INTRODUCTION

HEALTH ASSESSMENT
 RODUC
O HEALT
SESSM
P R E S E N T E D B Y : M R . U M A R H AYAT
N U R S I N G I N S T RU C TO R S N C
 DEFINITION
• Health is a state of wellbeing. (WHO)
• A state of complete physical, mental, and social well-being and not
merely the absence of disease or infirmity. (1948 WHO)
• Assessment is defined as a systematic , dynamic process by which
the nurse through interaction with client, significant others and
health care providers, collects and analyze data about the client.
(ANA).
 HEALTH ASSESSMENT
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 examination
after taking a health history.
 COMPONENTS
There are two components of health assessment.

HEALTH
HISTORY

PHYSICAL
EXAMINATION
 HEALTH HISTORY

Health assessment / History is organized systematic

assessment of human body which involves the use of
one's senses to determine the general physical and
mental condition of body by collecting both
subjective and objective data.
 PHYSICAL EXAMINATION

Physical examination is defined as a complete assessment of a

patient's physical and mental status.
A Physical assessment is the systematic collection of objective
information that is directly observed or is elicited through
examination techniques.
 PURPOSES
To establish a data base of client’s normal abilities, risk factors that
can contribute to dysfunction and any current alteration in
function.
To get a clear picture of a client’s health status and health related
problems.
To identify cause and extent of disease.
To identify the problems at early stage.
 CONTINUE…
To determine the nature of treatment required for the client.
To get a holistic view of the client.
To contribute in medical research.
To identify client’s strength, weakness, knowledge, attitude,
motivation, support systems and coping skills.
To compare clients health status with a ideal status.
 TERMINOLOGIES
 Diagnosis – It is the determination of the nature and extent of a
disease.
 Prognosis – It is the forecast/ prediction of the course and
duration of a disease.
 Etiology – It is the science of the cause of a disease.
 Signs – The presence of a disease that can been seen or elicited
E.g. Fever.
 Symptoms – Any evidence as to the nature and location of a
diseases noted by the client.
TYPES OF NURSING ASSESSMENT
In order to effectively determine a diagnosis and treatment for a
patient, nurses make four assessments
1. Initial assessment
2. Focused assessment
3. Time-lapsed assessment
4. Emergency assessment
1.INITIAL ASSESSMENT
• The initial assessment, also known as triage, helps to determine the
nature of the problem and prepares the way for the ensuing
assessment stages.
• The initial assessment is going to be much more thorough than the
other assessments used by nurses.
• Components may include obtaining a patient's medical history or
putting him through a physical exam, or preparing a psychosocial
assessment for a mental health patient.
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Other components may include obtaining a patient's vital

signs and taking subjective statements from the patient, as
well as double-checking the subjective symptoms with the
objective signs of the condition.
2. FOCUSED NURSING ASSESSMENT
• The focused assessment is the stage in which the problem
is exposed and treated.
• Due to the importance of vital signs and their ever-
changing nature, they are continuously monitored during
all parts of the assessment.
 CONTINUE…
Focused assessments may also include X-rays or other types
of tests. Depending on the malady, initial treatment for pain
and long- term treatment for the root cause of the malady
is administered and monitored. Part of the goal of the
focused assessment is to diagnose and treat the patient in
order to stabilize her condition.
3. TIME-LAPSED ASSESSMENT

After the medical condition is properly diagnosed and a

treatment plan is implemented, the time-lapsed assessment
is conducted to evaluate how the patient reacts to the
agreed treatment plan and how their condition is evolving.
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Depending on the issue, a time-lapsed assessment can last

from a few hours to a few months. Throughout this time, the
patient is constantly evaluated and their condition is
compared to previously recorded parameters to see if the
treatment is effective.
4. EMERGENCY ASSESSMENT
The emergency assessment is performed during emergency
procedures, when it is crucial to evaluate the patient's
airway, breathing and circulation, as well as the exact cause
of the problem.
 CONTINUE…
Emergency assessments can take place outside typical
healthcare settings and in these situations the registered
nurse must also make sure that no other people are
negatively affected by the emergency rescue process. If the
emergency assessment is a success and the patient's vital
signs are stabilized, the next step is usually a focused
assessment.
 SUBJECTIVE VS OBJECTIVE
• Subjective Symptoms – When the symptoms are note
by the client himself. E.g. Pain.
• Objective Symptoms – When the symptoms are noted
by the observer as well as by the client. E.g. Jaundice .
 HEALTH HISTORY

HEALTH HISTORY: It is a collection of subjective data in

detail regarding client’s health in a chronological order .
FACTORS AFFECTING THE
COLLECTION OF SUBJECTIVE DATA
• Physical setting
• Client’s Personality and Behavior
• Nurses Personality and Behavior
• Communication Skill
• Patient’s Problem
 COMPONENTS OF HEALTH HISTORY
• Biographic Data
• Chief Complaints History of present illness
• Past health History
• Family History
• Occupational and
• Environmental History
• Psychosocial History
 CHIEF COMPLAINTS

• Chief complaints is a brief assessment of client’s problem

for which clients seeks medical care.
• It should be written in clients statement.
 CONTINUE…..
• H/O Present Illness
• Signs and Symptoms
• Duration
• Treatment taken (Other complaints such as loss of appetite,
insomnia, disorders of stomach etc.
• Client’s Health Habits – Eating , Sleeping etc.
 PAST MEDICAL HISTORY
• Childhood Illness – Mumps, Measles and so on.
• Medical disease – HT, DM, Anemia etc.
• Surgery – Any H/O Hospitalization – Any hospitalization in
the Obstetric History – No of live births, abortions, mode
of delivery
 FAMILY HISTORY

• Family Tree (Pedigree Chart)

• Information about family members
• Family history of any illness (Diabetic Mellitus,
Hypertension etc.)
OCCUPATIONAL HISTORY

• Collecting data regarding clients job, nature of job,

environment in job, exposure to any hazardous substances.
 PSYCHO SOCIAL HISTORY

Food habits
Smoking – Likes and Pattern of
and Food Exercises
Alcoholism dislikes sleep
fads
 CONTINUE…

Review of Systems
Information is gathered system wise
 INTERVIEW
 "Interview" word is derived from french word
"entirevior" it means "glimpse" to each other.

 It is goal directed purposeful interaction between two people.

 An interview is a conversation between two or more people
(the interviewer and the interviewee) where questions are
asked by the interviewer to obtain information from the
interviewee.
 Therapeutic interaction that has a purpose.
 It is both an art and a skill.
 It is primarily patient centered.
 PURPOSE OF INTERVIEW
 Gather information to base nursing care
 Establish a helping relationship
 Identifying health status, concerns, & problems
 Screening purpose
 PHASES OF INTERVIEW
Introductory Phase:
 Orientation, time/comfort and Purpose
 Client/patient/resident needs to understand the
purpose of the interview.
 Interview Environment
 Physical (Privacy, Noise, seating, light, temp)
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2. Working Phase:
 Build trust & rapport Information gathering

 Patient readiness (less sensitive topics first)

 Use of therapeutic self (comm. techniques) Goal in mind.

3. Termination Phase:

 Closure/summarize info in a positive and “hopeful”

manner

 Plan for future Goal achieved/not

 TERMINATING A SESSION
 Pre Summary – provide a five minute signal that the time is
almost up.
Allow for final input: “Is there anything else I should know
about you?”
 Summary – Clarify misunderstandings or differing perceptions
Determine the agenda for subsequent interviews or follow up
 Review – what has been learned during the interview
Instructions for what should be done (or avoided) following the
interview.
 REFERENCES

• Bicklay, L. S. (1999). Bates’ guide to physical examination and history

taking (7th ed). Philadelphia: J. B. Lippincott.
• Weber, J. R. (2001). Nurses' handbook of health assessment (4thed).
Philadelphia: Lippincott.