INTRODUCTION TO

HEALTH ASSESSMENT
Health Assessment
BScN 2nd Year

10/10/2021 PREPARED BY SIR JERRY ZAHID GF 1

NC
 OBJECTIVES
By the end of the unit, learners will be to:

 Discuss the need for health assessment in general

nursing practice

 Explain the concepts of health assessment, collection,

and diagnosis.

 Identify types of health assessments.

 Document health assessment data using a

problem oriented approach.

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 NEED OF HEALTH ASSESSMENT
IN
NURSING
 Accurate physical assessment requires an organized and
systematic approach using the techniques of inspection,
palpation, percussion, and auscultation.

 It also requires a trusting relationship and rapport between

the nurse and the patient to decrease the stress the patient
may have from being physically exposed and vulnerable.

 The patient will be much more relaxed and cooperative if you

explain what will be done and the reason for doing it.

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 NEED OF HEALTH ASSESSMENT
IN
NURSING
 While the findings of a nursing assessment do
sometimes contribute to the identification of a medical
diagnosis, the unique focus of a nursing assessment is
on the patient's responses to actual or potential
problems.

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 NURSING ASSESSMENT
 Is a major component of nursing care.

 Is a process which includes both physical

and psychological aspect to evaluate client’s
condition.

 Enables the nurse to make a judgment about

the client’s health status , ability to manage
his/her health care and need for nursing.

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 BASIC
CONCEPTS
 Health: (WHO) a state of complete physical,
mental & social Wellbeing, not merely the
absence of disease.

 Wellness: Level of wellbeing, a person

perceives of being healthy.

 Disease: Alteration of structure and

function of body.
Disease or discomfort.

 Illness: A response a person has to an

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illness.
 CONT
…
 The new definition, considers health as a dynamic
state of well being with different levels of functional
abilities at different point in time. So a diabetic
patient no doubt has a disease, but there are times
when the client feels well and can be called healthy.
 Illness is a response to a disease and sickness 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.
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 PHASES OF THE NURSING PROCESS
It is systematic, deliberate, problem solving, decision making
process that nurses use to achieve a certain result.
It consists of A.D.P.I.E steps.
Diagnosis

Assessment Planning

Implement
Evaluation
ation

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 CONTI....
Phase Title Description
I. Assessment Collecting subjective and objective data
II. Diagnosis Analyzing subjective and objective data to
make a professional nursing judgment
(nursing diagnosis, collaborative problem,
or referral.
III Planning Determining outcome criteria and
developing a plan
IV Implementati Carry ing out the plan
on
V Evaluation Assessing whether outcome criteria have
been met and revising the plan as
necessary

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 COMPONENTS OF HEALTH ASSESSMENT

Health
Assessment

Health History Physical Examination

History of present illness Inspection

Past /present Medical history Palpation
Family History, social Hx Percussion
Auscultation

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 FACTS ABOUT PHYSICAL
ASSESSMENT:
 a. Physical assessment is an organized
systemic process of collecting objective data
based upon a health history and head- to-toe or
general systems examination. A physical
assessment should be adjusted to the patient,
based on his needs. It can be a complete physical
assessment, an assessment of a body system, or
an assessment of a body part.

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 FACTS ABOUT PHYSICAL
ASSESSMENT:
b. The physical assessment is the first step in the
nursing process. It provides the foundation for
he nursing care plan in which your observations
play an integral part in the assessment,
intervention, and evaluation phases.

 c. The chances of overlooking important

data are greatly reduced because the physical
assessment is performed in an10 organized,
systematic manner, instead of a random
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 PURPOSES OF A PHYSICAL
ASSESSMENT:
A. 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.
(1) 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.
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 CONTI….

(2) Objective data: Are detectable by an observer or can

be tested by using an accepted standard.
● A blood pressure reading, discoloration of the skin,
and seeing11 the patient in the act of crying are
examples of objective data.
(3) Objective data are sometimes called signs, whereas
subjective data are sometimes called symptoms.

(4) Data means more than signs or symptoms; it also

includes demographics, or patient information that is not
related to a disease process.
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 CONTI….
B. The purposes for a physical assessment are:

(1) To obtain baseline physical and mental data on the patient.

(2) To supplement, confirm, or question data obtained in the

nursing history.

(3) To obtain data that will help the nurse to establish

nursing diagnoses and plan patient care.

(4) To evaluate the appropriateness of the nursing

interventions in resolving the patient's identified
pathophysiology problems

(5) To evaluate the physiological outcome of care.

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 IMPORTANCE OF PHYSICAL
ASSESSMENT:
1. To early detect and treat diseases and disorders.
2. To identify actual and potential health problems.

3. To establish a data based from which the subsequent

phases of the nursing evolve.

4. To assess the client’s impact of activity and exercise on the

client’s overall level of health.

5. To assess the client’s routine exercise pattern and

observe how the client’s body system response to
activity & exercise.
6. To establish the client-nurse relationship
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 IMPORTANCE OF PHYSICAL
ASSESSMENT:

7. To obtain information about the client’s health

including, physiologic, psychologic, sociocultural,

cognitive, developmental and spiritual aspects.

8. To identify the client’s strength and

weaknesses.

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 COMPARING SUBJECTIVE AND OBJECTIVE DATA
Subjective Objective
Description Data elicited and verified Data directly or indirectly observed
by the client through measurement
Sources •Client Observations and physical
•Family and significant assessment findings of the nurse or
others other health care professionals.
•Client record  Documentation of assessments made
•Other health care in client record.
professionals Observations made by the client's
family or significant others.
Methods used •Client interview Observation and physical
to obtain examination
data
Skills needed Interview and therapeutic  Inspection
to obtain data communication skills  Palpation
Caring ability and  Percussion
empathy  Auscultation
 Listening skills
Examples.  "I have a headache."  Respirations 16 per minute
 "It frightens me." BP 180/100, apical pulse 80 and
 "I am not hungry." irregular
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 TYPES OF ASSESSMENT

Types of
Assessment

Initial Focus or
On going
Comprehe Problem Emergency
nsive or
Partial Oriented

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 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 17

gathered during a step-by-step physical

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 INITIAL COMPREHENSIVE
ASSESSMENT
 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.

17

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 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.
18
This type of assessment may be performed in the hospital,
community,
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 ONGOING OR PARTIAL
ASSESSMENT

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.

18

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 ASSESSMEN
T
 It is performed when a comprehensive database exists for a client
and he/she comes to the health care agency with a specific health
concern.

 Consists of a thorough assessment of a particular client problem and

does not cover areas not related to the problem. For example, if your
client, John P.. tells you that he has ear pain, you would ask him
questions about the pain, possible hearing loss, dizziness, ringing in his
ears, and personal ear care. Sexual functioning & bowel habits would
be unnecessary and inappropriate.

 The physical examination should focus on his ears, nose, mouth, and
19
throat. At this time, it would not be appropriate to repeat all system
examinations such as the heart and neck vessel or abdominal
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 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 life20- sustaining physical
functions.

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 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
Objective
O Assumption / Diagnosis
Planning
A Intervention
Evaluation
P Revision
I

E
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 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

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 REFERENCES BOOKS

Bickley, L. S., Szilagyi, P. G., & Bates, B. (2007).

2/26/2016

Bates' guide to physical examination and history
taking (11th Edi). Philadelphia: Lippincott Williams &

Shahzad Bashir, NLCON, Karachi.

Wilkins.

 Weber, Kelley's. (2007). Health Assessment in Nursing,

3rd Ed: North American Edition. Lippincott Williams
& Wilkins.

 Jarvis, Carolyn. (2011). Physical Examination and

Health Assessment - Text + Mosby's Nursing Video
Skills: Physical Examination & Health 23
Assessment Package. W B Saunders Co.
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