Adult Health Assessment Guide

Advanced Nursing Health Assessment of
Adult
For 1st Year Adult Health Nursing Students
By: Tadele K (Ass’t Professor)
Email: kinati2010@gmail.com
Salale University, CHS, Department of Nursing, June, 2023! 1

Course Syllabus
 Course Code: GNUR5023
 Course Credit: 3 Cr.Hr
 Course type: Nursing specialty course
 Program - MSc in Adult Health Nursing
 Placement: Year I, Semester II
 Enrollment: Regular
 Course Delivery: Block

Course Description
 This health assessment course has been designed to provide
advanced level knowledge and psychomotor skills necessary for
assessing the health status of adult clients/patients.
 Students are grounded in the theoretical perspectives, empirical
documentation, and practice skills necessary for advanced
communication (i.e., clinical interviewing, focused and
comprehensive history taking), biopsychosocial and physical
assessment, critical diagnostic reasoning, and clinical decision
making.
 Students acquire the required advanced knowledge and skills within
a case based, problem focused learning framework that integrates
theoretical, empirical, and experience based practical knowledge.

Course Objectives
 On successful Completion of this course, students will be able to:
 Describe advanced health assessment techniques in nursing
practice
 Demonstrate techniques of physical examination, and health
screening
 Organize comprehensive history of patients based on Gordon’s
approach and medical Human response pattern approach
 Distinguish the difference between normal and abnormal
findings of body structures
 Compare critical reasoning approaches to advanced health
assessment and patient-centered care.
 Compile and report a comprehensive database, physical
examination, laboratory and diagnostic study results.
 Practice Orem’s Self care theory

Course contents
 Introduction to health assessment
 Health history and physical examination
 Approaches of Health Assessment in Nursing
 Nutritional assessment
 Assessment of integumentary system (Skin, Hair and Nails)
 Assessment of Head, Eye, Ear, Nose and Throat (HEENT)

Course contents
 Assessment of Neck, lymphoglandular system
 Assessment of the respiratory system
 Assessment of the cardiovascular system
 Assessment of the renal system
 Assessment of breast and axilla
 Assessment of gastrointestinal system
 Assessment of the reproductive system
 Assessment of the musculoskeletal system
 Assessment of the neurologic system

Teaching/Learning
Strategies
 Lecture, presentation
 Demonstration /skill
lab/
 Hospital attachment
 Audio visual
 Reading
assignment....and
Experience sharing
Teaching
aids/materials/
 Lap top
 LCD
 Different forms/
formats/
 White board
 Parker
 Textbooks

Evaluation
 Individual Presentation (30%)
 Skill lab /demonstration exam/ (30%)
 Final written examination (40%)

References
 Bickley, L.S. (2012). Bates' pocket guide to
physical examination and history taking. 5th Ed.
Lippincott, Williams & Wilkins
 Patricia M (2007). Nursing Health Assessment, 2nd
Ed.

Introduction

Brainstorming
Health Defined …?
 The absence of disease concept?
 The WHO definition?
 Dunn’s level of wellness?
 The adaptation model? (internal/external factors)
 The freedom from pain model?
 Holism? (mind, body, spirit)

Holistic Principles of Health
 All state of health and disease have a psychological component
 Every person presents a complex but, unique interaction of body, mind
and spirit
 The primary responsibility for health lies not with a health care provider,
but with one’s self
 Individuals need to be in control of and regulate their destiny
 Holistic health care providers must determine to what extent the
atmosphere of dependency is created within the context of helping
roles
 Holistic health concept believers take the position that illness is not bad
 Positive wellness and not just the absence of disease is the goal of
holistic health
 Practitioners of holism must come to know themselves as human beings
before prompting optimal health in others

Hence, Health is defined as … ?
It is a state of physical, mental, social,
spiritual, emotional and economical well
being not merely the absence of disease or
infirmity. (Terris M., 1978)

Nursing Defined?
 Florence Nightingale ?
 Virginia Henderson ?
 ANA?

Nursing Defined?
 “The unique function of the nurse is to assist
the individual, sick or well, in the
performance of those activities contributing to
health, its recovery, or to a peaceful death that
the client would perform unaided if he had the
necessary strength, will, or knowledge. And to
do this in such a way as to help the client gain
independence as rapidly as possible.”
Virginia H.

Nursing Defined?
 “Nursing is the protection, promotion, and
optimisation of health and abilities,
prevention of illness and injury, alleviation of
suffering through the diagnosis and treatment
of human response, and advocacy in the care
of the populations.” ANA

Nursing Process

Overview of Nursing process
 Definition:
It is a systematic problem solving process that guides all
nursing actions.
 Purpose:
To help the nurse provide goal directed, Client -
centered care

♣ Components of Nursing process
1.Assessment:
Systematic and continuous collection of client data
The nurse carefully examine the client’s body parts to
determine any abnormalities
Document of relevant data

Types of Assessments {4}
1.Initial comprehensive assessment (admission assessment,
Triage) is performed when the client enters a health care
services.
 The purposes are to evaluate the client’s health status, to
identify functional health patterns that are problematic,
and to provide an in-depth, comprehensive database,
which is critical for evaluating changes in the client’s
health status in subsequent assessments.
 Vital signs, patients statement …

Types of Assessments
2.Focused assessment: Collects data about a problem that
has already been identified.
 This type of assessment has a narrower scope and a
shorter time frame than the initial assessment.
 In focus assessments, nurse determine whether the
problems still exists and whether the status of the
problem has changed (i.e. improved, worsened, or
resolved).
 This assessment also includes the appraisal of any new,
overlooked, or misdiagnosed problems.

3.Emergency assessment: It takes place in life-
threatening situations in which the preservation of life is
the top priority.
 Time is of the essence rapid identification of and
intervention for the client’s health problems.
 Often the client’s difficulties involve airway, breathing
and circulatory problems (the ABCs).
 Abrupt changes in self-concept (suicidal thoughts) or
roles or relationships (social conflict leading to violent
acts) can also initiate an emergency.
 Once the ABCs are stabilized, the emergency assessment
may turn into an initial or focused assessment,
depending on the situation.

4.Time-lapsed assessment or Ongoing assessment:
It takes place after the initial assessment to evaluate any
changes in the clients functional health.
 Nurses perform time-lapsed reassessment when
substantial periods of time have elapsed between
assessments (e.g. periodic output patient clinic visits,
home health visits, health and development screenings).
 During the time-lapsed assessment, the current status of
the patient is compared to the previous baseline during
and prior to treatment

Types of the Data
 Subjective (Patients
description )
 Objective (measureable and
observable)
Sources the Data
 Primary – Patient
 Secondary- others sources

Methods of Assessment
 Observation
 Interview
 Health history
 Symptom analysis
 Physical examination
 Laboratory and diagnostic data

Components of Nursing process
2.Diagnosis:
Compare clinical findings with normal and abnormal
variation and development events
Interpret data
Validate diagnoses
Document diagnoses

 Diagnosis: 3 activities in Diagnosing includes:-
Data Analysis
Problem Identification
Formulation of Nursing Diagnosis

 Diagnosis: components = PES/PE
 Components of a nursing diagnosis: PES or PE
Problem -P
Etiology - E
Defining characteristics (sign/ symptoms ) -S

 Diagnosis: Types:-
1.Actual nursing diagnosis
2.Risk nursing diagnosis
3.Possible nursing diagnosis
4.Wellness nursing diagnosis
5.Syndrome nursing diagnosis

1.Actual Nursing Diagnosis:
 A client problem that is present at the time of the nursing
assessment.
 It is based on the presence of signs and symptoms.
 Patient problem + Etiology + symptoms
 Examples:
 Imbalanced Nutrition less than body requirements r/t decreased
appetite as manifested by decrease body weight
 Ineffective airway clearance r/t to viscous secretions as
manifested by productive cough

2.Possible nursing diagnosis:
 One in which evidence about a health problem is
incomplete or unclear therefore requires more data to
support or reject it; or the causative factors are unknown
but a problem is only considered possible to occur.
 Problem + etiology
 Examples:
Possible low self-esteem r/t loss job
Possible altered thought processes r/t unfamiliar
surroundings

3.Risk Nursing diagnosis:
 is a clinical judgment that a problem does not exist, therefore no S/S
are present, but the presence of risk factors indicate that a problem is
only likely to develop unless nurse intervene or do something about it.
 No subjective or objective cues are present therefore the factors that
cause the client to be more vulnerable to the problem is the etiology of
a risk nursing diagnosis.
 Problem + risk factors
 Examples:
 Risk for infection r/t compromised immune system
 Risk for injury r/t decreased vision after cataract surgery.

4.Wellness nursing diagnosis
 Clinical judgment about an individual, family and
community in transition from a specific level of wellness
to a higher level of wellness
E.g. Knowledge deficit regarding breast feeding RT first
time birth.

5.Syndrome nursing diagnosis
 Comprises of a cluster of problems
 Eg:
Rape trauma syndrome
Disuse syndrome.

3.Outcome identification
Identify expected outcomes
Individualize to the person
Culturally appropriate
Realistic and measurable
Include a timeline

4.Planning
Establish priorities
Develop outcomes
Set timelines for outcomes
Identify interventions
Integrate evidence-based trends and research
Document plan of care

5.Implementation
Implement in a safe and timely manner
Use evidence-based interventions
Collaborate with colleagues
Use community resources
Coordinate care delivery
Provide health teaching and health promotion
Document implementation and any modification

6.Evaluation
Progress toward outcomes
Conduct systemic, ongoing, criterion-based evaluation
Include patient and significant others
Use ongoing assessment to revise diagnoses,
outcomes, plan
Disseminate results to patients and family

Explanatory Model
 Formulated by Kleinman
 ls a set of questions care providers can ask during an
assessment which provides insight into what is most
important for the client in terms of their health,
illness, and care.

Explanatory Model
 What do you call your problem? What name do you give it?
 What do you think has caused it?
 Why did it start when it did?
 What does your sickness do to your body? How does it
work inside you?
 How severe is it? Will it get better soon or take longer

Explanatory Model
 What do you fear most about your sickness?
 What are the chief problems your sickness has caused for
you (personally, family, work, etc.)?
 What kind of treatment do you think you should receive?
 What are the most important results you hope to receive
from the Treatment?

Nursing Documentation
 Is the record of nursing care that is planned and delivered to individual
clients by qualified nurses or other caregivers under the direction of a
qualified nurse.
 It contains information in accordance with the steps of the nursing
process.
 It is the principal clinical information source to meet legal and
professional requirements, care nurses' knowledge of nursing
documentation, and is one of the most significant components in nursing
care.
 Quality nursing documentation plays a vital role in the delivery of quality
nursing care services through supporting better communication between
different care team members to facilitate continuity of care and safety of
the clients.

Contents of Nursing Documentation
 Admission form
 Is a fundamental record which documents a client's status,
reasons why the client is being admitted, and the initial
instructions for that client's care and is completed by a nurse
when a client is admitted.
 Nursing care plan
 Is a clinical document recording the nursing process, which is a
systematic method of planning and providing care to clients.
 Progress note
 Is the record of nursing actions and observations in the nursing
care process which nurses to monitor and control the course of
nursing care.

Critical Thinking

What Is Critical Thinking?
 Is a combination of:
Reasoned thinking
Openness to alternatives
Ability to reflect
A desire to seek truth

What is Critical Thinking?
 “…reasonable reflective thinking that is focused on deciding
what to believe or do” (Ennis, 2000)
 Process through which nurses analyze and make sense of situ
ations in order to make sound clinical decisions.
 “the art of thinking about your thinking while you are thin
king in order to make your thinking better…” (Paul, 1988)

Components of Critical Thinking
A. Skills:
Cognitive (intellectual) activities and processes
used in problem solving and decision making.
Gather information
Identify problems
Recognize gaps in own knowledge
Listening, reading
Organizing information
visualizing, exploring, evaluating credibility

Components of Critical Thinking
B.Attitudes: Attitudes are like feelings and traits of mind
Independent thinking
Intellectual curiosity
Intellectual humility
Intellectual empathy
Intellectual courage
Intellectual perseverance
Fairmindedness

Critical Thinking….
 Critical Thinkers Ask Questions.
 Inquiring Minds WANT to KNOW!
 What am I taking for granted?
 Did I explore all points of view?
 Do I understand the question?
 What information do I need?
 Do I need to report anything?
 What complications should I anticipate?
 Which is my highest priority?
 Are there ethical or cultural issues I should consider?

Why Is Critical Thinking Important for Nurses ?
Nurses deal with complex situations
Our clients are unique
Nurses apply knowledge to provide holistic care
Nursing is an applied discipline
Nursing uses knowledge from other fields
Nursing is fast paced /stepped/

Five Major Categories of Critical Thinking
1.Contextual awareness
2.Inquiry /review/
3.Considering alternatives
4.Examining assumptions
5.Reflecting critically

The Four Critical Thinking Skills
Reading
Listening
Observing
Analyzing

1.To Improve Critical Reading
 Highlight the main ideas as you read.
 Join a study group and see if your main idea is the same as fellow
group member’s.
 Dialogue with yourself to identify the main idea of your reading.
 Try to state the main idea in your own words

2.To Improve Critical Listening
 Restate the points made in a discussion with others to
see if you understand them.
 Focus on what a speaker is saying and listen for key point
 While listening, make note of anything you find
confusing, and ask about it later.

3.To Improve Critical Observing
 Remove any restrictions in your mind
 Eliminate or decrease any distraction
 Ask yourself if you understand the most important points?
 Create new ways of looking at situations
 Always look from outside the situation

4.Improve Critical Analyzing
 Maintain clear and accurate logic
 Take all details into consideration
 Use systematic and scientifically based process
 Use both cognitive and psychomotor skills

Barriers to Creative Thinking
 Resistance to change, rigid mindset, practice guided by tradition,
habit, routines
 Stereotypical perceptions of clients
 Fear of making mistakes
 Unwillingness to take risks or look for alternative strategies
 Decision making without sufficient data or supported by rationale
 Failure to evaluate effectiveness of nursing actions

Critical Thinking and Creativity
 Critical thinkers = creative thinkers
 Question the status quo.
 Search for new and practical strategies for improvement.
 Group think: a major block to creativity

How Is the Nursing Process Related to Critical Thinking?
 Nursing process is a problem -
solving process that uses many individual critical thinking skills

Decision Making
 Think about your choice of specialty….. What influenced
you?

Decision Making
 Decision making in nursing is a complex process that may
be defined as a series of decisions, including obtaining
subjective and objective data in relation to a patient
situation and the evaluation of that data to implement
actions to achieve a desired outcome (Lauri et al.,2001).

Decision Making …
 DECIDE: a model of the decision-making process steps
 D = define the problem
 E = establish the criteria
 C = consider all the alternatives
 I = identify the best alternative
 D = develop and implement a plan of action
 E = evaluate and monitor the solution and feedback when
necessary

Decision making models in Nursing
1. Rational Model
 Consists of a structured four-step sequence:
 identifying the problem
 generating alternative solutions
 selecting a solution
 implementing and evaluating the solution
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Salale University, CHS, Department of Nursing, June, 2023!

 Techniques used in rational model of decision-making are:
 SWOT analysis
 Pareto analysis (the 80/20 rule/ the vital few and the trivial
many)(80% of a project’s benefit can be achieved by doing 20% of
the work or 80% of problems can be traced to 20% of the causes)
 Decision trees (listing all possibilities, branching's ,..)
 Management by Objectives (objective based)
66

2. Simon’s Normative Model
 This model based on premise that decision making is not rational
 The model state that decision making is characterized by:
 Limited information processing
 Use of rules of thumb or shortcuts
 Satisfying
67

3. Group Decision Making Model
 Groups can accumulate more knowledge and facts
 Groups have a broader perspective and consider more alternative
solutions
 Individuals who participate in decisions are more satisfied with the
decision and are more likely to support it
68

4. Clinical Decision Making Model:
 Information-processing model that uses a scientific hypothetic-deductive,
quantitative approach,
 The intuitive-humanistic model that focuses on intuition and how the
knowledge gained from nursing experience enriches the clinical decision
making process and
 The clinical-decision model that uses both hypothetico-deductive and
pattern recognition.
 Critical pathways are used as a technique in clinical decision making.
69

What affects decision making?
 Knowledge
 Skills
 Experience
 Behaviors /attitude, emotions, family, patients, …values
 Environmental factors
 Stress
 Fatigue, …

The Health History Taking

The Health History Taking
o It is the systematic collection of subjective and objective data
that is used for determining a client’s functional health
pattern status for the purpose of nursing diagnosis.
o It is also a chronological and detailed health record of a client.

Purposes of History Taking
 To elicit information regarding all of the variables that
may affect the client’s health experience and status.
 Guides on which body parts or systems to focus during
physical examination.
 To establish a trusting relationship between the nurse and
the patient.
 Develops understanding about the patient.
 Serves as a background material related to the
development of the present symptoms.

Phases of History Taking
1.Introductory phase: introduction of self and explains
the purposes of the interview to the patient.
 An explanation of note taking, confidentiality, Comfort
and privacy
2.Working phase: This is the actual data collection phase.
3.Summary and closure phase: The nurse summarizes
information obtained form the patient during the working
phase and validates problems and goals with the patient.
 Possible plans to resolve the problems are identified and
discussed with the patient.

Techniques of Effective History Taking
 Great the patient according to the norm and culture then call
according to his/her title and name, and give undivided
attention.
 Keep comfort (for patient with pain) and privacy
 Never be in a hurry even when you are in a limited time.
 Design questions appropriately /avoid leading questions/
 Facilitation: you can use posture, actions, or words that
encourages the patient to say more but do not specify the
topic.

Techniques of Effective History Taking
 Reflection: This is the repetition of the patient’s words to
encourage him/her to give you more details.
 Clarification: when the patient’s words are ambiguous or
associations are not clear, you must ask for clarifications.
 Empathetic response: this is the recognition of feelings such
as embarrassment, shame suffering and responding to
patients in a way that shows understanding and acceptance.
 Confrontation: If you observe clues of anger, anxiety, or
depression.

Cultural Variations & History Taking
 Cultural variations in communication and self-disclosure
styles seriously affect the information obtained.
 The nurse should be aware of possible variations in the
communication styles of self and patient.
 When misunderstanding or difficulty in communicating is
evident, the nurse should seek help.

Ethical Considerations & History Taking
 The patient has a full right to know why you are collecting the
information.
 The individual patient/ client is fully informed about the process of
data collection and the decision of the patient is freely made.
 Following the interview the nurse selectively records information
that is pertinent to the health status of the patient.
 When data collection is completed and the data recorded, the
written record is maintained in a secure place and made available
only to those health professionals directly involved in the care of
the patient.

Physical Examination

Physical Examination
 Reviewing of the whole system…
 Indications:
Routine screening
Eligibility prerequisite for health insurance, military
service, job, sports, school,…
Admission to a hospital or long term care facility

Things to Do Before Starting PE
 Think /Organize/
 Consider Environment
 Accommodate special needs (cultural sensitivity)
 Equipment - clean surface & clean equipment
 Room - quiet, warm & well lighted
 Maintain privacy
 Observe & Listen

Components of Physical Examination
 Inspection
 Palpation
 Percussion
 Auscultation
Note: there is 5th skill known as olfaction

1.Inspection
 “the use of the senses of vision and hearing to observe the normal
condition or any deviations from normal of various body parts.”
 The nurse inspects or looks body parts to detect normal
characteristics or significant physical sings.
 Inspection helps to know normal characteristics before trying to
distinguish abnormal findings in different ages.
 The quality of an inspection depends on the nurse's willingness to
spend time doing a thorough job.

Inspection
 Use vision and hearing
 Always first
 Look for symmetry
 Use good lighting
 Use good exposure

Principles of Accurate Inspection
 Good lightening either day light or artificial light is suitable.
 Expose body parts being observed only.
 Look before touching.
 Warm room for examination of the client “not cold not hot".
 Observe for color, size, location, texture, symmetry and sounds.
 Compare each area inspected with the opposite side of body if
possible.
 Use pen light to inspect body cavities.

2.Palpation
 Touch & feel with hands to determine:
 Texture – use fingertips (roughness, smoothness).
 Temperature – use back of hand (warm, hot, cold).
 Moisture (dry, wet, or moist).
 Organ location and size
 Consistency of structure (solid, fluid, filled)
 Slow and systematic
 Light to deep
 Light palpation (tenderness)
 Deep palpation (abdominal organs/masses)

Principles of Accurate Palpation
 Examiner finger nails should be short
 Use sensitive part of the hand
 Light Palpation precedes deep palpation
 Tender area are palpated last
 Tell client to take slow deep breath to enhance muscle relaxation.
 Examine condition of the abdominal organs
 Depressed areas must be approximately “2cm”
 Assess turgor of skin measured by lightly grasping the body part with
finger tips.
 Bimanual palpation used to assess organs deep in the abdomen by using two
hands, one on each side of body part or organs being felt

Palpation
Light Deep

3.Percussion
 Tap a portion of the body to elicit tenderness that varies with the
density of underlying structures.
 Percussion denotes location, size and density of underlying structures,
percussion requires dexterity.
 Methods of percussion:
 Direct method: involving striking the body surface directly with one or
two fingers. Elicits pain/tenderness/
 Indirect method: performed by placing the middle finger of the
examiner’s non dominant hand “pleximeter hand” firmly against the
body surface with palm and fingers remaining off the skin, and the tip
of the middle finger of the dominant hand “plexor” strikes the base of
the distal joint of the pleximeter. Use a quick & sharp stroke
 Elicits sounds

Percussion

5 Percussion Sounds Produced in Different
Body Regions
1. Resonant – normal lung
2. Hyper resonant: it’s a louder and lower pitched than resonant
sounds. Normally heard in children and very thin adults , and
abnormally in emphysema
3. Tympany : A hollow drum-like sound produced when a gas-
containing cavity is tapped sharply. Tympany is heard if the chest
contains free air (pneumothorax) or the abdomen is distended
with gas air filled (stomach)
4. Dull or thud like sounds are normally heard over dense areas such
as the heart or liver. Dullness replaces resonance when fluid
replaces air-containing lung tissues, such as occurs with
pneumonia, pleural effusions, or tumors
5. Flat: shown in no air areas such as thigh muscle, bone and tumor

Auscultation
 “To listen for various breath, heart, and bowel sounds”
 Direct or immediate auscultation is accomplished by the unassisted
ear that is without amplifying device.
 This form of auscultation often involves the application of the ear
directly to a body surface where the sound is most prominent.
 Mediate auscultation: the use of sound augmentation device such as a
stethoscope in the detection of body sounds.

Auscultation
 Listening to body sounds
 Movement of air (lungs)
 Blood flow (heart)
 Fluid & gas movement (bowels)
 Remember the sound changes in
the abdomen…

Olfaction
 Another skill that used during assessment, certain alteration is body
function create characteristic body odors, smelling can detect
abnormalities that unrecognized by other means.
 Assessment of characteristic odors:
 Alcohol odor from oral cavity means ingestion of alcohol
 Ammonia from urine means urinary tract infection
 Body odor from skin, particularly in areas where body parts rub together
 Halitosis from oral cavity means poor dental and oral hygiene, gum disease.
 Sweat, fruity ketones from oral cavity may be from diabetic acidosis.

Variations for physical assessment of the
geriatric client
Remember: normal variation related to aging may be observed in all parts of the p/exm.
 Dividing the physical assessment into parts in order to avoid fatigue in the older
client.
 Provide room with comfortable temperature and no drafts.
 Allow sufficient time for client to respond to directions.
 If possible assess the elderly clients in a setting where they have an opportunity to
perform normal activities of daily living in order to determine the client’s optimum
potential.

Steps of Physical Examination

Vital Signs
 Vital Signs (Reading Assignment)
Equipment?
Sites?
Temp, pulse, BP, RR, (pain??)?
Values?

Approaches of Health Assessment in Nursing

Approaches of Health Assessment in Nursing
 The functional health assessment approach (Gordon’s approach)
 The medical approach (Body Systems Model)
 Orem’s approach to self-care assessment

Gordon’s Approach (NANDA)

Gordon’s Approach (NANDA) Components
1- Health Perception-Health
Management Pattern
2- Nutritional—Metabolic Pattern
3- Elimination Pattern
4- Activity—Exercise Pattern
5- Sexuality—Reproduction Pattern
6- Sleep—Rest Pattern
7- Sensory—Perceptual Pattern
8- Cognitive Pattern
9- Role—Relationship Pattern
10- Self-Perception-Self-Concept
Pattern
11- Coping-Stress Tolerance Pattern
12- Value—Belief Pattern

1.Health Perception-Health Management
Pattern
 Determine how the client perceives and manages his or
her health.
 Compliance with current and past nursing and, medical
recommendations.
 The client's ability to perceive the relationship between
activities of daily living and health.

Health Perception-Health Management
Pattern
 Client's Perception of Health: Describe your health.
 Client's Perception of Illness: Describe your illness or current health
problem.
 Health Management and Habits: Tell me what you do when you have
a health problem.
 Compliance with Prescribed Medications and Treatments: Have you
been able to take your prescribed medications? If not, what caused
your inability to do so?
 Subjective and Objective data
 Different types of Dx

2.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 and objective data
 Different types of Dx

3.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
 Subjective and Objective data
 Habits, frequencies, sounds ….

4.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.
 Subjective and Objective data

5.Sexuality- Reproduction Pattern
 Consider female and male separately
 Identify both subjective and objective data

6.Sleep- Rest Pattern
 Mention all subjective and Objective data
 i.e. sleep habits, special problems, sleep aids…

7.Sensory - Perceptual Pattern
 Pain Assessment
 Special Aids
 Identify all subjective and objective data

8.Cognitive Pattern
 Ability to Understand
 Ability to Communicate
 Ability to Remember
 Ability to Make Decision
 Mental status examination
Different types of Dx

9.Role- Relationship Pattern
 Roles and responsibility at work, home, social …
 Observe family members

10.Coping Stress Tolerance Pattern
 Perception of Stress and Problems in Life
 Coping Methods and Support Systems

11.Value-Belief Pattern
 Values, Goals, and Philosophical Beliefs
 Are there certain health practices or restrictions that are
important for you to follow while you are ill or
hospitalized? Explain.
 Observe religious practices, Bible , clergy,….

The Medical Approach (Body Systems Model)

The Medical Approach (Body Systems Model)
1. Biographic Data
Full name
Address and telephone
numbers
Birth date and birth
place
Sex
Religion and race
Marital status
Social security number
Occupation (usual and
present)
Source of referral
Usual source of
healthcare
Source and reliability of
information
Date of interview

2. Chief Complaint / CC/
 The main reason for:
Health care visits
Hospitalization
 With duration

3. History of Present Illness
 Gathering information relevant to the chief complaint, and the client's
problem, including essential and relevant data, and self medical treatment.
Components:
 Client's summary and usual health
 Investigation of symptoms: "onset, date, gradual or sudden, duration,
frequency, location, quality, and alleviating or aggravating factors"
 Negative information
 Relevant family information
 Disability "affected the client's total life"

Symptom Analysis (P Q R S T)
a. Provocative or Palliative
 First occurrence :
 What were you doing when you first experienced or noticed the
symptom?
 What to trigger it ? stress? Position?, activity?
 What seems to cause it or make it worse? For a psychological
symptom.
 What relieves the symptom : change diet? Change position ? Take
medication ? Being active?
 Aggravation: what makes the symptom worse?

b. Quality Or Quantity
 QUALITY:
 How would you describe the symptom- how it feels, looks, or sounds?
 QUANTITY:
 How much are you experiencing now?
 Is it so much that it prevents you from performing any activity?

C. Region Or Radiation
 Region :
 Where does the symptom occur?
 Radiation :
 Does it travel down your back or arm, up your neck or down your legs?

d. Severity scale
 Severity
 How bad is symptom at its worst?
 Course
 Does the symptom seem to be getting better, getting worse?

e. Timing
 Onset :
 On what date did the symptom first occur
 Type of onset :
 How did the symptom start sudden? Gradually?
 Frequency :
 How often do you experience the symptom ; hourly ? Daily ? Weekly?
monthly
 Duration :
 How long does an episode of the symptom last

4. Past Health History
 Purpose: to identify all major past health problems of the
client.
This includes:
 Childhood illness e.g. history of rheumatic fever.
 History of accidents and disabling injuries
 History of hospitalization (time of admission, date, admitting
complaint, discharge diagnosis and follow up care
 History of operations "how and why this done“
 History of immunizations and allergies
 Physical examinations and diagnostic tests

5. Family History
 Purpose: to learn about the general health of the client's blood
relatives, spouse, and children and to identify any illness of
environmental genetic, or familiar nature that might have implications
for the client's health problems.
 Family history of communicable diseases.
 Heredity factors associated with causes of some diseases.
 Strong family history of certain problems.
 Health of family members "maternal, parents, siblings, aunts,
uncles…etc.".
 Cause of death of the family members "immediate and extended family".

6. Environmental History
 Purpose:
 To gather information about surroundings of the client",
including physical, psychological, social environment, and
presence of hazards, pollutants and safety measures.“

7. Current Health Information
 The purpose is to record major current health related information.
 Allergies: environmental, ingestion, drug, other.
 Habits "alcohol, tobacco, drug, caffeine"
 Medications taken regularly "by doctor or self prescription
 Exercise patterns
 Sleep patterns (daily routine)
 The pattern life (sedentary or active)

8. Psychosocial History
 Includes:
 How client and his family cope with disease or stress,
and how they responses to illness and health.
 You can assess if there is psychological or social problem
and if it affects general health of the client.

9. Review of Systems (ROS)
 Collection of data about the past and the present of each of the
client systems.
 Review of the client’s physical, sociologic, and psychological
health status may identify hidden problems and provides an
opportunity to indicate client strength and disabilities

9. Review of Systems includes:
 General review of skin, hair, head, face, eyes, ears, nose, sinuses,
mouth, throat, neck nodes and breasts.
 Assessment of respiratory system
 Assessment of Cardiovascular system
 Assessment of gastrointestinal system.
 Assessment of urinary system
 Assessment of genital system
 Assessment of extremities and musculoskeletal system
 Assessment of endocrine system

Orem's Approach of History Taking
130

Dorothea Orem (Biography, 1914-2007)
 Born in 1914 in Baltimore, US
 Earned her diploma at Providence Hospital –Washington, DC,1930
 1939 – BSN Ed., and 1945 – MSN Ed., at Catholic University of
America
 She worked as a staff nurse, private duty nurse, nurse educator
and administrator and nurse consultant.
 Received honorary Doctor of Science degree in 1976.
 Theory was first published in Nursing: Concepts of Practice in
1971, second in 1980, in 1995, and 2001.
131

Orem’s theories
1. Theory of self care
2. Theory of self care deficit
3. Theory of nursing system
132

1. Theory of Self-Care
 According to this theory, self-care is a learned behavior and a
deliberate action in response to a need.
 Why and how people care for themselves
133

1. Theory of Self-Care (concepts)
 Self-care
 Self-care agency
 Self-care requisites
 Therapeutic self-care demand
134

Self-care
135

Self-care agency
136

Basic conditioning factors
137

Self care requisites
138

Therapeutic self care demand
139

2. Theory of Self-Care Deficit
 This theory purports that nursing care is needed when people are
affected by limitations that do not allow them to meet their self-
care needs.
 Why people can be helped through nursing
 The relationship between the nurse and the client is established
when a self-care deficit is present.
 Self-care deficits, not medical diagnosis, determine the need for
nursing care.
 According to Orem, the only legitimate need for nursing care is when
a self-care deficit exists.
140

 “The condition that validates the existence of a requirement for
nursing in an adult is the health associated absence of the
ability to maintain continuously the amount and quality of
therapeutic self-care in sustaining life and health, in
recovering from disease or injury, or in coping with their
effects.”
141

 Nurses meet the self care needs through:
 Acting or doing for another
 Guiding
 Providing physical or psychological support
 Providing and maintaining an environment that supports
personal development
 Teaching
142

3. Theory of Nursing Systems
 This is the unifying theory that “subsumes the theory of self-care
deficit which subsumes the theory of self-care” (Orem, 1991, p. 66).
 The Theory of Nursing Systems attempts to answer the question
“What do nurses do?”
 This was the original question that prompted the development of
Orem’s theory.
 Describes and explains relationships that must be made and
maintained for nursing to be produced
143

 The nurse determines whether or not there is a legitimate need for
nursing care.
 Is a person able to meet self-care needs?
 Does a deficit exist?
 If a deficit exists, then the nurse plans care that identifies what is
to be done by whom: the nurse, the client, or other (family or
significant other).
 Collectively, the actions of all these people are called the nursing
system.
144

 This describes:
 How the patient’s self care needs will be met by the nurse, the
patient, or both
 Nursing responsibilities
 Roles of the nurse and patient
 Rationales for the nurse-patient relationship
 Types of actions needed to meet the patient’s demands
 Orem identified three types of nursing systems:___>
145

1.Wholly compensatory nursing system, the nurse supports and
protects the client, compensates for the client’s inability to care
for self, and attempts to provide care for the client. E.g. Post
anesthetic pts
146

2.Partly compensatory nursing system, both the nurse
and client perform care measures. E.g. Ambulating the
pts /selective activities/
147

3.Supportive-educative nursing system, the nurse’s actions are to
help clients develop their own self-care abilities through knowledge,
support, and encouragement. E.g. Educating about insulin self
administration
148

Orem’s General Theory of Nursing
149

150

Orem’s Nursing Process
 Consists of 3 steps:
 Step 1: determine why a patient needs care
 Step 2: design a nursing system & plan the delivery of care
 Step 3: management of nursing systems - planning,
initiating, & controlling nursing actions
151

Application of Orem’s theory
 Practice
 Used as a bases for different clinical practices, e.g.
diabetes self care
 Education
 Bases for different curriculums
 Research
 Used a conceptual framework for different researches
152

‘’The bridge between knowledge and skill is practice.
The bridge between skill and mastery is time’’ Jim
Bouchard
Thank You!

 The ways to mastery ……
1st Attention
2nd Acquisition
3rd Ascension

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