health assessment

1. Nursing Health Assessment
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2. The first assessment begin in (1992) by American
medical association
 In (1995) health assessment considered as
basic human right
 Preventive health care divided in three
categories, primary, secondary and tertiary
prevention. Each level of prevention is based on
a thorough assessment of the client's health as
status.
 Periodic health assessment needed to be
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3. Health Assessment
Holistic approach:
1. The interview
2. Psychosocial assessment
3. Nutritional assessment
4. Assessment of sleep-wakefulness patterns
5. The health history.
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4. Psychosocial assessment
 Psychological assessment involves person's
growth and development throughout his life.
 Discuss crises with the clients to assess
relationship between health & illness. “It
depends on multiple G&D theories e.g.
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5. Stages of Age
 Infancy period: birth to 12 months
Neonatal Stage: birth-28 days
Infancy Stage: 1-12 months
 Early childhood Stage: It’s refers to two integrated stages of
development
Toddler: 1 - 3years.
Preschool: 3 - 6 years.
 Middle childhood 6-12 years
 Late childhood:
Pre pubertal: 10 – 13 years.
Adolescence: 13 - 19 years
 Young adulthood 20-40 years
 Middle adulthood 40-65years
 Late adulthood 65 and more

6. Nutritional assessment
 Nutrition plays a major role in the way an
individual looks, feels,& behaves.
 The body ability to fight disease greatly
depends on the individual's nutritional
status
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7. Major goals of nutritional assessment
1. Identification of malnutrition.
2. Identification of over consumption
3. Identification of optimal nutritional status.
Components of Nutritional Assessment
1. Anthropometric measurement.
2. Biochemical measurement.
3. Clinical examination.
4. Dietary analysis
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8. 1. Anthropometric measurement
 Measurement of size, weight, and proportions of
human body.
 Measurement includes: height, weight, skin fold
thickness, and circumference of various body parts,
including the head, chest, and arm.
 Assess body mass index (BMI) to shows a direct and
continuous relationship to morbidity and mortality in
studies of large populations. High ratios of waist to hip
circumference are associated with higher risk for illness
& decreased life span.
BMI = (Wt. in kilograms) = 60 = 60
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9. BMI RANGE
Condition
Rang kg/m2
Very thin
less than 16.0
Thin
16.0 - 18.4
Average
18.5- 24.9
Overweight
25–29.9
Obese
30-34.9
Highly obese
≥ 35

10. 2. Biochemical Measurement
 Useful in indicating malnutrition or the development
of diseases as a result of over consumption of
nutrients. Serum and urine are commonly used for
biochemical assessment.
 In assessment of malnutrition, commonly tests
include: total lymphocyte count, albumin, serum
transferrin, hemoglobin, and hematocrit …etc.
These values taken with anthropometric
measurements, give a good overall picture of an

11. 3. Clinical examination
 Involves, close physical evaluation and may
reveal signs suggesting malnutrition or over
consumption of nutrients.
 Although examination alone doesn't permit
definitive diagnosis of nutritional problem, it
should not be overlooked in nutritional
assessment
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12. Nutritional assessment technique for clinical
examination
A. Types of information needed
 Diet: Describe the type: regular or not,
special, "e.g. teeth problem, sensitive
mouth.
 Usual mealtimes: How many meals a day:
when? Which are heavy meals?
 Appetite: "Good, fair, poor, too good".
 Weight: stable? How has it changed?
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13.  Food preferences: e.g." prefers beef to other
meats"
 Food dislike: What & Why? Culture related?
 Usual eating places: Home, snack shops,
restaurants.
 Ability to eat: describe inabilities, dental
problems: "ill fitting dentures, difficulties with
chewing or swallowing
 Elimination" urine & stool: nature, frequency
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14.  Psycho social - cultural factors: Review any thing which can
affect on proper nutrition
 Taking Medications which affect the eating habits
 Laboratory determinations e.g.: “Hemoglobin, protein,
albumin, cholesterol, urinalyses"
 Height, weight, body type "small, medium, large"
After obtaining information, summarize your findings and
determine the nutritional diagnosis and nutritional plan of
care.
Imbalanced nutrition: Less than body requirements,
related to lack of knowledge and inadequate food
intake

15. B. Signs & symptoms of
malnutrition
 Dry and thin hair
 Yellowish lump around eye, white rings around
both eyes, and pale conjunctiva
 Redness and swelling of lips especially
corners of mouth
 Teeth caries & abnormal missing of it
 Dryness of skin (xerosis): sandpaper feels of
skin
 Spoon shaped Nails " Koilonychia “ anemia
 Tachycardia, elevated blood pressure due to
excessive sodium intake and excessive
cholesterol, fat, or caloric intake
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16. 16

17. 4. Dietary analysis
 Food represent cultural and ethnic background
and socio- economic status and have many
emotional and psychological meaning
 Assessment includes usual foods consumed &
habits of food
 The nurse ask the client to recall every thing
consumed within the past 24 hour including all
foods, fluid, vitamins, minerals or other
supplements to identify the optimal meals
 Should not bias the client's response to
question based on the interviewer's personal
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18. Diseases affected by nutritional problems
1- Obesity: excess of body fat.
2- Diabetes mellitus.
3- Hypertension.
4- Coronary heart disease.
5- Cancer.
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19. Assessmentofsleep-wakefulness patterns
 Normal human has “homeostasis” (ability to
maintain a relative internal constancy)
 Any person may complain of sleep-pattern
disturbance as a primary problem or
secondary due to another condition
 1/4 of clients who seek health care complain
of a difficulty related to sleep
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20. Factors affecting length and quality ofsleep
1. Anxiety related to the need for meeting a tasks,
such as waking at an early hour for work.
2. The promise of pleasurable activity such as
starting a vacation.
3. The conditioned patterns of sleeping.
4. Physiologic wake up.
5. Age differences.
6. Physiologic alteration, such as diseases
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21.  Good sleep depends on the number of awakenings
and the total number of sleeping hours
 The nurse can assess sleep pattern by doing
interview with the client or using special charts or
by EEG
Disorders related to sleep
1.Sleep disturbances affects family life, employment, and
general social adjustment
2. Feelings of fatigue, irritability and difficulty in
concentrating
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22. 4. Illusions, hallucination (visual & tactile )
5. Decreased psychomotor ability with decreased
incentive to work
6. Mild Nystagmus
7. Tremor of hands
Increase in gluco-corticoid and adrenergic
hormone secretion
9. Increase anxiety with sense of tiredness
10. Insomnia "short end sleeping periods“
11. Sleep apnea "periodic cessation of breathing that

23. 12. Hypersomnia: "sleeping for excessive periods”
the sleep period may be extended to 16-18 hours
a day
13. Peri-hypersomnia. "Condition that is described
as an increased used for sleep "18-20 hours a
day" lasts for only few days
14. Narcolepsy "excessive day time drowsiness or
uncontrolled onset of sleep.
15. Cataplexy: abrupt weakness or paralysis of
voluntary muscles e.g. arms, legs & face last
from half second to 10 minutes, one or twice a
year
16. Hypnagogic hallucinations: " Disturbing or
frightening dream that occur as client is a falling a
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24. Assessment of sleep habits
 Let the client record the times of going to sleep and
awakening periods, including naps.
 Allow client to described their sleep habits in their own
words
You can ask the following questions:
How have you been sleeping?‖
Can you tell me about your sleeping habits?"
Are you getting enough rest?"
Tell me about your sleep problem"
Good History includes: a general sleep history,
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25. Nutritional-Metabolic Pattern
Assessing the client's nutritional-metabolic pattern is to
determine the client's dietary habits and metabolic
needs. The conditions of hair, skin, nails, teeth and
mucous membranes are assessed.
Subjective Data
Dietary and Fluid Intake
Describe the type and amount of food you eat at breakfast,
lunch, and supper on an average day
Do-you take any vitamin supplements? Describe.
Do you find it difficult to tolerate certain foods? Specify.
Do you ever experience nausea and vomiting? Describe.
Do you ever experience abdominal pains? Describe

26. Condition of Skin
Describe the condition of your skin.
How well and how quickly does your skin heal?
Do you have any skin lesions? Describe-
Do you have any itching? What do you do for relief?
Condition of Hair and Nails
Have you had difficulty with scalp itching or sores?
Do you use any special hair or scalp care products?
Have you noticed any changes in your nails? Color
Cracking? Shape? Lines?

27. Metabolism
What would you consider to be your "ideal weight"?
Have you had any recent weight gains or losses?
Do you have any intolerance to heat or cold?
Have you noted any changes in your eating or drinking
habits? Explain.
Have you noticed any voice changes?
Objective Data
Assess the client's temperature, pulse, respirations,
and height and weight.

28. Wellness Diagnoses
0pportunity to enhance nutritional metabolic pattern
Opportunity to enhance effective breastfeeding
Opportunity to enhance skin integrity
Risk Diagnoses
Risk for Altered Body Temperature
Hypothermia
Risk for Infection
Risk for altered nutrition less than body requirements .
Risk for Aspiration

29. Actual Diagnoses
Fluid Volume Deficit
Fluid Volume Excess
Altered Nutrition: Less than body
requirements
Altered Nutrition: More than body
requirements
Ineffective Breastfeeding

30. Elimination Pattern
Adequacy of the client's bowel and bladder.
The client's bowel and urinary habits.
Bowel or urinary problems
Use of urinary or bowel elimination devices.

31. Subjective Data
Bowel Habits
How frequent are your bowel movements?
Do you use laxatives? What kind and how often do
you use them?
Do you use enemas or suppositories? How often and
what kind?
Do you have any discomfort with your bowel
movements? Describe.

32. Bladder Habits
How frequently do you urinate?
What is the amount and color of your urine?
Do you have any of the following problems with
urinating:
 Pain? Blood in urine? Difficulty starting a stream?
Incontinence? Voiding frequently at night? Voiding
frequently during day? Bladder infections?
Have you ever had a urinary catheter? Describe.
When? How long?
Objective Data
Refer to abdominal assessment, and the rectal
assessment.

33. Associated nursing-Diagnoses
Wellness Diagnoses
Opportunity to enhance adequate bowel elimination
pattern
Opportunity to enhance adequate urinary
elimination pattern
Risk Diagnoses
Risk for constipation
Risk for altered urinary elimination

34. Actual Diagnoses
Altered Bowel Elimination Constipation
Diarrhea
Bowel Incontinence
Altered Urinary Elimination Patterns of Urinary Retention
Total Incontinence
Stress Incontinence

35. Activity-Exercise Pattern
Activities of daily living, including routines of exercise,
leisure, and recreation.
Activities necessary for personal hygiene, cooking,
shopping, eating, maintaining the home, and working.
An assessment is made of any factors that affect or
interfere with the client's routine activities of daily living.

36. Subjective Data
Describe your activities on a normal day. (Including hygiene
activities, eating activities.)
Do you have difficulty with any of these self-care activities?
Explain.
Does anyone help you with these activities? How?
Do you use any special devices to help you with your
activities?
Does your current physical health affect any of these activities
e.g. dyspnea, shortness of breath, palpations, chest pain.
pain, stiffness, weakness)? Explain.
Occupational Activities
Describe what you do to make a living.
Do you feel it has affected your health?

37. Objective Data
Refer to Thoracic and Lung Assessment
Cardiac Assessment
Peripheral Vascular Assessment
Musculoskeletal Assessment.
Associated Nursing Diagnoses
Wellness Diagnoses
Opportunity to enhance effective cardiac output
Opportunity to enhance effective self-care activities
Opportunity to enhance adequate tissue perfusion
Opportunity to enhance effective breathing pattern

38. Risk Diagnoses
Risk for Disorganized Infant Behavior
Risk for Peripheral Neurovascular Dysfunction
Risk for altered respiratory function
Actual Diagnoses
Activity Intolerance
Impaired Gas Exchange
Ineffective Airway Clearance
Ineffective Breathing Pattern
Disuse syndrome
Impaired Physical Mobility
Inability to Sustain Spontaneous Ventilation
Altered Tissue Perfusion

39. Sexuality-Reproduction Pattern
Subjective Data
1- Female
Menstrual history:
Last cycle begin?
Duration ?
Any change or abnormality ?
Describe any mood changes or discomfort before,
during, or after your cycle

40. Obstetric history
How many times have you been pregnant?
Describe the outcome of each of your pregnancies.
If you have children, what are the ages and sex of each?
Explain any health problems or concerns you had with
each pregnancy. If pregnant now .
Contraception
What do you or your partner do to prevent pregnancy?
Describe any discomfort or undesirable effects this method
produces.
Have you had any difficulty with fertility? Explain

41. Do you have or have you ever had a sexually
transmitted disease? Describe.
Describe any pain, burning, or discomfort you have
while voiding.
Objective Data
Refer to Breast Assessment, d Abdominal Assessment,
and urinary-Reproductive Assessment
Special problems

42. Associated nursing Diagnoses
Wellness Diagnosis:
Opportunity to enhance sexuality patterns
Risk-Diagnosis
Risk for altered sexuality pattern
Actual Diagnoses
Sexual Dysfunction, Altered Sexuality Patterns

43. Sleep-Rest Pattern
Subjective data
Sleep Habits:
How would you rate the quality of your sleep?
Special Problems
Do you ever experience difficulty with falling asleep?
Remaining asleep? Do you ever feel fatigued after
a sleep period?
Sleep Aids
What helps you to fall asleep? medications?
reading? relaxation technique? Watching TV?

44. Objective Data
1. Observe appearance
a. Pale b. Puffy eyes with dark circles
2. Observe behavior
a. Yawning
b. Dozing during day
c. Irritability
d. Short attention span

45. Associated nursing Diagnoses
Wellness Diagnosis:
Opportunity to enhance sleep
Risk Diagnosis
Risk for sleep pattern disturbance
Actual Diagnosis:
Sleep Pattern Disturbance.

46. Sensory-Perceptual Pattern
Subjective Data
Describe your ability to see, hear, feel, taste, and smell.
Describe any difficulty you have with your vision, hearing,
and ability to feel (e.g., touch, pain, heat, cold), taste
(salty, sweet, bitter, sour), or smell.
Pain Assessment
Complete Symptom Analysis
Special Aids:
What devices (e.g., glasses, contact lenses, hearing
aids)
Describe any medications you take to help you with
these problems.
Objective Data

47. Associated Nursing Diagnoses
Wellness Diagnosis:
Opportunity to enhance comfort level
Risk Diagnoses
Risk for pain
Actual Diagnoses
Pain

48. Cognitive Pattern
Subjective Data
Ability to Understand:
Explain what your doctor has told you about your
health.
Ability to Communicate:
Can you tell me how you feel about your current state
of health?
Ability to Remember:
Are you able to remember recent events and events
of long ago? Explain.
Ability to Make Decisions:

49. Objective Data
Refer to the Mental Status Assessment
Associated nursing Diagnoses
Wellness Diagnosis: Opportunity to enhance
cognition
Risk Diagnosis: Risk for altered thought
processes
Actual Diagnoses:
Acute confusion
Chronic Confusion

50. Role-Relationship Pattern
Subjective Data
Perception of Major Roles and Responsibilities in
Family
Describe your family.
Are there any major problems now?
Perception of Major Roles and Responsibilities at
Work
Describe your occupation.
What is your major responsibility at work?
Perception of Major Social Roles and Responsibilities

51. Objective Data
1. Outline a family genogram for your client.
2. Observe your client's family members.
Associated Nursing Diagnoses
Wellness Diagnoses:
Opportunity to enhance effective relationships
Opportunity to enhance effective communication
Risk Diagnoses:
High risk for Loneliness
Risk for Altered Parent/Infant/Child Attachment
Actual Diagnoses:
Impaired Verbal Communication
Impaired Social Interaction: Social Isolation

52. Coping-Stress Tolerance Pattern
Subjective Data
Perception of Stress and Problems in Life
Describe what you believe to be the most stressful
situation in your Life.
How has your illness affected the stress you feel?
Coping Methods and Support Systems:
What do you usually do first when faced with a
problem?
What helps you to relieve stress and tension?
Do you use medication, drugs, or alcohol to help
relieve stress? Explain.
Objective Data
Refer to the Mental Status Assessment.