NCM 101:Health Assessment 1.

Assessment

A. Overview of Nursing Process: Definition: Assessment is the first step of

the nursing process, involving the
A health assessment is a comprehensive systematic collection of data about the
evaluation of a person's health status, patient.
which may include physical examinations,
Purpose: The purpose of the assessment is
medical history review, and sometimes
to gather comprehensive health
psychological evaluations. It aims to gather
information to identify the patient’s needs,
information about an individual's health
problems, and strengths, which will inform
and identify any potential issues or areas
the subsequent steps in the nursing
for improvement.
process.
General outline of what a health
Components:
assessment may involve:
Subjective Data: Information that patients
1. Personal Information: Age, gender, race,
report, such as feelings, perceptions, and
and occupation.
concerns. This includes health history,
2. Medical History: Past illnesses, surgeries, present symptoms, and family history.
medications, allergies, and family health
Objective Data: Observable and
history.
measurable data collected through physical
3. Lifestyle Factors: Diet, exercise, smoking, examinations, laboratory results, and
alcohol consumption, and sleep patterns. diagnostic tests.

4. Physical Examination: Vital signs (blood Tools and Techniques: Nurses employ a
pressure, heart rate, temperature), height, variety of tools (e.g., interviews, physical
weight, and a general physical check-up. exams, diagnostic tests) and techniques
(e.g., observation, auscultation) to collect
5. Screening Tests: Depending on age and data.
risk factors, tests might include blood tests,
cholesterol levels, diabetes screenings, or Critical Thinking: Assessment requires
cancer screenings. critical thinking to interpret the collected
data accurately and to understand the
6. Mental Health Evaluation: Assessment patient's context (cultural, social,
of emotional well-being, stress levels, and environmental factors).
mental health history.
2. Nursing Diagnosis
This information can help healthcare
providers make informed decisions about Definition: A nursing diagnosis is a clinical
diagnosis, treatment, and preventive care. judgment about an individual, family, or
community responses to actual or potential
The nursing process comprises five key health problems or life processes.
steps: Assessment, Nursing Diagnosis,
Planning, Implementation (Interventions), Purpose: The purpose of the nursing
and Evaluation (ADPIE). Each of these steps diagnosis is to identify specific health
plays a crucial role in ensuring that care is problems that nurses can address through
tailored to meet the individual needs of their interventions.
patients.
Types of Nursing Diagnoses:
Actual Diagnosis: A problem that is Goals should be Specific, Measurable,
currently present (e.g., Acute Pain). Achievable, Relevant (Realistic), and Time-
bound to promote clarity and effectiveness.
Risk Diagnosis: A problem that may
develop (e.g., Risk for Infection). 4. Implementation (Intervention)

Health Promotion Diagnosis: A patient's Definition: Implementation involves

readiness to enhance health (e.g., executing the nursing interventions
Readiness for Enhanced Nutrition). outlined in the care plan.

Components of Nursing Diagnoses: Purpose: The purpose of intervention is to

apply the planned strategies to address the
Each nursing diagnosis typically involves
identified issues and achieve the set goals.
three parts:
Types of Interventions:
Problem Statement: Describes the health
issue (NANDA-I). Independent Interventions: Actions that
nurses can initiate on their own (e.g.,
Etiology: Identifies the related factors or
positioning a patient for comfort).
causes (why the problem is happening).
Dependent Interventions: Actions that
Symptoms: Defines the defining
require a provider’s order (e.g.,
characteristics or evidence supporting the
administering medication).
diagnosis.
Collaborative Interventions: Actions that
3. Planning
involve working with other healthcare
Definition: Planning involves setting professionals (e.g., coordinating care with a
measurable and achievable short- and long- dietitian).
term goals for the patient's care based on
Documentation: Nurses must document
the nursing diagnosis.
the implementation of interventions to
Purpose: The purpose of planning is to maintain continuity of care and provide
prioritize the patient's needs and determine legal protection.
the best strategies to address those needs
5. Evaluation
effectively.
Definition: Evaluation is the systematic
Components:
process of determining the effectiveness of
Goals: Specific, measurable outcomes that nursing interventions and whether patient
are time-bound (e.g., "Patient will report a outcomes have been achieved.
pain level of 3 or lower within 2 hours").
Purpose: The purpose of evaluation is to
Prioritization: Ranking of nursing diagnoses assess the patient's progress toward goals
based on urgency and importance. and to determine whether the care plan
should be continued, modified, or
Collaboration: Nurses often collaborate discontinued.
with the healthcare team, including the
patient, to develop a comprehensive care Components:
plan.
Assessment of Outcomes: Nurses compare
SMART Goals Development: the patient’s current status against the
established goals.
Reassessment: If goals are not met, the potential problems that arise during the
nurse reassesses the situation to determine course of care.
possible reasons, which may lead to
Components:
changes in the care plan.
- Regular monitoring of vital signs
Documentation of Outcomes: As with
other steps, evaluation must be - Assessment of specific conditions or
documented to provide a clear record of concerns (e.g., pain level, wound healing)
patient progress.
- Follow-up on previously identified issues.
B. Health Assessment in Nursing Practice
3.Focused or Problem-Oriented
Health assessment in nursing practice is a Assessment
systematic approach to collecting and
analyzing patient data to inform clinical Definition: A focused assessment is a
decision-making and improve patient targeted evaluation of a specific problem or
outcomes. concern the patient presents with.

Different types of health assessments: Purpose: To provide an in-depth

exploration of a particular health issue to
1. Initial/Comprehensive Assessment formulate an appropriate care plan.
Definition: The initial or comprehensive Components:
assessment is a thorough and detailed
evaluation of a patient’s health status upon - Assessment based on the patient's
their first encounter with the healthcare presenting complaint or health concern,
system. such as respiratory distress or abdominal
pain.
Purpose: To gather baseline data about the
patient’s health, including medical history, - Collection of relevant health history and
physical examination findings, and physical examination relevant to the
psychological assessments. specific issue.

Components: 4. Emergency Assessment

- Health history (medical, surgical, family, Definition: An emergency assessment is a

social, and medication history) rapid evaluation of a patient in a critical or
life-threatening situation.
- Physical examination (vital signs, head-toe
assessment) Purpose: To quickly identify and address
immediate health threats and prioritize
- Assessment of functional status, lifestyle, interventions.
and risk factors.
Components:
2. Ongoing or Partial Assessment
- Focused assessment based on the
Definition: This type of assessment occurs patient's presenting symptoms (e.g.,
after the initial one and is a continual airway, breathing, circulation).
process that monitors changes in the
patient’s condition. - Rapid evaluation of vital signs and
neurological status.
Purpose: To evaluate the effectiveness of
interventions and identify any changes or - Swift action to stabilize the patient and
address life-threatening conditions.
Importance of Health Assessments in pressure) to identify changes in a patient’s
Nursing condition and monitor their health status
over time.
- Health assessments are vital to providing
holistic care and ensuring that all aspects of 3. Evaluating Functional Status
a patient’s health are considered.
Activities of Daily Living (ADLs): Nurses
- They guide nursing interventions, help assess patients’ abilities to perform ADLs,
track patient progress, and facilitate which helps determine their independence
effective communication among healthcare and need for assistance or intervention.
providers.
Mobility and Safety: Evaluating a patient’s
C. Nurses’ Role in Health Assessment. mobility and safety concerns is essential for
fall prevention and ensuring a healthy
The role of nurses in health assessment is
environment.
critical and multifaceted, serving as a
foundation for patient care and clinical 4. Identifying Patient Needs and Concerns
decision-making. Nurses are often the first
Holistic Approach: Nurses consider
healthcare professionals to interact with
physical, emotional, social, and spiritual
patients, which positions them uniquely to
aspects of health in their assessments,
gather essential health information and
recognizing that each might impact the
establish a baseline for ongoing care.
patient’s overall well-being.
The nurse's role in health assessment:
Cultural Competence: Nurses must be
1. Initial Patient Interaction culturally sensitive and aware, taking into
account diverse backgrounds and beliefs
Building Rapport: Nurses initiate the health
that can affect health perceptions and
assessment process by creating a trusting
behaviors during assessments.
relationship with patients. This rapport
encourages open communication, making 5. Documenting Findings
patients more likely to share accurate
Accurate Record-Keeping: Nurses are
health information.
responsible for documenting assessment
Patient History : Nurses gather findings accurately and comprehensively in
comprehensive health histories, including clinical records. This information is vital for
medical, surgical, family, social, and communication with the healthcare team
medication histories, which are essential in and continuity of care.
understanding the patient's background
Utilization of Technology: Nurses often use
and current health situation.
electronic health record systems to log
2. Conducting Assessments patient data, track changes over time, and
ensure accessible information for all
Physical Examination: Nurses perform
healthcare providers involved in the
thorough physical examinations to assess
patient’s care.
various body systems. They utilize
techniques such as inspection, palpation, 6. Analyzing and Interpreting Data
percussion, and auscultation to collect data
Clinical Judgment: Nurses analyze data
on the patient’s physical health.
collected during assessments to identify
Vital Signs Monitoring: Nurses routinely health issues or changes in the patient’s
measure and document vital signs condition. This includes recognizing
(temperature, pulse, respiration, and blood abnormal findings that may require further
investigation by other healthcare
professionals. Health assessment in nursing practice is a
systematic approach to collecting and
Prioritization: Nurses use their clinical analyzing patient data to inform clinical
judgment to prioritize care based on decision-making and improve patient
assessment findings, addressing the most outcomes.
immediate health concerns first.
A. Collection of Subjective Data
7. Collaborating with Healthcare Teams
THROUGH INTERVIEW AND HX HISTORY
Interdisciplinary Collaboration : Nurses
share assessment findings with doctors, 1. Biographic Data
therapists, and other healthcare
Gather basic information about the patient
professionals to develop a comprehensive
such as:
care plan tailored to the patient's individual
needs. A. Name :

Advocacy: Nurses advocate for patients by B. Age :

communicating their needs and
C. Gender :
preferences, ensuring that patient voices
are heard and considered in care decisions. D. Ethnicity :
8. Education and Counseling E. Marital status :
Patient Education: Nurses play an essential F. Occupation :
role in educating patients about their
health conditions, treatments, and G. Contact information:
preventive care during the assessment 2. Reason for Seeking Health Care
process.
Understand and document why the patient
Empowering Patients: Through health is seeking medical attention. This includes
assessments, nurses identify areas where any specific symptoms or issues they want
patients may need more information or to address.
support, helping them navigate their health
challenges and engage in self-management. 3. Chief Complaint

9. Continuous Monitoring and Record the primary issue or symptom in the

Reassessment patient's own words. This provides a clear
focus for the assessment and further
Ongoing Assessment: Nurses engage in evaluation.
ongoing assessments throughout the
duration of patient care. This ensures that 4. History of Present Illness (HPI)
any changes in health status are quickly Collect detailed information about the chief
identified and addressed. complaint, including:
Feedback Loop: Nurses continually A. Onset:
evaluate the effectiveness of interventions
based on ongoing assessments and modify When did the symptoms start? -
the care plan as needed.
B. Location:
___________________________________
Where is the symptom occurring?
Steps of Health Assessment
C. Duration:
How long have the symptoms been 9. Developmental Level
present?
For pediatric patients, assess
D. Characteristics: developmental milestones and growth
patterns. For adults, consider age-related
What does the symptom feel like? -
concerns that may affect health.
E. Aggravating and relieving factors:
10. Psychosocial History
What makes it worse? What alleviates it?
Explore the patient’s social support system,
F. Severity: mental health history, and coping
mechanisms. This may include: - Support
How intense are the symptoms (e.g., on a from family and friends - Stress factors
scale from 1 to 10)? (work, finances, relationships) - Mental
5. Past Health History health issues (depression, anxiety, past
trauma) - Life events that may impact
Obtain information about previous medical health
conditions, surgeries, hospitalizations, and
any chronic illnesses. 11. Review of Systems (ROS)

6. Family Health History Conduct a comprehensive review of each

body system to identify any additional
Investigate the health of immediate family symptoms or health concerns. This
members to identify potential hereditary systematic approach helps in identifying
conditions or diseases. This may include: issues not mentioned in the chief
(Parents, Siblings,Grandparents) complaint. This thorough collection of
Note any significant health issues like heart subjective data helps healthcare providers
disease, diabetes, cancer, etc. understand the patient's overall health
status, making it easier to develop a
7. Current Medications suitable care plan and address any
concerns.
Document all medications the patient is
currently taking, including: B. Collection of Objective Data
- Prescription medications The collection of objective data during a
health assessment is a critical component
- Over-the-counter drugs
of nursing and medical practice. Objective
- Herbal supplements data refers to the measurable, observable
facts and information obtained through
- Vitamins
physical examinations, diagnostic tests, and
- Include details about dosage, frequency, other quantitative methods, as opposed to
and purpose, as well as any known drug subjective data, which comes from the
allergies. patient’s experiences, feelings, or
perceptions. Here, we can delve into the
8. Lifestyle significance, methods, tools, and
Assess lifestyle factors that may impact considerations related to the collection of
health, including: - Diet and nutrition - objective data.
Exercise habits - Tobacco use (smoking
status) - Alcohol consumption - Significance of Objective Data
Recreational drug use
1. Accuracy and Reliability A. Inspection: Observing physical traits
(e.g., skin color, body posture) and
Objective data provides concrete evidence behavioral signs.
that helps establish a baseline for a B. Palpation: Using hands to feel for
patient’s health status and offers reliable abnormalities in organs or tissues (e.g.,
insights into physical conditions. swelling, tenderness).
C. PercussionTapping on the body surface
to assess underlying structures (e.g., lung
2. Guiding Clinical Decision-Making sounds). -
D. Auscultation: Listening to sounds made
Healthcare professionals rely on objective by organs (e.g., heart murmurs, breath
data to make informed decisions regarding sounds).
diagnosis, treatment, and intervention
strategies. 2. Vital Signs Monitoring

3. Monitoring Changes Measurement of heart rate, respiratory

rate, blood pressure, temperature, and
Continuous collection of objective data oxygen saturation levels provides crucial
allows for the monitoring of a patient’s data about a patient’s physiological state.
progress over time and can indicate
responses to treatments or the progression 3. Semi-Quantitative and Quantitative
of diseases. Tests

4. Enhancing Communication Laboratory tests, such as complete blood

counts (CBC), blood chemistry, or urinalysis,
Objective data serves as a common provide important objective data for
language among healthcare professionals, diagnoses.
ensuring clarity and consistency in Imaging Studies: Radio-logical evaluations
understanding a patient’s condition. (X-rays, MRI, CT scans) present visual data
regarding internal structures and can help
5. Legal and Documentation Standards identify abnormal growths, fractures, or
diseases.
Accurate documentation of objective
findings is critical for legal and clinical 4. Functional Assessments
documentation, providing evidence of care
delivered and aiding in continuity of care. Tools such as the Barthel index or mobility
assessments provide objective measures of
Methods of Collecting Objective Data a patient’s functional capabilities.

1. Physical Examination 5. Standardized Assessment Tools

This includes inspection, palpation, Utilization of tools like the Glasgow Coma
percussion, and auscultation to gather Scale for consciousness or the Braden Scale
information regarding the body's systems. for assessing skin risk helps standardize
Examples include: evaluations.
 Ensure that assessment tools and devices
6. Monitoring Devices are appropriately calibrated and
functioning correctly to maintain accuracy.
5. Documentation
Use of devices such as electrocardiograms
(ECGs), pulse oximeters, and automatic vital Record objective data promptly and
signs monitors can offer immediate and accurately, ensuring it is clear, concise, and
objective readings of a patient's condition. reflects clinical writing standards.
Interprofessional Collaboration
Collaborating with other healthcare
Tools and Techniques for Data Collection
professionals can enhance the collection
process, as each discipline can contribute
Health History Forms: Structured valuable insights into the patient’s
documents to gather baseline information condition through various objective data.
about a patient’s past medical history,
family history, and lifestyle factors.

Assessment Grids and Templates:

Organized formats that help ensure
comprehensive data collection, guiding
practitioners through necessary
examinations.
Electronic Health Records (EHR): Systems
that facilitate the documentation, storage,
and retrieval of objective data about
patients efficiently.

Considerations for Collecting Objective

Data

1. Environment
Ensure the environment is conducive to
assessment; a quiet and comfortable space
enhances accuracy in auscultation and
overall examinations.
2. Patient Comfort and Consent
Explain procedures to gain patient
cooperation and alleviate anxiety. Ensure
you have the consent of the patient before
conducting assessments.
3. Cultural Sensitivity
Be aware of cultural considerations that
may influence communication and comfort
during assessments.
4. Hardware Calibration