’s bladder before examination to help them feel more relax and facilitates
palpation of the abdomen and pubic area.
 PATIENT PREPARATION

 The sequence of assessment differs with children and adults.

 Children always proceed from the least invasive or uncomfortable aspect of the
exam to the invasive.
 PREPARING THE ENVIRONMENT

 Important to prepare the environment before starting the assessment.

 Environment needs to be well lighted and the equipment should be organized for efficient use.

 Room should be warm enough to be comfortable to the patient.

 Providing PRIVACY is important.

 Culture, age and gender of both the patient and nurse influenced how comfortable the patient will be and what
special arrangements might be needed.
 POSITIONING OF PATIENTS

 Several positions are frequently required during the physical assessment.

 It is important to consider the patient’s ability to assume a position.
 Patient’s physical condition, energy level and age should be taken into consideration.
 Some positions are embarrassing and uncomfortable should not be maintained for a long period of time.
 Assessment should be organized so several body areas can be assessed in one position, thus minimizing the
number of position changes.
 Draping should be arranged so that areas to be assessed is exposed and other body areas are covered.
 Drapes provide not only a degree of privacy but comfort as well.
 INSTRUMENTATION

 All instruments needed for health assessment must be ready for use,
clean and in good working condition and readily accessible.

 Equipment is frequently set up on trays and ready for use.

VITAL SIGNS
ANTHROPOMETRIC MEASUREMENT
SKIN, HAIR AND NAIL EXAMINATIONS
HEAD AND NECK EXAMINATIONS
EYE EXAMINATIONS
EAR EXAMINATIONS
MOUTH THROAT, NOSE , SINUS
EXAMINATION
 TECHNIQUES IN PHYSICAL
EXAMINATION

 INSPECTION

 AUSCULTATION

 PALPATION

 PERCUSSION
 INSPECTION

 Visual Examination by assessing using the sense of SIGHT

 Visual inspection is use to assess moisture, color, and body texture

surfaces as well as shape, position, size, color and body symmetry

 Sufficient lighting to see clearly.

 Inspection can be obtained with other assessment techniques.

 PALPATION
 Examination of the body using the sense of TOUCH
 Pads of the fingers are used ( nerve endings ) makes them highly sensitive to tactile discrimination
 Palpation is used to determine the following :

1. Hair Texture
2. Skin Temperature
3. Vibration of a Joint
4. Position, size, consistency and mobility of organ masses
5. Urinary Bladder Distention
6. Pulsation
7. Tenderness or Pain
 TYPES OF PALPATION
 LIGHT PALPATION : precedes and must be done prior to DEEP PALPATION since heavy pressure on
fingertips can dull the sense of touch

 DEEP PALPATION : not usually done on routine palpation and requires significant Practitioner’s Skills
performed with extreme caution because it can damage internal organs
not indicated for patients who have acute abdominal pain or pain that is not
yet diagnosed

Palpating for Skin Temperature : Dorsum of the Hand ( Back )

Testing for Vibration : Use the Palmar Surface of the Hand
 GENERAL GUIDELINES FOR PALPATION

 Hands should be clean, warm and finger nails short

 Areas of tenderness should be palpated last.
 Effectiveness of palpation depends on patient’s relaxation.
 Ways by which patient can relax :
1. Gowning or draping the patient appropriately
2. Positioning the patient comfortably
3. Ensuring hands are warm.

 During palpation, nurse should be sensitive to patient’s verbal and facial expression indicating
discomfort.
 PERCUSSION

 Act of striking the body surface to elicit sounds that can be heard or vibrations that can be felt
2 Types of Percussion
1. Direct Percussion : Strikes the area to be percussed directly with the pads of two, three
fingers or pad of the middle finger
 Strikes are rapid and the movement is from the wrist
 2. Indirect Percussion : Striking of an object ( finger ) held against the body area to be
examined
o Pleximeter and Plexor
o Used to determine the size and shape of internal organs by establishing borders
 5 SOUNDS OF PERCUSSION

 FLATNESS : Extremely dull sound

 DULLNESS : Thud like sound produced by dense tissue ( liver, spleen, heart )

 RESONANCE : Hollow sound ( Lungs filled with air )

 HYPERRESONANCE : Booming sound can be heard by an emphysematous lung

 TYMPANY : Musical and Drumlike sound produced from air filled stomach ( distended ) lungs
( emphysema or pneumothorax )
 DIAGNOSTIC AND LABORATORY
PROCEDURES

 Diagnostic tests are procedures performed to confirm or determine the presence of

disease in an individual suspected of having a disease.

1. Identify changes in patient’s health condition before symptoms occur

2. Aid in diagnosing a disease or health condition
3. Plan management and treatment for disease and condition
4. Evaluate patient’s response to treatment
5. monitor the course of disease over time
 DIAGNOSTIC TESTS AND PROCEDURES

 BLOOD EXAMINATIONS
CBC ( Complete Blood Count )
Lipid Profile ( Cholesterol level , LDL, HDL )
FBS ( Fasting Blood Sugar )
Blood Typing ( ABO, Rh Typing )
ABG ( Arterial Blood Gas )

 Urinalysis
 Fecalysis
 Culture Sensitivity Tests ( Specimen : Blood, Urine, Sputum )
 Tissue Sample Test ( Biopsy )
 DIAGNOSTIC TESTS AND PROCEDURES

 Radiologic Examinations ( Chest Xrays/ Ultrasound/ Computed Tomography ( CT Scan ) and Magnetic
Resonance Imaging ( MRI )
 PATIENT’S CHART

 Patient’s Chart or Medical Chart is a complete record of the patient’s key clinical data and medical
history (Demographics, Vital Signs, Diagnoses, Medications Treatment Plans, Progress Notes,
Problems, Immunizations Dates, Allergies, Radiologic Studies and Laboratory tests.)
 Accurate and complete medical charts ensures systematic documentation of a patient’s medical
history, diagnosis , treatment and care.
 Inclusions : ( Surgical History, Obstetric History, Medication Allergies, Family History, Social
History Habits, Immunization Records and Development History , Demographics and Medical
Encounters )
 ONLY the patient and the health care team providing care to the patient can view the medical
chart.
 Practice CONFIDENTIALITY AND RESPECT FOR PRIVACY
 CORE VALUES OF NURSING IN
CONDUCTING HEALTH ASSESSMENT

 CARING : Promoting health, healing and hope in response to human condition

 INTEGRITY : Respecting the dignity and moral wholeness of every person without conditions or
limitation

 DIVERSITY : Affirming the uniqueness of and differences among persons, ideas, values and
ethnicities

 EXCELLENCE : Co-creating and implementing transformative strategies with daring ingenuity