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Nursing Health Assessment
Assessment is refers to systematic
appraisal of all factors relevant to a
client’s health.
Health Assessment components
•Nursing Health History
•Physical Examination
•Records & reports
•Review of lab & diagnostic test results
Nursing Health Assessment
Nursing Health Assessment
Nursing Health Assessment
Nursing Health Assessment
Nursing Health Assessment
Nursing Health Assessment
Nursing Health Assessment
Nursing Health Assessment
Nursing Health History
Through the health history, the nurse elicits a
 detailed, accurate, and chronologic health record as
 seen from the client’s perspective.

Data collection techniques
 Provide privacy and comfort for the patient
 Greet the client and introduce yourself
 Establish a verbal contract with the client that
  delineates the purpose of the history taking
  session, the client role , and a time limit for the
  interview
 Ask open- ended questions  how may I help you
Components of Nursing History
1.Biographical Data

 Date & Time
 Client’s name, address, telephone #, social ID#.
 Name , address, telephone#, of person to contact if
    emergency or other situation.
   Gender ,race, ethnic origin, religious preference.
   Age , birth date, birth place, and marital status.
   Occupation and level of education
   Health insurance
2. Chief complaints
Identify the client reason for seeking health care.
 A brief statement (client own words) for the current
  problem.
 A description of onset and duration of problem
Present Health History
The history of present health concern or illness is the
  single most important factor in helping the health care
  team to arrive at a diagnosis or determine the person
  needs
 A detailed chronologic statement of the
  problem, beginning with when the client last felt well
  and ending with a description of the current condition.
Past Health History
A detailed summary of the person’s past health is an
  important part of the database.
 Immunization status
 Known allergies
 Childhood illness
 Adult illness
 Psychiatry illness
 Injuries – burns, fractures, head injuries
 Hospitalization
 Surgical and diagnostic procedures
 Medication history
 Use of alcohol and other drugs.
Family History
 Cancer
 Hypertension
 Heart disease
 Diabetes
 Epilepsy
 Mental illness
 Tuberculosis
 Kidney disease
 Arthritis
 Asthma
 Alcoholism
 obesity
Review of systems
Subjective information about what the patient
  feels or sees with regard to major systems of
  the body
Skin
Rash, itching, change in pigmentation, or
  texture, sweating, hair growth and
  distribution, condition of nails.
Skeletal
Stiffness of joints, pain, deformity, restriction of
  motion, swelling, redness, heat.
Head
Headaches , dizziness, syncope, head injuries.
Eyes
Vision, pain, diplopia, photophobia, blind
  spots, itching, burning, discharge, recent changes
  in appearance of vision, contact lens
  , glaucoma, cataracts.
Ears
Hearing acuity, earache, discharge
  tinnitus, vertigo.
Nose
Sense of smell, frequency of
  colds, obstruction, epistaxis, sinus pain, use of
  any nasal spray.
Teeth
Pain, bleeding, swollen, extractions, dentures,.
Mouth and Tongue
Soreness of tongue or buccal
  mucosa, ulcers, swelling
Throat
Sore throat, tonsillitis, hoarseness, dysphagia.
Neck
Pain, stiffness, swelling, enlarged glands or
Endocrine
Goiter, thyroid
  tenderness, tremors, weakness, tolerance to heat and
  cold, changes in hat or glove size, changes in skin
  pigmentation, libido, bruisability, muscle
  cramps, polyuria, polydipsia, polyphagia, hormone
  therapy.
Respiratory
Pain in the chest relatioship to
  respiration, dyspnea, wheezing, cough, sputum, hem
  optysis, night sweats, last chest X-Ray, exposure to
  TB.
Cardiac
Presence of pain or distress and
  location, palpitations, Orthopnea, edema, cyanosis,
  BP, last ECG.
Hematologic
Lymph nodes
Enlargement, tenderness,
Gastrointestinal
Appetite and digestion, intolerance to certain
  classes of food.
Pain associated with hunger or
  eating, eructation, regurgitation, heartburn, na
  usea, vomiting, hematemesis.
Regularity of BM, hemorrhoids, jaundice, h/o of
  ulcer, gall stones, polyps, tumors
Genitourinary
Dysuria, urgency, frequency, hematuria, nocturia
  , polydipsia, poly uria, oliguria, edema of the
  face, hesitency , stress incontinence, passage of
  stones, h/o STD
Neuromuscular
Mental status – orientation to time
  , place, person.
Memory – recalling past medical history
Cognitive level
Patient ‘s description of personality

Preseence of
  tics, twitching, weakness, paralysis, tremor, In
  coordination, fatigue, sensory
  loss, temperature, touch, muscle
  pain, cramps.

General constitutional symptoms
Fever, chills, malaise, fatigability, recent loss or
Nursing Health Assessment
Nursing Health Assessment
PHYSICAL EXAMINATION
General principles:
 Physical examination is the second component of a complete
  Nursing health assessment.
 Examine the client in quiet, warm , well lighted room;
  consider privacy and comfort.
 Practice and adhere to standard precaution throughout
  the entire physical examination.
Assessment techniques:
 Inspection
 Auscultation
 Palpation
 percussion
Nursing Health Assessment
Assessment techniques

Palpation

 Temperature                Vibration
 Texture                    Position
 Moisture                   Size
 Organ size and location    Presence of lumps or
 Rigidity or spasticity     masses

                             Tenderness, or pain
Percussion
 Assess underlying
  structures for
  location, size, density of
  underlying organs.

 Direct – sinus tenderness

 Indirect- lung percussion

 Blunt percussion-
       organ tenderness
       (CVA tenderness)
Assessment techniques
Percussion sounds
 Flatness – bone or muscle

 Dullness – heart, liver, spleen

 Resonance – air filled lungs (hollow)

 Hyperresonance – emphysematous lung
  (hyperinflated)

 Tympany – air-filled stomach (drumlike)
Assessment techniques
Auscultation

 Listening to sounds produced by the body:
  Heart
  Blood vessels
  Lungs
  Abdomen

 Instrument: stethoscope

   Diaphragm –   high pitched sounds
   Bell –   low pitched sounds
Vital signs
Height and weight
General appearance:
Race, sex, general physical
   development, nutritional state, mental
   alertness, evidence of
   pain, restlessness, body
   posture, clothes, apparent
   age, hygiene, grooming.
Skin – observe (skin
   color, pigmentation, lesions, jaundice, c
   yanosis, scars, superficial
   vascularity, moisture, edema, color of
   mucous membrane, hair
   distribution, nails )
Palpation:
Head
Observe ( symmetry of face, configuration of skull, hair color
and distribution, scalp.
Palpation: hair texture, masses, swelling or tenderness of scalp
Eyes and Vision

Eye brows                        Normal or Absent
Eye lashes                       Infection , sty
Eye lids                         Edema, lesions, ectropian, entropian.
Eye balls                        Sunken, protruded
Conjunctiva                      Pale, red, prulent
Sclera                           Jaundiced
Cornea and iris                  Irregularities, abrasions
Pupils                           Dilated , constricted, reaction to light
Lens                             Opaque, or transferent
Fundus                           Congestion, haemorrhaig spots
Eye muscles                      Strabimus
Ears
Discharges, cerumen obstructing the ear passage, hearing acuity
Nose
Discharges, septal deviations , polyp
Mouth and pharynx
Lips
redness , swelling, cracked, cyanosis, angular stomatitis.
Odour of the mouth
foul smelling
Teeth
discolorations , dental caries.
Mucous membrane and gums
Ulceration, bleeding, swelling , pus formation.
Tongue
Pale, dry, lesions, tongue tie.
Throat and pharynx
enlarged tonsils, redness, pus
Neck
Lymph nodes: enlarged , palpable.
Thyroid glands: enlarged
ROM: Flexion, extension, and rotation
Chest
Thorax – shape, symmetry of expansion, posture
Breath Sounds: sigh , swish, rustle, wheezing, rales,
 crepitations, pleural rub.
Heart
size , location, cardiac murmur
Breast
Enlarged lymph nodes.
Abdomen
Observation : Skin
 rashes, hernia, scars, ascites, distension, pregnancy.
Auscultation: Bowel sounds, fetal Heart Sounds.
Palpation: liver margin, palpable spleen, tenderness
 , inguinal hernias.
Percussion: presence of gas, fluid or mass.
Extremities
Movements of joints, tremors, anke edema, clubbing of
 fingers, varicose veins, reflexes.
Edema
           RATING                        ASSESSMENT
             1+                5mm depth , recovers immediately
             2+                8-10 mm depth , duration 10-15 sec
             3+                   11-20mm , duration 15-30sec
             4+                    >20mm , duration >30sec
Back
 spina bifida , curves
Genitals and Rectum:
Inguinal lymph glands – enlarged , palpable
Patency of urinary meatus and rectum (infant)
Descent of testes ( Infant)
Vaginal Discharges, presence of STD,
  haemorrhoids, enlarged prostate gland,
  pelvic masses.
Neurological:
Co-ordination , reflexes, equilibrium,
  sensation
Nursing Health Assessment
Nursing Health Assessment
Nursing Health Assessment
Nursing Health Assessment

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Nursing Health Assessment

  • 2. Assessment is refers to systematic appraisal of all factors relevant to a client’s health. Health Assessment components •Nursing Health History •Physical Examination •Records & reports •Review of lab & diagnostic test results
  • 11. Nursing Health History Through the health history, the nurse elicits a detailed, accurate, and chronologic health record as seen from the client’s perspective. Data collection techniques  Provide privacy and comfort for the patient  Greet the client and introduce yourself  Establish a verbal contract with the client that delineates the purpose of the history taking session, the client role , and a time limit for the interview  Ask open- ended questions  how may I help you
  • 12. Components of Nursing History 1.Biographical Data  Date & Time  Client’s name, address, telephone #, social ID#.  Name , address, telephone#, of person to contact if emergency or other situation.  Gender ,race, ethnic origin, religious preference.  Age , birth date, birth place, and marital status.  Occupation and level of education  Health insurance
  • 13. 2. Chief complaints Identify the client reason for seeking health care.  A brief statement (client own words) for the current problem.  A description of onset and duration of problem Present Health History The history of present health concern or illness is the single most important factor in helping the health care team to arrive at a diagnosis or determine the person needs  A detailed chronologic statement of the problem, beginning with when the client last felt well and ending with a description of the current condition.
  • 14. Past Health History A detailed summary of the person’s past health is an important part of the database.  Immunization status  Known allergies  Childhood illness  Adult illness  Psychiatry illness  Injuries – burns, fractures, head injuries  Hospitalization  Surgical and diagnostic procedures  Medication history  Use of alcohol and other drugs.
  • 15. Family History  Cancer  Hypertension  Heart disease  Diabetes  Epilepsy  Mental illness  Tuberculosis  Kidney disease  Arthritis  Asthma  Alcoholism  obesity
  • 16. Review of systems Subjective information about what the patient feels or sees with regard to major systems of the body Skin Rash, itching, change in pigmentation, or texture, sweating, hair growth and distribution, condition of nails. Skeletal Stiffness of joints, pain, deformity, restriction of motion, swelling, redness, heat. Head Headaches , dizziness, syncope, head injuries. Eyes Vision, pain, diplopia, photophobia, blind spots, itching, burning, discharge, recent changes in appearance of vision, contact lens , glaucoma, cataracts.
  • 17. Ears Hearing acuity, earache, discharge tinnitus, vertigo. Nose Sense of smell, frequency of colds, obstruction, epistaxis, sinus pain, use of any nasal spray. Teeth Pain, bleeding, swollen, extractions, dentures,. Mouth and Tongue Soreness of tongue or buccal mucosa, ulcers, swelling Throat Sore throat, tonsillitis, hoarseness, dysphagia. Neck Pain, stiffness, swelling, enlarged glands or
  • 18. Endocrine Goiter, thyroid tenderness, tremors, weakness, tolerance to heat and cold, changes in hat or glove size, changes in skin pigmentation, libido, bruisability, muscle cramps, polyuria, polydipsia, polyphagia, hormone therapy. Respiratory Pain in the chest relatioship to respiration, dyspnea, wheezing, cough, sputum, hem optysis, night sweats, last chest X-Ray, exposure to TB. Cardiac Presence of pain or distress and location, palpitations, Orthopnea, edema, cyanosis, BP, last ECG. Hematologic
  • 19. Lymph nodes Enlargement, tenderness, Gastrointestinal Appetite and digestion, intolerance to certain classes of food. Pain associated with hunger or eating, eructation, regurgitation, heartburn, na usea, vomiting, hematemesis. Regularity of BM, hemorrhoids, jaundice, h/o of ulcer, gall stones, polyps, tumors Genitourinary Dysuria, urgency, frequency, hematuria, nocturia , polydipsia, poly uria, oliguria, edema of the face, hesitency , stress incontinence, passage of stones, h/o STD
  • 20. Neuromuscular Mental status – orientation to time , place, person. Memory – recalling past medical history Cognitive level Patient ‘s description of personality Preseence of tics, twitching, weakness, paralysis, tremor, In coordination, fatigue, sensory loss, temperature, touch, muscle pain, cramps. General constitutional symptoms Fever, chills, malaise, fatigability, recent loss or
  • 23. PHYSICAL EXAMINATION General principles:  Physical examination is the second component of a complete Nursing health assessment.  Examine the client in quiet, warm , well lighted room; consider privacy and comfort.  Practice and adhere to standard precaution throughout the entire physical examination. Assessment techniques:  Inspection  Auscultation  Palpation  percussion
  • 25. Assessment techniques Palpation  Temperature  Vibration  Texture  Position  Moisture  Size  Organ size and location  Presence of lumps or  Rigidity or spasticity masses  Tenderness, or pain
  • 26. Percussion  Assess underlying structures for location, size, density of underlying organs.  Direct – sinus tenderness  Indirect- lung percussion  Blunt percussion- organ tenderness (CVA tenderness)
  • 27. Assessment techniques Percussion sounds  Flatness – bone or muscle  Dullness – heart, liver, spleen  Resonance – air filled lungs (hollow)  Hyperresonance – emphysematous lung (hyperinflated)  Tympany – air-filled stomach (drumlike)
  • 28. Assessment techniques Auscultation  Listening to sounds produced by the body: Heart Blood vessels Lungs Abdomen  Instrument: stethoscope  Diaphragm – high pitched sounds  Bell – low pitched sounds
  • 29. Vital signs Height and weight General appearance: Race, sex, general physical development, nutritional state, mental alertness, evidence of pain, restlessness, body posture, clothes, apparent age, hygiene, grooming. Skin – observe (skin color, pigmentation, lesions, jaundice, c yanosis, scars, superficial vascularity, moisture, edema, color of mucous membrane, hair distribution, nails ) Palpation:
  • 30. Head Observe ( symmetry of face, configuration of skull, hair color and distribution, scalp. Palpation: hair texture, masses, swelling or tenderness of scalp Eyes and Vision Eye brows Normal or Absent Eye lashes Infection , sty Eye lids Edema, lesions, ectropian, entropian. Eye balls Sunken, protruded Conjunctiva Pale, red, prulent Sclera Jaundiced Cornea and iris Irregularities, abrasions Pupils Dilated , constricted, reaction to light Lens Opaque, or transferent Fundus Congestion, haemorrhaig spots Eye muscles Strabimus
  • 31. Ears Discharges, cerumen obstructing the ear passage, hearing acuity Nose Discharges, septal deviations , polyp Mouth and pharynx Lips redness , swelling, cracked, cyanosis, angular stomatitis. Odour of the mouth foul smelling Teeth discolorations , dental caries. Mucous membrane and gums Ulceration, bleeding, swelling , pus formation. Tongue Pale, dry, lesions, tongue tie. Throat and pharynx enlarged tonsils, redness, pus
  • 32. Neck Lymph nodes: enlarged , palpable. Thyroid glands: enlarged ROM: Flexion, extension, and rotation Chest Thorax – shape, symmetry of expansion, posture Breath Sounds: sigh , swish, rustle, wheezing, rales, crepitations, pleural rub. Heart size , location, cardiac murmur Breast Enlarged lymph nodes.
  • 33. Abdomen Observation : Skin rashes, hernia, scars, ascites, distension, pregnancy. Auscultation: Bowel sounds, fetal Heart Sounds. Palpation: liver margin, palpable spleen, tenderness , inguinal hernias. Percussion: presence of gas, fluid or mass. Extremities Movements of joints, tremors, anke edema, clubbing of fingers, varicose veins, reflexes. Edema RATING ASSESSMENT 1+ 5mm depth , recovers immediately 2+ 8-10 mm depth , duration 10-15 sec 3+ 11-20mm , duration 15-30sec 4+ >20mm , duration >30sec
  • 34. Back spina bifida , curves Genitals and Rectum: Inguinal lymph glands – enlarged , palpable Patency of urinary meatus and rectum (infant) Descent of testes ( Infant) Vaginal Discharges, presence of STD, haemorrhoids, enlarged prostate gland, pelvic masses. Neurological: Co-ordination , reflexes, equilibrium, sensation