The document provides guidance on conducting a comprehensive health assessment, including collecting a health history and performing a physical examination. It describes the components of a health history, such as biographical data, chief complaints, past and family medical history, functional status, and psychosocial factors. The document also offers best practices for preparing the patient and environment for the assessment and using effective communication techniques.

1. HEALTH
ASSESSMENT By,
Mr. Aby Thankachan, M.Sc(N), Ph.D (N), PGDSH, RN, RM
Asst . Professor , Dept. of Medical Surgical Nursing
Hindusthan College of Nursing, Coimbatore

2. HEALTH
ASSESSMENT

3. INTRODUCTION
• The nurse is in a unique
position to determine each
patient’s current health
status, distinguish
variations from the normal,
& recognize improvements
or deteriorations in his or

4. • Conducting a health
assessment involves collecting,
validating, and analyzing
subjective data (symptoms) and
objective data (signs) to
determine the patient's overall
level of physical, psychological,
sociocultural, developmental,

5. • Subjective data are based on
patient experiences and
perceptions, are known only by
the patient (e.g., pain and
nausea), and are reported by
the patient.
• Objective data are measurable
and are directly observed or

6. HEALTH ASSESSMENT
• Nursing health assessment involves
gathering information about the
status of the patient.
• The nurse then evaluates and
synthesizes the information (data).
• The nurse plans appropriate nursing
interventions based on this data and
evaluates patient care outcomes to
deliver the best possible care for

7. • A health assessment includes a
health history and a physical
assessment.
• A Health history / History
collection is a collection of
subjective information that
provides information about the
patient's health status.
• Physical assessment is a collection

8. • A health assessment may be
comprehensive, ongoing partial,
focused, or emergency.
• A comprehensive health assessment is
broad and includes a complete health
history and physical assessment.
• A comprehensive assessment is usually
conducted when a patient first enters a
health care setting, with information

9. • An ongoing partial health
assessment, or follow-up assessment,

10. • A focused health assessment is
conducted to assess a specific problem.
• For example, if a woman is having
abdominal pain, the nurse asks questions
questions about urinary problems, bowel
problems, allergies, and menstrual history
during the health history and then
assesses vital signs and abdominal
structures during the physical
assessment.
• Focused assessments may also be used to

11. • An emergency health assessment is
a type of rapid focused assessment
conducted when addressing a life-
threatening or unstable situation.
• Assessment of the airway, breathing,

12. Purposes
• Health assessment allows the nurse to focus
on person's health status and abilities to
perform tasks.
• It helps in detecting any related loss of
function or change in the ability to
function.
• Accurate health assessment provides the
foundation for therapeutic nursing care.

13. • Assessments are used to plan, implement,
and evaluate teaching and care to promote
an optimal level of health through
interventions to prevent illness, restore
health, and facilitate coping with disabilities

14. Lifespan Considerations
• A comprehensive assessment includes
cognitive (Eg: thinking, reasoning,
remembering, etc.), psychosocial, and
emotional development in addition to
physical growth.
• The nurse should identify growth and
development patterns from infancy
through adolescence, adulthood, and

15. HEALTH
HISTORY AND
DIMENSIONS
OF HEALTH

19. Cultural Considerations and Sensitivity
• Each person is a unique individual.
• Nurses must consider patients within the
context of family, culture, and community.
• Nurses and other health care professionals
need to provide health care services in a
sensitive, knowledgeable, and non-
judgmental manner with respect for people's
health beliefs and practices when they are
different than those of the care provider.
• Nurses should know risk factors for
alterations in health that are based on cultural
backgrounds, as well as normal variations
that occur within cultures.
• In addition, it is important to consider how

20. Patient Preparation
• When conducting a nursing health assessment,
it is important to consider and remain sensitive
to the patient's physiologic needs (e.g., pain
or decreased stamina because of age or illness)
and psychological needs (e.g., anxiety about
having the examination).
• Explain that the first part of the assessment
will involve questions about the patient's
health concerns, health habits, and lifestyle
and that the information will only be shared
with the patient's other health care providers.

21. • The patient may be anxious for various
reasons.
• Reassure the patient by explaining that
the assessments should not be painful.
• Explaining the assessment in general
terms can help decrease the patient's
embarrassment, fear of possible
abnormal physical findings, or fear of
"failing" a test.
• Be sure to then explain each assessment
in greater detail as it is performed.
• Explain that drapes (covers) will be used
during the examination, and only the

22. Environmental Preparation
• Privacy and respect for the patient are
primary concerns when conducting a
health assessment.
• In an outpatient setting, such as a clinic
or primary care center, separate
examnation rooms provide a quiet,
private space for assessment.
• Prepare the examination room before
the health assessment is conducted by
preparing the examination table,
providing a gown and drape for the
patient, and gathering instruments and
special supplies needed for the

23. Environmental Preparation
• If the area is open to others, an
enclosure with a curtain or screen is
essential.
• The room should be warm enough to
prevent chilling, and the area or room
should be adequately lit, either by
sunlight or overhead lighting.
• For all settings, if necessary, assist the
patient with undressing.
• Ask the patient to empty the bladder
before the examination to promote
patient comfort during the assessment

24. HEALTH HISTORY
• A health history is a collection of
data that provides a detailed profile
of the patient's health status.
• Nurses use therapeutic
communication skills and
interviewing techniques during the
health history to establish an
effective nurse-patient relationship
and to gather data to identify actual
and potential health problems as

25. • Information is collected during an
interview with the patient, who is the
primary source of data.
• The patient's family members and/or
caregivers may also be an important
source of data.
• They can sometimes offer insight that
cannot be gained from patients who
may be acutely ill, in pain,or cognitively
impaired.
• The health records of the patient, if
available, can also be used to collect
additional information.

26. • Components of the health history include
biographical data, the reason the patient is
seeking health care, present health or
history of present health concern, past
health history, family history, functional
health, psychosocial and life style factors,
and a review of systems (a series of
questions about all body systems that helps to
reveal concerns or problems as part of the
health history).
• The nurse should adapt questions to the
individual patient, omitting questions that
do not apply and adding questions that
seem pertinent, based on the setting,

27. Biographical Data
• Biographical information is factual
demographic data about the Patient.
• Depending on the health care setting, some
biographical data may be collected by people
other than the nurse.
• For example someone in the admissions
department may obtain demographic data,
including the patient's name, address, and
billing and insurance information.
• Additional biographical information includes
biological sex, age and birth date, marital
status, occupation, religious preference, and

28. Biographical Data
• Differences in language and culture
may have an effect on the quality and
safety of health care.
• Language has been identified as the
biggest barrier to health care and
appears to increase the risks to patient
safety.
• It is important to note the patient's
preferred language for discussing
health care, as well as any sensory or

30. Reason for Seeking Health Care /
Chief Complaints
• REASON FOR PRESENT
HOSPITALIZATION
• This is the information gathered when the
nurse set an agenda during the patient
centered interview.
• The reason for requesting care is a
statement in the patients own words that
describes the patient's reason for seeking
care.
• This can help to focus the rest of the
assessment.
• Nurse collects patients chief concerns or
problems and compare the data collected

31. Reason for Seeking Health Care /
Chief Complaints
• Ask an open-ended question, such as, "Tell me
why you are here today.
• Try to record whatever the person has to say in
the person's exact words.
• For example, if Deepika comes into the clinic and
tells you "I am having trouble sleeping. At
night, I can't seem to stop my thoughts. All I
do is worry,“
• It is important to document the patient's own
words.
• It would be incorrect to document the
following: "Patient complains of insomnia and
anxiety"

32. Present Medical History / History or
Present Health Concern
• When taking the patient's history of
present health concern, be sure to explore
the symptoms thoroughly.
• Encourage the patient to describe and
explain any symptoms.
• The description should include
information regarding the onset of the
problem, location, duration, intensity,
quality/description,

33. • Location - Where is the symptom located?
• Onset and duration - When did it start?
How long has it lasted?
• Precipitating factors - What makes
symptoms worse? Are there activities (e.g.
exercise) that affect the symptoms?
• Relieving factors -What does the patient do
to become more comfortable or relieve the
symptoms?
• Quality - Have the patient describe what
the symptom feels like.
• Severity - Have the patient rate the severity
on a scale of 0 to 10.
• Concomitant symptoms- Does the patient
experience other symptoms along with the

34. Examples of Appropriate questions
• When did you first begin having this
problem?
• Did it happen suddenly or slowly?
• Show me exactly where you are
having this problem?
• What other symptoms have you had
with this problem?
• How have you treated this problem?

35. Past Health History
• A patient's past health history may provide insight into
causes of current symptoms.
• It also alerts the nurse to certain risk factors.
• A past health history includes childhood and adult
illnesses, chronic health problems and treatment,
and previous surgeries or hospitalizations.
• This history should also include accidents or injuries,
obstetric history, allergies, and the date of most recent
immunizations.
• Ask the patient about health maintenance screenings,
such as routine mammograms and colorectal tests,
including dates and results, as well as the use of
safety measures.

36. Examples of Appropriate questions
• Tell me about the childhood illnesses, such
as measles or mumps, that you had.
• What are you allergic to?
• Describe any accidents, injuries, and
surgeries you have had ?
• What prescribed or over-the-counter
medications do you use?
• Do you take any herbal or dietary
supplements?
• What is the date of your most recent

37. Family History
• Information about a person's family
history will provide information about
diseases and conditions for which an
individual patient may be at increased
risk.
• Certain disorders have genetic links.
• For example, a family history of
cancer is a risk factor for cancer.
• Information regarding contact with
family members with communicable

38. • It would be important to note that a
family member had recently recovered
from pertussis (whooping cough),
especially if the patient is presented
with respiratory symptoms.
• This information can also identify
important topics for health teaching
and counseling.
• For example, if a child with asthma is
living in a household with family
members who smoke, the child is at
great risk for exacerbations of the
disease.

39. • How old are the members of
your family?
• If any members of your family
are not living, what caused
their death?
• Is there any history of this
health problem you have in
other family members?
Qns

40. Functional Health Assessment
• A functional health assessment
focuses on the effects of health or
illness on a patient's quality of life,
including the strengths of the patient
and areas that need to improve.
• Assess the patient's ability to
perform activities of daily living
(ADLs) or self-care activities.
Eating, bathing, dressing, and

41. • "Do you have difficulty or require assistance
with bathing or dressing?"
• "Do you have difficulty or require assistance
with toileting or moving around?"
• "Do you have difficulty or require assistance
with eating or preparing meals?"
• "Do you have difficulty or require assistance
with shopping or administering your own
medications?"
• *Tell me about your driving. Who provides
transportation?"
• "Do you have difficulty or require assistance
with housekeeping, finances, or laundry?"
Qns

42. Psychosocial & Lifestyle Factors
• A patient's lifestyle contributes to his or her
overall health and well-being.
• For example, smoking is related to many
health problems.
• Discussion of one or more of these topics
may cause strong personal reactions by a
patient.
• It is very important to be nonjudgmental and
explain why you need to know certain
information.
• Consider assessing these factors at the end
of the interview, because these issues may
naturally arise during the review of systems.
• Also, a trusting relationship has been

43. • Ask about the patient's social support and network
of available assistance.
• Ask about confidants, skillful supporters, and
people that are able to help the patient to cope with
any health alteration, illness, or other change.
• Support provided by caregivers, family, friends, and
social organizations can ensure that a patient's
recovery is more successful and prevent
complications in the future.
• Ask about the patient's level of activity and exercise,
sleep and rest, and nutrition.
• Obtain information related to the patient's
interpersonal relationships and resources; values,
beliefs, and spiritual resources; self-esteem and
self-concept: and coping and stress management.