The first step for assessing a person's health and disease status. A detailed comprehension of health assessment can enable health care professionals to work more confidently in the clinical setting.

1. LESSON PLAN
ON HEALTH
ASSESSMENT
MAMTA PARIHAR
M.Sc. Nursing 1st year
G.C.O.N. Jodhpur

2. The appearance of a
disease is swift as an
arrow; its disappearance
slow, like a thread.
~Chinese Proverb

3. INTRODUCTION
• Assessment is the first stage of the
nursing process in which the nurse
carries out a complete and holistic
nursing assessment of every patient's
needs, regardless of the reason for the
encounter.

4. HISTORY
• Health assessment has been separated
from physical assessment to include the
focus on health occurring on a continuum
as a fundamental teaching.
• In the healthcare industry it is understood
health occurs on a continuum, so the term
used is assessment but may be preference
by the speciality's focus such as nursing,
physical therapy, etc.

5. NURSING ASSESSMENT
• Every health care professional
performs assessments to make
professional judgments related to his
or her client. However the purpose of
nursing history and physical
examination differs greatly from that
of medical or other type of health
examination.

6. HEALTH ASSESSMENT
• It is a part of nursing assessment.
• It’s a systematic and continuous
collection, validation and
communication of client data as
compared to what is the standard or
norm. It includes the clients perceived
needs, health problems, related
experiences, health practices, values
and life styles.

7. DEFINITION
• A health assessment is a plan of care that
identifies the specific needs of a person
and how those needs will be addressed by
the healthcare system or skilled nursing
facility.
• Health assessment is the evaluation of the
health status by performing a physical
exam after taking a health history. It is
done to detect diseases early in people
that may look and feel well.

8. PURPOSES
1] Identify a client’s health status &
actual or potential health problems
or Needs.
2] To establish plans to meet the
identified needs
3]Deliver specific nursing
interventions to meet those needs.

9. TYPES OF ASSESSMENT
There are 4 different types of assessment:-
1] Initial Comprehensive assessment
2] Problem focused assessment
3] Emergency assessment
4] Time lapsed reassessment

10. Type Time performed Purpose Example
Initial
assessment
Performed
within
specified time
after
admission to a
health care
agency.
To establish a
complete
database for
problem
identification,
reference, and
future
comparison
Nursing
admission
assessment

11. Type Time performed Purpose Example
Proble
m-
focuse
d
assess
ment
Ongoing
process
integrated
with
nursing
care
To
determine
the status of
a specific
problem
identified in
an earlier
assessment
Hourly
assessment of
client’s fluid
intake and
urinary output in
an ICU
Assessment of
client’s ability to
perform self
care while
assisting a client
to bathe.

12. Type Time
performed
Purpose Example
Emerge
ncy
assessm
ent
During any
physiologic
or
psychologic
crisis of the
client
To identify
life-
threatening
problems
Rapid assessment
of a person’s
airway, breathing
status, and
circulation during
a cardiac arrest
Assessment of
suicidal
tendencies or
potential for
violence.

13. Type Time
performed
Purpose Example
Time
-
lapse
d
reass
essm
ent
Several
months
after
initial
assessme
nt
To
compare
the
client’s
current
status to
baseline
data
previously
obtained.
Reassessment
of a client’s
functional
health patterns
in a home care
or outpatient
setting or, in a
hospital, at
shift change.

14. STEPS OF THE ASSESSMENT PHASE
Phase Description Purpose Activities
A
S
S
E
S
S
M
E
N
T
COLLECTING,
VALIDATING
ORGANIZING,
RECORDING
DOCUMENTI
NG
DATA.
To establish
data base about
the client’s
response to
health concerns
or illness and
the ability to
manage health
care needs.
 Obtain a nursing health history
 Conduct a physical assessment
 Review client records
 Review Nursing literature
 Consult support persons
 Consult health professionals
update data as needed organize
data validate data communicate
/ document data.

15. Assessment
Observation of the patient
+ interview of patient And
family and society +
examination of the patient
+
Review Of Medical Record

16. COLLECTING DATA
• Gathering of information about client.
• Includes physical, psychological,
emotional, socio-cultural, spiritual
factors that may affect client’s health
status.
• Includes past health history of client.
• Includes current or present problems
of the client.

17. Types of data
Subjective Data
• symptoms or covert data
• can be verified described by only
the person who affected.
• Eg. Itching, pain, feelings of
worry.
• It includes the client’s sensations,
feelings values, beliefs, attitudes
and perception of personal health
status and life situation.
Objective data
• 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 E.G.
• Discoloration of skin, BP
reading.

18. Sl.
No.
Subjective Data Objective Data
1
I have
fever
Body tem – 1000F
Tachycardia – 100 bt/mt
Dull & tired Dried lips
2
I feel sick to
my stomach
Vomited 100ml of green tinged fluid
Abdomen firm
Slightly distended
Active bowel sounds in all 4 quadrants
3
I am short of
breath
RR – 28br/mt
Tachypnoea
Lung sound diminished in ® lower lobe.

19. Methods Data Collection
Observing – Occurs whenever the
nursing is in contact with the client or
support persons.
Interviewing – used while taking the
nursing health History
Examining – Major method used in the
physical health assessment.
In reality, the nurse uses all three methods
simultaneously when assessing clients.

20. OBSERVING
• Gather data by using the senses.
• Observation is a conscious, deliberate
skill that is developed through effort &
with an organized approach.
• Using the senses to observe client data.
• Vision
• Smell:
• Hearing
• Touch :

21. INTERVIEWING
• A planned purposeful conversation with the
patient to get information, identify, problems
evaluate changes, to teach or to provide
support or counseling.
• It an essential skill for obtaining information
for the nursing history, consists of asking
questions designed to elicit subjective data
from the family members.
• There are 2 approaches in interview
1.Direct 2.Indirect or nondirective

22. Direct Indirect or nondirective
Highly structured & elicits
specific information
Rapport- building interview
(understanding between two
or more people)
Nurse establishes purpose of
interview and controls the
interview
Nurse allows the client to
control the purpose, subject
matter and pacing
Clients who responds may
have limited opportunity to ask
question or Discuss concerns

23. Types of interview questions
•Closed question
•Open ended question
•Neutral questions
•Leading question

24. Closed
question
Open ended
question
Neutral
questions
Leading
question
Used in direct
interview,
Are restrictive
Generally
requires yes of
No or short
factual answers
Often begin with
when, where,
who, what, do,
did or does, or is,
are, was.
Eg.
Are you having
pain now?
What medication
did you take?
Associated with
nondirective interview
Invite clients to
discover & explore,
elaborate, clarify or
illustrate their thoughts
or feelings.
It specifies only the
broad topic to be
discussed & invites
longer that one or two
words. An open ended
question begins with
what or how?
Eg. What brought you
to hospital?
How did you feel in
that?
Is a question the
client can answer
with out direction or
pressure from the
nurse.
Used in non
directive that
question.
Eg.
How do you feel
about that?
Why do you think
you had the
operation?
Used in directive
interview &
Thus directs
client answer.
Eg.
You’re stressed
about surgery
tomorrow, aren’t
you?
You’ll take
medicine won’t
you?

25. Planning the interview and setting
• Before beginning an interview, the nurse
reviews available information.
Eg. Operative report, information about the
current illness.
• Each interview is influenced by time, place,
seating arrangement or distance, and
language.

26. Stages of an interview
• Opening or introduction 2 steps
1] establish rapport
2] orientation
• Body or development – closing

27. EXAMINING
• Physical examination or physical assessment
is a systematic data collection method that
uses observation to detect health problems.
• Assessment sequencing
• Cephalo caudal approach- head to toe assessment
• Body system approach-examine all the body
system
• Review of system approach- examine only
particular area affected

28. CEPHALO CAUDAL APPROACH- HEAD TO
TOE ASSESSMENT
• General
• General health status, vital signs and weight, nutritional
status.
• Mobility and self care
• Observe posture, assess gait, and balance,, evaluate
mobility, activities of daily living.
• Head face and neck
• Evaluate cognition level of consciousness, orientation,
mood, language and memory, Sensory function, test
vision, test hearing, cranial nerves, lymph nodes.
• Skin hair and nails
• Inspect scalp hair and nails. Evaluate skin turgor.
Observe skin lesion, assess wound.

29. CONT….
• Chest
• Inspect and palpate breast, inspect and auscultation
lungs, auscultate heart.
• Abdomen
• Inspect, auscultation, and palpate four quadrants.
Palpate and percusses liver, stomach, and blader,
bowel elimination.
• Genitalia
• Inspect male and female accordingly.
• Extremities
• Palpate arterial pulses, observe capillary refill,
evaluate edema, assess joint mobility, assess sensory
function assess circulation

30. BODY SYSTEM APPROACH-EXAMINE ALL
THE BODY SYSTEM
• General presentation of symptoms- fever, chills,
malaise, pain, sleep pattern, fatigability.
• Diet – appetite, like , dislikes, restrictions,
• Skin hair and nails- rash or irruption, itching,
color or texture change, excessive sweating,
abnormal nail.
• Musculoskeletal- Joint stiffness, pain, restricted
motion, swelling, redness, heat, deformity.
• Head and neck- Eyes, Ears, Nose, Throat
Mouth

31. • CONT…
• Chest and lungs-
• Heart and blood vessels-
• Gastrointestinal-
• Genitourinary-
• Neurological-
• Psychiatric-.

32. REVIEW OF SYSTEM APPROACH-
EXAMINE ONLY PARTICULAR AREA
AFFECTED
• To conduct examination in this approach
nurse uses techniques of
• 1) Inspection
•2) Auscultation,
•3) Palpation,
•4) Percussion.

33. Inspection,
• During inspection, the examiner observes:
• External signs: Body features and
symmetry appearance
• Nutritional state or weight, Skin color,
Frequency and volume of breaths
during respiration, Movement of
the abdomen and each side of
the chest during respiration, Hair
distribution
• divercation of recti muscle.

34. AUSCULTATION
• Auscultation is Examining the
internal organs by listening to the
sounds that they give out, usually
using a stethoscope.
• Electronic stethoscopes
• Auscultogram-
• Immediate auscultation
• Mediate auscultation
• Doppler auscultation

35. PALPATION
• Palpation: - Examination of organ by
touches or pressure of the hand over the
part , a process of feeling an object in or
on the body to determine its size, shape,
firmness, or location.
• Manual palpation
• Virtual palpation
• Computerized palpation
• Palpation under general anesthesia

36. PERCUSSION
• Tapping with the fingers or with a light
hammer upon any part of the body.
• There are four types of percussion
sounds:
• Hyper resonant
• Normal resonance
• Impaired resonance
• Dull
• Stony dull

37. SOURCES OF DATA
•Sources of data are primary
and secondary.
•Client
•Support people
•Client Records

38. COMPONENTS OF A NURSING HEALTH HISTORY
• Biographic data
• Reason for visit/Chief complaint
• History of present illness
• Past Health History
• Family History
• Review of systems
• Lifestyle
• Social data
• Psychological data
• Pattern of health care

39. VALIDATING DATA
• The information gathered during
assessment phase must be
complete, factual, and accurate
because the nursing diagnoses and
interventions are based on this
information.
• Validation is double checking or
verifying the data is accurate and
factual.

40. ORGANIZATION OF DATA
• It uses a written or computerized format
that organizes data systematically according
to priority of needs.
DOCUMENTING DATA
• Record in a factual manner
• Eg. Data in factual manner Wrong manner
• Slice of toast – I Appetite is good”
• Egg - I “normal appetite”
• Juice - 250ml.
• Coffee- 240ml.

41. THANKS FOR
YOUR PATIENCE
ANY
?