The document provides information on conducting a health assessment, including definitions of key terms, the purposes and types of assessments, frameworks for organizing assessment data, and the components and process of a health assessment. It describes taking a health history to collect subjective data on the client's biographic information, chief complaints, history of present illness, past medical history, family history, lifestyle, and obstetric history if applicable. It also covers preparing for and conducting a physical examination as the objective part of a health assessment.

1. HEALTH ASSESSMENT
Prepared By;Mr.Mihir Patel
Lecturer,JCN,Bhandu

2. Terminology
Health
It is a state of complete physical, mental and social well being and not merely the
absence of disease or infirmity.
Assessment
It is a systematic and deliberate process of gathering the information
regarding client’s health.
Diagnosis
It is the determination of the nature and extent of a disease.
Prognosis
It is the forecast of the course and duration of a disease.
Etiology/Cause
It is the science of the cause of a disease.
Tachycardia
Heart rate more than the normal is known as tachycardia.
Bradycardia
Heart rate less than the normal is known as bradycardia.

3. Cont…
Health Assessment
Health assessment is collecting data about client’s health
status. Health assessment is very important in any health care
setting. The two components of a health assessment are
health history and Physical assessment.
OR
It is a detailed study of the entire body in order
to determine the general or mental condition of
the body.

4. Purposes of Health Assessment
 To get a clear picture of the client’s health status and
health related problems.
 To collect data about physical, mental and social well being of
client.
 To evaluate the changes in client’s health status.
 To determine the nature of treatment required for client.
 To contribute in medical research.
 To compare the client’s state of health with ideal state.
 To determine the cause and extent of disease.

5. Types of Health Assessment
A health assessment may be comprehensive, ongoing, partial, focused or
emergency.
1.Comprehensive Health Assessment (CHA)
CHA includes health history and complete physical examination and is
usually done when a client enters health care setting. It provides a
baseline for comparing later Assessments.
2.Ongoing Partial Assessment (OPA)
OPA is one that is conducted at regular intervals during the care of the
client. This types of assessment focused on identified health problems to
monitor positive or negative changes and evaluate the effectiveness of
intervention.

6. Cont…
3.A Focused Assessment
It is conducted to assess a specific health problem.
4.An Emergency Assessment
It is a type of rapid focused assessment conducted to
determine potentially fatal situations.

7. Frameworks for Health Assessment
There are three major frameworks for organizing assessment data are;
 Functional Health Framework
 Head to toe Framework
 Body systems Framework
Functional Health Framework
It evaluates the effects of mind, body and environment in relation to a
person’s ability to perform the tasks of daily living.
Head to toe Framework
It is a system for collecting data in an organized manner starting from
the head and proceeding systematically downwards to the toe. It is also
known as cephalocaudal framework.
Body System Framework
It focuses on the pathophysiology involved within the specific body
system also known as system wise framework.

8. Conducting a Health Assessment
Reviewing General Information
It is good to collect some general information about the client
using secondary data sources. Primary data collected from
primary sources.
Consideration of the culture
Cultural sensitivity is important when conducting a health
assessment.
Preparation of Client
The Client’s physiological and psychological needs should
be considered before and during the health assessment. The
nurse should explain to the client about the process and what
to expect during assessment. This will help to reduce the
Anxiety and will make the client comfortable.

9. Cont..
Preparation of the Environment
The environment may be comfortable or both nurse and the client. A
warm, quiet well lit room is ideal. All the needed equipment in full
functional capacity must be available. Provide privacy,confidentiallity
must be ensured.
Organizing and Documenting
Document pertinent information obtained during the interview.
Introduction to the Client. The nurse must introduce herself/himself
before starting the interview.
Health History
It is a collection of Subjective data that provides a detailed profile of the
client’s health status.Throughut the interview the nurse must evaluate
his/her verbal and nonverbal message.

10. Component of Health Assessment
The two components of a health assessment are health history and
Physical assessment.
Health Assessment
Health History Physical
Examination

11. HEALTH HISTORY
During the interview obtain information about the client’s health
history and family health history.
Health History: A health history is a collection of subjective data that
provides a detailed profile of the client health status. History Taking
includes;
1.Biographic Data
Name,Address,Gender,Age,Marrital Status, Occupation,
Religious, income, Primary health Care Provider,
Educational qualification etc…
Others: Patient's Name, Age,Sex,Hospital Name
File No./MLC No., Source providing history, Date/ Time
of admission, OPD No.IPD No., Ward, Bed No., Doctor's Unit,
Provisional Diagnosis, Surgery done/Date of Surgery Name of
the Surgery, Residential Address Mother Tongue, Marital Status,
Educational Status, Occupation, Monthly income.

12. Cont…
2.Chief Complaints
Document in client’s own wards. It is the brief statement of client’s
problem for which client seeks medical care.
 It should be written in client’s statement.
 In case of multiple problems indicate priority of complaints.
 Write problems in chronological order.
3.History Related to Present Illness
Onset, signs and symptoms,duration,treatment taken if any for the
same. Other complaints such as loss of appetite,insomia,disorders of
stomach etc.. Also should be found out.
Note: Include Location,Quality,Quantity,Chronolgy,Setting,Associate
symptoms and relieving factors.

13. Cont…
4.Past Medical History
It is the collecting information regarding client’s previous health
experience with any disease,surgery.Childhood illness,allergey,mental
disease,accident,injury,surgery,herbal or dietary supplements.
Note:Allergy,Medical disease,Surgery,trauma,Injury,Childhood disease.
5.Family History Ramilaben
64 Years
Hypertension
Ashokbhai
66 Years

14. Cont…
H & L
Male
Female
Present Client
Healthy and Living
Death
Sex Unknown

15. Cont…
Information about all family members (Father,Mother,Grandparents,
Brothers and Sister) Living or dead, Cause of death (If death) condition
of their health(If Living) family history of any illness e.g. Diabetes
mellitus, Cancer, heart diseases etc..
6.Life style/High risk behavior
Smoking, alcoholism, substance abuse. if yes, how much and since
when? Food habits, like and dislikes, pattern of sleep,excersice pattern
And health care facility.

16. Cont…
7.Obstetrical History
Menstrual history, history of pregnancy and their complications, if any
history of dead or alive children etc..