“international health organizations and nursing organizations”

1. GBSN SEMESTER III YEAR II
HEALTH ASSESSMENT
Patriotic Health Sciences Institute of Nursing
Introduction to Health Assessment Concepts
Objectives
By the end of the unit, learners will be able to:
1. Discuss the need for health assessment in general nursing practice.
2. Explain the concepts of health, assessment, data collection, and diagnosis.
3. Identify types of health assessments
4. Document health assessment data using a problem oriented approach
Activity 1
Identify the basic concepts that you will study in health assessment course.
Differentiate between health, illness, disease and wellness.
Can a diabetic client be called healthy?
What is the difference between a illness and sickness.
Stop!
Have you written your answers
Which Qs was most difficult for you
Now compare your answers
Activity 1 answers
Health, assessment, techniques to examine, health history, systems PE, documenting findings,
identifying abnormalities.
Health: A state of complete physical, mental & social wellbeing, not merely the absence of
disease. (WHO)
Wellness: Level of wellbeing, a person perceives of being healthy

2. Disease: Alteration of structure and function of body. ( Dis – ease)
Illness: A response a person has to a disease.
Definition
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.
REFLECTION
You walk into Mrs. Smith’s room for the first time. She is sitting on the edge of the bed crying
and has not changed into a hospital gown. You introduce yourself and say, “You seem very
upset.” Mrs. Smith tells you that she is concerned about her husband being left at home alone
while she is in the hospital for colon surgery.
POINTS
Situations requires the collection of additional data before making a nursing judgment. For
example, is Mr. Smith capable of caring for himself?
Collect information to make nursing judgments.
Health Assessment Purpose
The purpose of a nursing health assessment is to collect subjective and objective data to
determine a client’s overall level of functioning in order to make a professional clinical
judgment.
1. Build a therapeutic relationship
2. Identify client’s needs for nursing care
3. Determine teaching needs
4. For screening purpose
Types of Assessment
The four basic types of assessment are:

3. Data collection
What is a data?
Information, clue, observation, finding, sign and symptom
Data - complete and accurate
Type - Subjective and objective
Source – Primary or secondary
Which one is data here:
Pulse, Doppler machine, Diarrhea, temperature, 90% oxygen saturation, fever, SOB, abdominal
girth, weakness, cough, “I have a headache.” “It frightens me.” “I am not hungry.”
Data
SUBJECTIVE DATA (Interview)
Biographical information (name, age, religion, occupation)
Physical symptoms related to each body part or system (e.g., eyes and ears, abdomen)
Past health history

4. Family history
Health and lifestyle practices (e.g., health practices that put the client at risk, nutrition, activity,
relationships, cultural practices.)
OBJECTIVE DATA
(directly observed by the examiner)
Inspection
Palpation
Percussion
Auscultation
PREPARING FOR THE EXAMINATION
Principles
Set the stage
Environment
Brief explanation in start
Head to toe approach
External then internal
Normal to affected area
Self preparation
Anxiety
Organization
Mannerisms
Safety
Gentleness
Competence
Equipment preparation

5. Within reach and ready
Arranged as per need
Extra supplies / equipments
Clean & warm equipment
Patient preparation
Keep appointment
Comfort
Bladder empty
Change into gown
Properly covered
Environment
Privacy
Noise Control
Drapes
Adequate light
Room temperature
Client position
Techniques
Inspection
Palpation
Percussion
Auscultation
Inspection
Inspection involves using the senses of vision, smell, and hearing to observe and detect any
normal or abnormal finding.

6. Color
Size
Location
Symmetry
Movement
Behavior
Odors
Sounds
Palpation
Touch with different parts of hands
Dorsum / finger / ball of hands
With different degree of pressure
Light: 1-2 cm
Deep: 4-5 cm
Bimanual: using both hands to trap organ
PALPATE for
Texture (rough/smooth)
Temperature (warm/cold)
Moisture (dry/wet)
Mobility (fixed/movable/still/vibrating)
Consistency (soft/hard/fluid filled)
Strength of pulses (strong/weak/bounding)
Size (small/medium/large)
Shape (well defined/irregular)

7. Degree of tenderness
Percussion
Percussion involves tapping body parts to produce sound waves.
Sound produced determines the feature of underlying organ
1. Eliciting pain
2. determining location
3. size and shape
4. determining density
5. detecting abnormal masses
Percussion
Types of percussion
Mediate or Indirect
Immediate or Direct
Blunt or Fist
Percussion notes
Flatness
Dullness
Resonance
Hyper resonance
Tympany

8. Auscultation
Listening to body sounds with stethoscope
Used for listening heart sounds, breath sounds, vascular sounds, and abdominal sounds
Use Diaphragm & bell
Sound description is based on:
Pitch ( high and low )
Intensity
Duration
Quality
General survey
The general survey includes observation of the client’s
Physical development
Gender
Apparent age as compared to reported age
Skin condition and color

9. Dress and hygiene
Posture and gait
Level of consciousness
Behaviors, body movements, and affect
Facial expression
Speech
General survey documentation
Elderly women, oriented to person and place only, appears weak, unable to stand, guarding
abdomen, skin flushed, pt is shivering.
A 45 years old male, looks younger than his age, skinny, alert, oriented to x3. appears healthy
and in no acute distress, well groomed, respond appropriately and cooperative. No gross
abnormalities apparent. Posture is erect and comfortable for age. Gait is rhythmic and
coordinated with arms swinging at side.
Young lady of 25 years old seated on wheel chair, constantly shifting position and picking at the
paper on the table. Disoriented to time, place and person (require frequent orientation to the
examination process). Is thin and unkempt. Eye contact minimal. Talked throughout the
examination.
Mr. Mohsin, a young male, adult, fair skinned, with moustache and beard, tall and average built,
alert, cooperative and well groomed, in no apparent distress. Posture is erect and comfortable
for age. Gait is rhythmic and coordinated with arms swinging at side.
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

10. Use black pen