This document provides an overview of concepts related to health assessment. It defines key terms like health, assessment, data collection and diagnosis. It discusses the need for health assessment in general nursing practice and identifies different types of health assessments like initial, problem-focused, emergency and time-lapsed assessments. The document also provides examples of documenting a health assessment using a problem-oriented approach.

1. INTRODUCTION TO HEALTH
ASSESSMENT CONCEPTS
UNIT-1
Ms. Gulshan Umbreen
Lecturer, SNC
PhD Scholar (Epidemiology & Public Health

2. UNIT OBJECTIVES:
By the end of the unit, learners will be able to:
• Discuss the need for health assessment in general
nursing practice.
• Explain the concepts of Health, Assessment, Data
collection, and Diagnosis.
• Identify types of Health Assessments
• Document health assessment data using a
Problem Oriented Approach.

3. INTRODUCTION TO HEALTH
ASSESSMENT
• 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.

4. Cont......
• Each level of prevention is based on a thorough
assessment of the client's health as status.
• Periodic health assessment needed to be
performed by a physician, or a nurse

5. NEED FOR HEALTH ASSESSMENT IN GENERAL
NURSING PRACTICE
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.

6. Cont....
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.
6. Health assessment helps the nurse to diagnose
client’s problem & the intervention

7. Cont....
7. Complete health assessment involves a more
detailed review of client’s condition
8. Health assessment influence the choice of
therapies & client's responses

8. Explain the concepts of Health, Assessment,
Data collection, and Diagnosis.

9. HEALTH
• The condition of being sound in body, mind,
or spirit; especially freedom from physical
disease or pain
According to “WHO”
Health is a state of complete physical, mental
and social well-being and not merely the
absence of disease or infirmity.

10. ASSESSMENT:
• Assessment is defined as “The systematic
collection of all data and information
relevant to the care of patients, their
problems, and needs” (Taber’s, 2009).
or
Is the first step to determine heath status. It is
gathering of information to have all the
“necessary puzzle pieces” to make a clear
picture of the person's health status

11. Cont...
• Assessment: The most critical step
• Answers the questions: “What is happening?”
(actual problem), or
“What could happen?” (potential problem)
• Involves collecting, organizing, and analysing
information/data about the patient.

12.  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

13. Cont....
• Data Collection:
• Data collection is defined as the ongoing
systematic collection, analysis, and
interpretation of health data necessary for
designing, implementing, and evaluating public
health prevention programs.

14. Data Collection: A Holistic Approach
Types of data
• Subjective: “Symptoms” that the patient
describes; e.g. “I can’t do anything for
myself”
Objective: Signs that can be observed,
measured, and verified; e.g. swollen joints

15. Cont....
Sources of data
Primary: The patient; is always the best
source
Secondary: Everything/everybody else.

16. Cont....
• Diagnosis:
Nursing diagnose is independent role of the
nurse.
Nursing diagnoses depends on the client's
problems/response associated with specific
disorder

17. Nursing Diagnosis
• A statement that describes a specific human
response to an actual or potential health
problem that requires nursing intervention.
• A nursing diagnosis is a clinical judgment about
individuals, families, or communities and their
responses to actual and/or potential health
problems or life processes (NANDA
International, 2007).

18. Potentials for Nursing Diagnosis
• Safety
– Confusion
– History of falls
• Skin integrity
– Immobility
• Pain
– Fractured hip

19. Building A Nursing Diagnosis:
1. PROBLEM
2. ETIOLOGY
3. SYMPTOMS

20. PES:
PROBLEM
P – At risk for impaired skin integrity
RELATED TO (R/T)
E – Immobilization
AS EVIDENCED BY (AEB)
S – Bed rest and traction

21. Nursing Diagnosis Statement
• Potential for skin breakdown related to
immobility as evidenced by bed rest and
traction

22. Cont....
• Another Nursing Diagnosis Statement
• Pain related to fractured hip as evidenced by
patient states pain level 8/10.

23. ASSESSMENT
Is the systematic and continuous:
• Collection
• Organization
– Validation
• Documentation Of Data.

24. Collection of Data
• Gathering Of Information About The Client
• Includes Physical, Psychological, Emotion, Socio-cultural,
Spiritual Factors That May Affect Client’s Health Status
 Includes Past Health History Of Client (Allergies, Past
Surgeries, Chronic Diseases).
 Includes Current/Present Problems Of Client (Pain,
Nausea, Sleep Pattern, Religious Practices, Medication Or
Treatment The Client Is Taking Now)

25. Data Collection Methods
1. Observing: to observe is to gather data by using
the senses.
2. Interviewing: an interview is a planned
communication or conversation with a purpose.
3. Examining: Performance of a physical
examination. The physical examination is often
guided by data provided by the patient.

26. • A head-to-toe approach is frequently used
to provide systematic approach that helps
to avoid omitting important data

27. VALIDATING DATA
 The information gathered during the
assessment phase must be complete, factual,
and accurate because the nursing diagnosis and
interventions are based on this information.
 Validation is the act of "double-checking" or
verifying data to confirm that it is accurate and
factual.

28. Purposes of Data Validation
• Ensure that data collection is complete
• Ensure that objective and subjective data agree
• Obtain additional data that may have been
overlooked
• Avoid jumping to conclusion

29. Data Requiring Validation
Not every piece of data you collect must be
verified.
For example:
you would not need to verify or repeat the client’s
pulse, temperature, or blood pressure unless
certain conditions exist. Conditions that require
data to be rechecked and validated include:

30. • Discrepancies or gaps between the subjective
and objective data. For example, a male client
tells you that he is very happy despite learning
that he has terminal cancer.

31. Data Requiring Validation
• Discrepancies or gaps between what the client says at
one time and then another time. For example, your
female patient says she has never had surgery, but
later in the interview she mentions that her appendix
was removed at a military hospital when she was in
the navy

32. –Findings those are very abnormal and
inconsistent with other findings. For
example, the client has a temperature of
104
o
F degree. The client is resting
comfortably. The client’s skin is warm to
touch.

33. METHODS OF VALIDATION
• Recheck your own data through a repeat
assessment.
• For example, take the client’s temperature again
with a different thermometer.
• Clarify data with the client by asking additional
questions.
• For example: if a client is holding his abdomen

34. • The nurse may assume he is having abdominal
pain, when actually the client is very upset about
his diagnosis and is feeling.

35. »Verify the data with another health care
professional. For example, ask a more
experienced nurse to listen to the abnormal
heart sounds you think you have just heard.
»Compare you objective findings with your
subjective findings to uncover discrepancies.

36. • For example, if the client state that she “never
gets any time in the sun” yet has dark,
wrinkled, suntanned skin, you need to validate
the client’s perception of never getting any
time in the sun

37. ORGANIZING DATA
The nurse uses a written or computerized format
that organizes the assessment data
systematically. The format may be modified
according to the client's physical status.

38. Documenting Data
• To complete the assessment phase, the nurse
records client's data.
• Accurate documentation is essential and should
include all data collected about the client's health
status. Data are recorded in a factual manner and
not interpreted by the nurse.
E.g.: the nurse record the client's breakfast
intake as" coffee 240 mL. Juice 120 mL, 1 egg".
Rather than as "appetite good".

39. Purposes of documentation
• Provides a chronological source of client assessment
data and a progressive record of assessment findings
that outline the client’s course of care.
• Ensures that information about the client and family
is easily accessible to members of the health care
team; provides a vehicle for communication; and
prevents fragmentation, repetition, and delays in
carrying out the plan of care.
• Acts as a source of information to help diagnose new
problems.

40. Guidelines for documentation
• Document legibly or print neatly in unerasable ink
• Use correct grammar and spelling
• Use only abbreviations that are acceptable and
approved by the institution
• Avoid wordiness that creates redundancy
• For example, do not record: “Auscultated gurgly
bowel sounds in right upper, right lower, left upper,
and left lower abdominal quadrants. Heard 36 gurgles
per minute.” Instead record:
• “Bowel sounds present in all quadrants at
36/minute.”

41. • Use phrases instead of sentences to record data
• For example, avoid recording: “The client’s lung
sounds were clear both in the right and left lungs.”
Instead record:
“Bilateral lung sounds clear.”
• Record data findings, not how they were obtained
For example, do not record: “Client was interviewed
for past history of high blood pressure, and blood
pressure was taken.” Instead record: “Has 3-year history
of hypertension treated with medication. BP sitting right
arm 140/86

42. • Write entries objectively without making
premature judgments or diagnosis
Use quotation marks to identify clearly the client’s
responses. For example, record: “Client crying in
room, refuses to talk, husband has gone home”
instead of “Client depressed due to fear of breast
biopsy report and not getting along well with
husband.”

43. • Avoid recording the word “normal” for normal
findings
For example, do not record: “Liver palpation normal.”
Instead record: “Liver span 10 cm in right MCL and 4
cm in MSL. No tenderness on palpation.”
• Record complete information and details for all client
symptoms or experiences
For example, do not record: "Client has pain in lower
back.” Instead record: “Client reports aching-burning pain
in lower back for 2 weeks. Pain worsens after standing for
several hours. Rest and ibuprofen used to take edge off
pain.

44. • Include additional assessment content when
applicable(e.g., include information about the
caregiver or last physician contact).
• Support objective data with specific observations
obtained during the physical examination
• For example, when describing the emotional
status of the client as depressed, follow it with a
description of the ways depression is
demonstrated such as “dressed in dirty clothing,
avoids eye contact, unkempt appearance, and
slumped shoulders.”

47. TYPES OF ASSESSMENT
Focus
Assessment
Initial
Assessment
Time-lapsed
Assessment
Emergency
Assessment
Assessment

48. INITIAL COMPREHENSIVE
ASSESSMENT
An initial assessment, also called an admission
assessment, is performed when the client enters a
health care from a health care agency.
• 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.

49. PROBLEM-FOCUSED ASSESSMENT
A problem focus 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).

50. • This assessment also includes the appraisal
of any new, overlooked, or misdiagnosed
problems. In intensive care units, may
perform focus assessment every few minute.

51. EMERGENCYASSESSMENT
Emergency assessment 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).
Emergency assessment focuses on few essential
health patterns and is not comprehensive

52. Time-lapsed assessment or Ongoing
assessment
• Time lapsed reassessment, another type of
assessment, 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

53. • (e.g., periodic output patient clinic visits,
home health visits, health and
development screenings)

54. Frequency of assessment
• The persons under (35) years every (4-5) years.
• The persons from (35-45) every (2-3) years.
• Persons from (45-55) years of age undergo a
thorough health assessment every year.
• Persons over (55) years may needs assessment
every 6 months or less.
54

55. HEALTH ASSESSMENT
• Two components of the health assessment
– Health History
– Physical Assessment

56. Methods of Assessment
• The Primary Methods are
• Observing
• Interviewing
• Examining

57. Document health assessment data using a
Problem Oriented Approach.
Health History:
• 8/25/12 11:00 am
• Mrs. N is a pleasant, 54-year-old widowed
saleswoman residing in Karachi
• Referral. None
• Source and Reliability. Self-referred; seems
reliable.
• Chief Complaint: “My head aches.”

58. Cont…
• Present Illness:
For about 3 months, Mrs. N has had increasing
problems with frontal headaches. These are usually
bifrontal, throbbing, and mild to moderately severe.
She has missed work on several occasions because of
associated nausea and vomiting. Headaches now
average once a week, usually are related to stress,
and last 4 to 6 hours.

59. • They are relieved by sleep and putting a damp
towel over the forehead. There is little relief
from aspirin. No associated visual changes,
motor-sensory deficits, or paresthesias.
• She thinks her headaches may be like those in
the past but wants to be sure, because her
mother died following a stroke.

60. • She is concerned that they interfere with her
work and make her irritable with her family.
She eats three meals a day and drinks three
cups of coffee a day and tea at night.
• Medications. Aspirin, 1 to 2 tablets every 4 to
6 hours as needed. “Water pill” in the past for
ankle swelling, none recently.
• *Allergies. Ampicillin causes rash.
• Tobacco. About 1 pack of cigarettes per day
since age 18 (36 pack-years).
• Alcohol/drugs. No illicit drugs.

61. Past History:
• Childhood Illnesses. Measles, chickenpox. No
scarlet fever or rheumatic fever.
• Adult Illnesses. Medical: Pyelonephritis, 1998,
with fever and right flank pain; treated with
ampicillin; developed generalized rash with
itching several days later. Reports x-rays were
normal; no recurrence of infection.
• Surgical: Tonsillectomy, age 6; appendectomy,
age 13. Sutures for laceration, 2001, after
stepping on glass.

62. • Ob/Gyn: 3-3-0-3, with normal vaginal deliveries.
Three living children. Menarche age 12. Last
menses 6 months ago. Little interest in sex, and
not sexually active. No concerns about HIV
infection.
• Psychiatric: None.
• Health Maintenance. Immunizations: Oral polio
vaccine, year uncertain; tetanus shots × 2, 1991,
followed with booster 1 year later; flue vaccine,
2000, no reaction.
• Screening tests: Last Pap smear, 2008, normal.
No mammograms to date.

63. • Family History:
• Father died at age 43 in train accident. Mother
died at age 67 from stroke; had varicose veins,
headaches.
• One brother, 61, with hypertension, otherwise
well; second brother, 58, well except for mild
arthritis; one sister, died in infancy of unknown
cause.
• Husband died at age 54 of heart attack.
• Daughter, 33, with migraine headaches, otherwise
well; son, 31, with headaches; son, 27, well.
• No family history of diabetes, tuberculosis, heart
or kidney disease, cancer anemia, epilepsy, or
mental illness.

64. • Personal and Social History: Born and
raised in Las Cruces, finished high school,
married at age 19. Worked as sales clerk for
2 years, then moved with husband to
Islamabad had 3 children. Returned to work
15 years ago because of financial pressures.
Children all married. Four years ago, Mr. N
died suddenly of a heart attack, leaving little
savings. Mrs. N has moved to small
apartment to be near her daughter, Isabel.
Isabel’s husband, John, has an alcohol
problem.

65. Cont…
• Exercise and diet. Gets little exercise. Diet
high in carbohydrates. Safety measures. Uses
seat belt regularly. Uses sunblock. Medications
kept in an unlocked medicine cabinet. Cleaning
solutions in unlocked cabinet below sink. Mr.
N’s shotgun and box of shells in unlocked
closet upstairs.

66. • Review of Systems:
• General. *Has gained about 10 lbs in the past 4
years.
• Skin. No rashes or other changes.
• Head, Eyes, Ears, Nose, Throat (HEENT).
See Present Illness. No history of head injury.
Eyes: Reading glasses for 5 years, last checked 1
year ago. No symptoms.
• Ears: Hearing good. No tinnitus, vertigo,
infections.
Bickly, L. S. (2012).

67. • Nose, sinuses: Occasional mild cold. No hay
fever, sinus trouble.
• Throat (or mouth and pharynx): Some bleeding
of gums recently. Last dental visit 2 years ago.
Occasional canker sore.
• Neck. No lumps, goiter, pain. No swollen glands.
• Breasts. No lumps, pain, discharge. Does breast
self-exam sporadically.
• Respiratory. No cough, wheezing, shortness of
breath. Last chest x-ray, 1986, St. Vincent’s
Hospital; unremarkable.

68. • Cardiovascular. No known heart disease or
high blood pressure; last blood pressure taken in
2006. No dyspnea, orthopnea, chest pain,
palpitations. Has never had an
electrocardiogram (ECG).
• Gastrointestinal. Appetite good; no nausea,
vomiting, indigestion. Bowel movement about
once daily, *though sometimes has hard stools
for 2 to 3 days. when especially tense; no
diarrhea or bleeding. No pain, jaundice,
gallbladder or liver.

69. • Urinary. No frequency, dysuria, hematuria, or recent
flank pain; nocturia × 1, large volume. *Occasionally
loses some urine when coughs hard.
• Genital. No vaginal or pelvic infections. No
dyspareunia.
• Peripheral Vascular. Varicose veins appeared in both
legs during first pregnancy.
• For 10 years, has had swollen ankles after prolonged
standing; wears light elastic pantyhose; tried “water
pill” 5 months ago, but it didn’t help much; no history
of phlebitis or leg pain.

70. • Musculoskeletal. Mild, aching, low back pain,
often after a long day’s work; no radiation down
the legs; used to do back exercises but not now.
No other joint pain.
• Psychiatric. No history of depression or
treatment for psychiatric disorders. See also
Present Illness and Personal and Social History.
• Neurologic. No fainting, seizures, motor or
sensory loss. Memory good.

71. • Hematologic. Except for bleeding gums, no
easy bleeding. No anemia.
• Endocrine. No known thyroid trouble,
temperature intolerance. Sweating average. No
symptoms or history of diabetes.

72. Physical Examination:
• Mrs. N is a short, overweight, middle-aged
woman, who is animated and responds quickly to
questions. She is somewhat tense, with moist,
cold hands. Her hair is well-groomed. Her color is
good, and she lies flat without discomfort.
• Vital Signs. Ht (without shoes) 157 cm (5′2″ ). Wt
(dressed) 65 kg (143 lb). BMI 26. BP 164/98 right
arm, supine; 160/96 left arm, supine; 152/88 right
arm, supine with wide cuff. Heart rate (HR) 88
and regular. Respiratory rate (RR) 18.
Temperature (oral) 98.6°F.

73. References:
• Bickly, L. S. (2017). Bates’Guide to
Physical Examination and History
Taking (12th ed). Philadelphia: J. B.
Lippincott.
• Thompson B. (1991). Clinical manual of
health assessment (4th ed). St. Louis:
Mosby.
• Weber, J. R. (2001). Nurses handbook of
health assessment (4th ed). Philadelphia:
J. B. Lippincott.