Nursing assessment is a continuous, systematic process that involves collecting and analyzing data about a person's physical, psychological, social, and other needs. There are two main components of health assessment: taking history and physical examination. A health assessment evaluates characteristics like physical, social, spiritual/cultural, and mental health. Assessments are tailored based on factors like age, from newborns to adults to elderly individuals. Comprehensive assessments involve collecting medical history, conducting a physical exam, and reviewing laboratory results.

1. UNIT-3
HEALTH ASSESSMENT
By-Mandeep Kaur

2. Nursing assessment is a continuous,
systematic, critical, orderly analysing
and interpreting information about
physical, psychological , social needs of
a person, the nature of self care
deficient, others factors influencing
conditions and care.
HEALTH ASSESSMENT

3. There are two main components
of health assessment-
1.TAKING HISTORY
2.PHYSICAL EXAMINATION
COMPONENTS OF HEALTH ASSESSMENT

4. Characteristics of a healthy person can be discussed
under the following headings-
1.PHYSICAL CHARACTERISTICS
2.SOCIAL CHARACTERISTICS
3.SPIRITUAL AND CULTURAL CHARACTERISTICS
4.MENTAL CHARACTERISTICS
CHARACTERISTICS OF A HEALTH PERSON

5. Physical wellbeing refers to the normal functioning of all tissues , organs, and system
of the body.Some physical characteristics of a health individual are atated below-
1.GENERAL PHYSICAL EXAMINATION-Healthy appearance, appropriate
weight and height, intelligent, smiling face, well dressed and good posture.
2. MENTAL STATUS-Well oriented to person, place and time, maintain good eye
contact, fully conscious.
3.SPEECH-Clear and appropriate, correct selection of words during speech,
command on sentence and wordings.
1.PHYSICAL CHARACTERISTICS

6. 1.HEAD AND NECK
(a)HAIR
(b)FACE
(C)NECK
(d)EYES
(e)EARS
(f)NOSE
HEAD TO TOE EXAMINATION

7. 2.MOUTH
(a)LIPS
(b)BUCCAL MUCOSA
(c)GUMS
(d)TEETH
(e)TASTE
3.CHEST
4.HEART
5.BREAST
6.ABDOMEN
7.UPPER AND LOWER EXTREMITIES
8.SENSORY SYSTEM

8. A health individual should have good
relations, harmony with members
of family, society or community ,
also participate in social activities
and also active socially for over
all well being of the society
2.SOCIAL CHARACTERISTICS

9. A healthy individual should have holistic approach.He believes in
his religion but should show respect other's religions and beliefs.
He should also respect thecultural values of self, society as well
as should give respect to other's cultural norms and values.
3.SPIRITUAL AND CULTURAL
CHARACTERISTICS

10. Mental health is related to mind and refers to normal functioning of mind and
not merely the absence of mental disease and illness.Mentally health person
is free from mental conflicts and tension.A mentally healthy person maintains
good social relations with the people of society.
4.MENTAL CHARACTERISTICS

11. NEW BORN
ASSESSMENT

12. A complete physical assessment will be done that includes every body
system. Throughout the hospital stay, doctors, nurses, and other health care
providers continually assess the health of the baby, observing for signs of
problems or illness. Assessment may include:
1.FAMILY HISTORY
2.PAST MEDICAL HISTORY
3.PRESENT ILLNESS AND CHIEF COMPLAINT
4.ASSESSMENT OF DEVELOPMENT
5.REVIEW OF SYSTEM
6.HEAD TO TOE EXAMINATION
HEALTH ASSESSMENT OF INFANT

13. 1.FAMILY HISTORY-Information about
the financial, social, domestic , educational
and nutritional condition of the family can
be obtained from the mother or guardian.
2.PAST MEDICAL HISTORY-Health of
mother during pregnancy,Birth
history,History of neonatal stage,
Immunization,General health of the child
etc.

14. 3.Present illness and chief complaints
4.Assessment of Development-Weight , height and the circumference of
head or arm, developmental milestones.
5.Review of system-Presence of Pediculosis ,Ear discharge,Excessive
running of nose, allergic conditions.
6.Head to toe examination

16. Pre school going age (3-5) years is that
period in a child's life when intense
growth and development takes
places.Following component can be
included in the health assessment-
1.Past medical history of child.
2.Personal and family history of child.
3.Various health checkups related to the
growth and development of child.
Pre school
children

17. 4.Immunization status of child
5.Nutrition level of child and
his eating habits
6.Present condition of a child's
health and his major problems.
7.Head to toe physical
examination of a child.

18. 1.Past medical history
2.Personal and family history of children-
CHN mmeting is held at the time of admission in the
school.
3.Periodic checkup of children-checkup at
the time of admission, Health checkups of child after
4 year, Checkup at the time of leaving the school.
3.SCHOOL GOING CHILDREN

19. 4.Nutritional assessment-assessment
of food, child gets at home and the
supplementary meals given in the school.
5.Daily examination-is conducted by the
teachers.It is essential that the teachers can
be trained in diagnosing the illness and
providing routine treatment.It is necessary to
keep an eye on the cold, cough, headache,
skin diseases and other infections.

20. Adulthood of a person can be determined on the basis of his age at level of
maturity.Adulthood can be divided into three parts-
YOUNG ADULT-18-40 YEARS
MIDDLE AGED ADULTS-40-60 YEARS
IDERY ADULTS-ABOVE 60 YEARS OF AGE
Complete physical check up and history have an important place in the
health assessment of an adult person.It is essential to pay attention to the
following steps of health assessment-
HEALTH ASSESSMENT OF ADULT PERSON

21. 1.Psychological development
2.Cognitive development
3.Moral and spiritual
development
4.Health protection-
accidents,infections, suicide, sex
related problems, drug addiction,
obesity,blood pressure and mental
disorders are the major health
hazards of adult.

22. It is necessary to pay attention to the following factors-
1.Old people may be suffering from one or more than one health problems.
2.Symptoms of disease may not be well pronounced in the old people.
3.Old people may habitate to live with disease as they believe that now there
is no remedy for it.
4.Behaviour of family and society towards aged person plays an important
role in their health assessment.
HEALTH ASSESSMENT OF AGED PERSON

23. 1.Past medical history
• General health and strength
• Disease of youth and
childhood
• Surgery or serious accidents
• Previous treatment
2.Personal and family history-In
this attention is paid to place of birth,
marriage, divorce, education
,position of familyetc.
3.Present Illness

24. 4.CHIEF COMPLAINTS-While
assessing the health of old people,
their chief complaint should be
inquired so as the priorities may
be decided in the implementation
of care.

25. 5.REVIEW OF SYSTEM-head to toe
examination is desirable for correct
assessment .Result of examination
help in determining many disease or
health problems.

26. 6.ASSESSMENT OF DISABILITIES-They may
have problem in movement , sitting, getting up,
climbing the stairs and maintaining balance
etc.Old persons may be suffering from
physical, psychological response, social and
sexual impairment or disabilities.

27. Right from the time of confirmation of pregnancy, antenatal assessment of
the pregnant women begins.
1.COMPONENTS OF ANTENATAL ASSESSMENT
• Taking medical history
• Physical examination
• Laboratoey examination
• Monitoring of growth and
development of embryo
HEALTH ASSESSMENT OF PREGNANT
WOMEN

28. 2.MEDICAL HISTORY
History regarding cycle started
*Age at which menstrual cycle started
*Regularity of menstrual cycle, amount
and interval
*Obstetrical history
*Previous Pregnancy
*Experience at the time of delivery
*Age, sex , birth and weight of the child
delivered
*Health condition of former child at
present
*Planned/unwanted

29. 3.PERSONAL AND FAMILY HISTORY
*Social History
*Educational/standard of women and her
husband
*Marital and social sexual problem
*General status of health
4.PHYSICAL EXAMINATION
*General examination
*Measuring weight and height
*Vital signs
*Gynaecological examination
*Examination of breasts or abdomen
*Vaginal examination

30. 5.LABORATORY
EXAMINATION
*Testing haemoglobin
*Blood group and Rh factor,
WBC count
*Urine Examination
*Blood sugar test
*Stool test

31. 6.MONITORING OF GROWTH AND
DEVELOPMENT OF FETUS-Pregnant women
should be called to the clinic for examining the
growth of the embryo in womb in the following
manner-
*From 30 to 36 week , every 15 days.
*After that till pain starts, once in every 7 days

32. 7.DETECTING THE HIGH RISK PREGNANCY
*Age of the pregnant women is either below 15 or
above 30 years
*Multipara pregnant women
*Anaemia
*Malpresentation
*Pre eclampsia and eclampsia
*Antepartum Haemorrhage
*Longer period of gestation
*Hydramnios
*Medical conditions
*Earler still birth, baby died in womb, instrumental
delivery, c-section