Health THREE ASPECTS OF HEALTH Nursing Assessment Objectives of health assessment Reasons for doing assessment:- Reasons for doing assessment:- Importance of health assessment Conti… Types of Assessment Initial assessment Problem focused assessment Emergency assessment Time lapsed assessment Initial assessment Problem Focused Assessment Emergency assessment Time – lapsed reassessment Setting and environment Data collection Data collection is the process of gathering information about a client’s health status. It includes the health history, physical examination, results of laboratory and diagnostic tests, and material contributed by other health personnel. Types of data collection Two types: subjective data and objective data. 1. Subjective data, also referred to as symptoms or covert data, are clear only to the person affected and can be described only by that person. Itching, pain, and feelings of worry are examples of subjective data. Conti…. 2. Objective data, also referred to as signs or overt data, are detectable by an observer or can be measured or tested against an accepted standard. They can be seen, heard, felt, or smelled, and they are obtained by observation or physical examination. For example, a discoloration of the skin or a blood pressure reading is objective data Sources of data collection Sources of data are primary or secondary. Primary : It is the direct source of information. The client is the primary source of data. Secondary: It is the indirect source of information. All sources other than the client are considered secondary sources. Family members, health professionals, records and reports, laboratory and diagnostic results are secondary sources. Methods of data collection Conti…. Observation includes looking, watching, examining. Observation begins the moment the nurse meets the client. It is a conscious, deliberate skill that is developed through efforts and with an organized approach. Observation has two aspects: Noticing the data and Selecting, organizing, and interpreting the data.  2- Interviewing STAGES OF AN INTERVIEW An interview has three major stages: The opening or introduction The body or development The closing 3- Examination Inspection Auscultation Palpation Types of palpation Light palpation Deep palpation Bimanual palpation Percussion 4- Intuition Data Validation 3- Organization of data 4- Documenting Data

1. Health Assessment
Sankappa Gulaganji
Assst professor
Bldea’s Shri B M Patil INS, Vijayapur

2. Health
A state of complete physical, mental and social and
spiritual well-being, not merely the absence of
disease or infirmity” (WHO)
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4. THREE ASPECTS OF HEALTH
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Health is the measure of our body’s
efficiency and over-all well-being.
The health triangle is a measure of the
different aspects of health.
The health triangle consists of:
Physical, Social, and Mental Health.

5. NursingAssessment
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• The first phase of the nursing process, called assessment, is the
collection of data for nursing purposes. Information is
collected using the skills of observation, interviewing, physical
examination, and intuition and from many sources, including
clients, their family members or significant others, health
records, other health team members.

6. Objectives of health assessment
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 Surveillance of health status, identification of occult disease,
screening, and follow-up care.
 The periodic assessment, at regular intervals.
 Increasing client participation in health care.
 Accurately define the health and risk, care needs for
individuals.
 Health assessment is shared with the client in a clearly
and understandable manner.
 The client must share in decision making for his own care.

7. Reasons for doing assessment:-
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- To establish baseline information on the client
- To determine the client’s normal function
- To determine the client’s risk for dysfunction
- To determine the client’s strengths
- To provide data for the diagnosis phase

8. Reasons for doing assessment:-
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• To confirm or refuse data obtained in the health
history.
• Toidentify nursing diagnoses.
• To make clinical judgments about client's changing
health status.
• To evaluate bio-psycho-social & spiritual outcomes
of care.

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1. Systematic and continuous collection of client data.
2. It focus on client responses to health problems.
3.The nurse carefully examine the client’s body parts to
determine any abnormalities.
4.The nurse relies on data from different sources which can
indicate significant clinical problems.
5.Health assessment provides a base line used to plan
the clients care
Importance of health assessment

10. Conti…
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6.Health assessment helps the nurse to diagnose client’s
problem & the intervention.
7.Complete health assessment involves a more detailed review
of client’s condition.
8.Health assessment influence the choice of therapies &
client's responses.

11. Types of Assessment
1. Initial assessment
2. Problem focused assessment
3. Emergency assessment
4. Time lapsed assessment

12. Initial assessment
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• Performed within specified time after admission. To establish a
complete database for problem identification.
• Initial identification of normal function, functional status, and
collection of data concerning actual or potential dysfunction.
• Baseline for reference and future comparison.
• Eg: Nursing admission assessment

13. Problem Focused Assessment
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• Status determination of a specific problem identified during
previous assessment.
• To determine the status of a specific problem identified in an
earlier assessment.
• Ongoing process, integrated with nursing care, a few minutes to a
few hours between assessments.
Eg: hourly checking of vital signs of fever patient

14. Emergency assessment
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During emergency situation to identify any life
threatening situation.
Eg: Rapid assessment of an individual’s airway,
breathing status, and circulation during a cardiac arrest.

15. Time – lapsed reassessment
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• Comparison of client’s current status to baseline obtained
previously, detection of changes in all functional health patterns
after an extended period of time has passed
• Several months after initial assessment. To compare the client’s
current health status with the data previously obtained.
• Several months (3,6,9 months or more) between assessment

16. Setting and environment
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Assessment can take place in any setting where
nurses care for clients and their family members: in
the client’s home, at a clinic, in a hospital room.

17. Data collection
 Data collection is the process of
gathering information about a client’s
health status. It includes the health
history, physical examination, results of
laboratory and diagnostic tests, and
material contributed by other health
personnel.

18. Types of data collection
 Two types:
1. subjective data and
2. objective data.
1. Subjective data, also referred to as symptoms or covert data, are clear
only to the person affected and can be described only by that person.
Itching, pain, and feelings of worry are examples of subjective data.

19. Conti….
2. Objective data, also referred to as signs or overt data, are
detectable by an observer or can be measured or tested
against an accepted standard. They can be seen, heard, felt, or
smelled, and they are obtained by observation or physical
examination. For example, a discoloration of the skin or a
blood pressure reading is objective data

20. Sources of data collection
 Sources of data are primary or secondary.
1. Primary : It is the direct source of information. The client is the
primary source of data.
2. Secondary: It is the indirect source of information. All sources other
than the client are considered secondary sources. Family members,
health professionals, records and reports, laboratory and diagnostic
results are secondary sources.

21. Methods of data collection
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The methods used to collect data are
1. Observation,
2. Interview and
3. Examination.
4. Intution
1. Observation
Comprises more than the nurse’s ability to see the client, nurses also
use the senses of smell, hearing, touch, and, rarely, the sense of taste.

22. Conti….
Observation includes looking, watching, examining. Observation
begins the moment the nurse meets the client. It is a conscious,
deliberate skill that is developed through efforts and with an
organized approach.
 Observation has two aspects:
1. Noticing the data and
2. Selecting, organizing, and interpreting the data.

23. 23
Is a planned communication or a conversation with a
purpose, for example to get or give information, identify
problems of mutual concern, evaluate change, teach,
provide support. There are two approaches to
interviewing, directive and nondirective.
2- Interviewing

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•The directive interview is highly structured and
elicits specific information. The nurse establishes the
purpose of the interview and controls the interview.
The client responds to questions but may have
limited opportunities to ask questions or discuss
concerns.
•The nondirective interview or rapport- building
interview, by contrast the nurse allows the client to
control the purpose, subject matter, and pacing.

25. STAGES OF AN INTERVIEW
An interview has three major stages:
1. The opening or introduction
2. The body or development
3. The closing

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The physical examination is a systematic data collection method to
detect health problems. Is a systematic data collection method that
uses the senses of sight, hearing, smell, and touch to detect health
problems.
Toconduct the examination, the nurse uses techniques of
inspection, palpation, percussion and auscultation, intuition
3- Examination

27. 27
Is visual examination of the client that is done in a
methodical and deliberate manner. The client is
observed first from a general point of view and then
with specific attention to detail. Effective inspection
requires adequate lighting and exposure of the body
parts being observed.
Inspection

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Involves listening to sounds in the
body that are created by
movement of air or fluid. The
following organs most often
auscultated include the lungs, heart,
abdomen, and blood vessels.
Auscultation

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Uses the sense of touch to assess texture,
temperature, moisture, organ location and size,
vibrations and pulsations, swelling, masses, and
tenderness. Palpation requires a calm, gentle
approach and is used systematically, with light
palpation preceding deep palpation and palpation
of tender areas performed last.
Palpation

30. Types of palpation
Light palpation
Deep palpation
Bimanual palpation

31. Percussion
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Uses short, tapping strokes on the surface of the skin to create
vibrations of underlying organs. It is used for assessing the
density of structures or determining the location and the size of
organs in the body.
There are two types of percussion
1. Direct percussion
2. Indirect percussion

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Use of insight, instinct, and clinical experience to make
clinical judgments about the client.
Intuition plays a role in the nurse’s ability to analyze cues
rapidly, make clinical decisions, and implement nursing
actions even though
assessment data may be incomplete or ambiguous.
4- Intuition

33. Data Validation
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The information gathered during the assessment is “double-
checked” or verified to confirm that it is accurate and complete.
Validation, commonly referred to as double – checking the
information at hand, is the process of confirming the accuracy of
assessment data collected. Validation assists in verifying and
clarifying cues and inference.

34. 3- Organization of data
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After data collection is completed and information is validated, the nurse
organizes, or clusters, the information together in order to identify areas of
strengths and weaknesses. This process is known as data clustering. How
data are organized depends on the assessment model used. One of these
model is Head – to – Toe model.
The nurse uses a format that organizes the assessment data
systematically. This is often referred to as nursing health history or
nursing assessment form.

35. 4- Documenting Data
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To complete the assessment phase, the
nurse records client data. Accurate
documentation is essential and should
include all data collected about the client’s
health status.
To increase accuracy, the nurse records
subjective data in the client’s own words to
avoid the chance of changing the original
meaning.