MANIBA BHULA NURSING COLLEGE,

BARDOLI.

Subject: - Advance Nursing Practice

Topic: - Health Assessment

Submitted To, Submitted By,

Ms. L. Diva Channu Ms. Meghana Goswami
H.O.D of Child Health nursing 1st Year M.Sc. Nursing
M.B.N.C. M.B.N.C.
Submitted on,
 Health assessment
 Introduction
Nurses face endless variety of situations. In every clinical situation it is important for a nurse to think
critically and make sound judgement, so that the client ultimately receives the best nursing care. The
nurse makes inferences about the meaning of a client’s response to health problems or generalized
about client’s functional state of health.

 Definition
It is the deliberate and systemic collection of data to determine a client’s current and past health
status, functional status and coping strategies.

 Nursing assessment
Every health care professional performs assessment to make professional judgements related to his/
her client. However the purpose of nursing history and physical examination differs greatly from that
of medical or other type of health examination.
The purpose of nursing assessment is to collect subjective and objective data to determine the
client’s overall level of functioning in order to make a professional clinical judgment.
The nurse collects physiologic, psychological, sociocultural, developmental and spiritual data about
the client.
The end results of a nursing assessment is the formulation of nursing diagnosis that required nursing
care, the identification of collaborative problems that require interdisciplinary care and the
identification of problems that require immediate referral.

 Purpose
 To establish a data base (all the information about the client): nursing health history, physical
assessment, the physician’s history and physical examination, results of laboratory and
diagnostic test, material from other health professional
 To get data that reveal related experience and complaints.
 Assessment process
It is a systematic method by which nursing :plans and provides care for patients.
This involves a problem-solving approach that enables the nurse to identify patient problems and
potential at-risk needs (problems) and to plan, deliver, and evaluate nursing care in an orderly,
scientific manner.

 Components of nursing process:

The nursing process consists of five dynamic and interrelated phases:
1. Assessment
2. Diagnosis
3. Planning
4. implementation
5. evaluation.
 Types of assessment
1. Initial comprehensive assessment: It is also called admission assessment, is performed when
the client enters a health care agency. The purpose is to evaluate the client health status, to
identify functional health status that are problematic, and to provide an in-depth,
comprehensive database, which is critical for evaluating changes in the client’s health status
in subsequent assessment.
2. Problem focused assessment: This assessment collects data about a problem that has already
been identified. This type of assessment has a narrower scope and a shorter time frame than
the initial assessment. In focus assessment, nurse determines whether the problems still exist
and whether the status of problem has changed. This assessment also includes the appraisal of
any new, overlooked or misdiagnosed problem. Intensive care units may perform focus
assessment every few minutes.
3. Emergency assessment: It takes place in life- threatening situation in which the preservation
of life is the top priority. Time is of the essence in rapid identification of and intervention for
the client’s health problems. Often the client’s difficulties involves airway, breathing and
circulatory problems. Abrupt changes (suicidal thought) or roles or relationships (social
conflict leading to violent acts) can also initiate in emergency.
4. Time-lapsed assessment: It is also called on-going assessment. It is another type of
assessment, takes place after the initial assessment to evaluate any changes in the clients
functional health. Nurses perform this assessment when substantial periods of time have
elapsed between assessment like periodic out –patient clinic visit, home health visit, and
health and development screening.

 Steps of Assessment
A. Collection of data
 Subjective data collection
 Objective data collection
B. Validation of data
C. Organization of data
D. Recording/documentation of data
Assessment = Observation of the patient + Interview of the patient,
Family and society + Examination of the patient + Review of
medical record
A. Collection of data
 Gathering of information about the client
 Includes physical, psychological, emotion, sociocultural, spiritual factors that may affect
client’s health status
 Include past health history of client
 Include current/present history problem of client
o Types of Data
a) Subjective data:
 Also referred to as symptoms or sensations.
 Information from the client’s point of view is described by the person
experiencing it.
 Information supplied by family members, significant others; other health
professionals are considered subjective data.
Eg., pain, dizziness, ringing of ears/Tinnitus
 b) Objective data:
 Also referred to as sign
 Those can be detected observed or measured/tested using accepted standard or
norm.
 Mainly collected by general observation and by using the four physical
examination techniques: inspection, percussion, palpation and auscultation.
Eg., pallor, diaphoresis, BP= 150/100, yellow discoloration of skin.
o Methods of data collection
i. Interview: A planned, purposeful conversation/communication with the client to get
information, identify problems, evaluate change, to teach, or to provide support or
counselling.
Interviewing, an essential skill for obtaining information for the nursing history, consist
of asking question designed to elicit subjective data from the client or family members.
ii. Nursing health history: Data is collected about the current level of illness, review of
body systems, family history spiritual, mental and emotional reaction to illness.
Components of a health history:
 Biographic data: name, address, age, sex, marital status, occupation, religion.
 Chief complaint: primary reason why client seek consultation and hospitalization
 History of present illness: includes usual health status, chronological story,
family history, disability assessment.
 Past health history: includes all previous immunizations, experiences with
illness.
 Family history: reveals risk factors for certain disease (diabetes, hypertension,
cancer)
 Review of systems: review of all health problems by body systems.
 Lifestyle: include personal habits, diet, sleep or rest patterns, activities of daily
living.
 Social data: include family relationship, ethnic and educational background,
economic status.
 Psychological data: information about the client’s emotional state
 Pattern of health care: includes all health care resources: hospitals, clinic, health
centres, and family doctors.
iii. Diagnostic and Laboratory investigation data: The nurse must go through all
investigation results and interpret the deviation from normal.
iv. Observation: It used to gather data by using the 5 sense and instruments.
v. Examination: Systematic data collection to detect health problems using unit of
measurements, physical examination techniques, interpretation of laboratory results.
Physical examination: Systematic detail examination of all systems are carried
out.
Method of physical examination:
 Inspection: It is the visual examination of the client.
Guidelines for effective inspection
 Be systemic
 Fully expose the area to be inspected, cover other body parts to respect the
client’s modesty.
 Maintain comfortable room temperature.
 Observe colour, shape, size, symmetry, position and movement.
  Compare bilateral structures for similarities and differences.

 Palpation: It is the sense of touch to assess various parts of the body and helps
to confirm findings that are noted on inspection.
The hands, especially the finger tips are used to assess skin temperature, check
pulses, texture, moisture, lumps, tenderness or pain. Please remember to use
warm hands. Any tender area should be palpated last.
Types of palpation:
1. Light palpation: to check muscle tone and assess for tenderness.
2. Deep palpation: to identify abdominal organs and abdominal mass.

 Percussion: It is the striking of the body surface with short, sharp strokes in
order to produce palpable vibrations and characteristic sounds.
It is used to determine location, size, shape and density of underlying structures;
to detect presence of air or fluid in a body space; and to elicit tenderness.

Types of percussion:
§ Direct percussion: Percussion in which one hand is used and striking
finger of the examiner touches the surface being percussed.
§ Indirect percussion: Percussion in which two hands are used and plexor
strikes the fingers of the examiner’s other hand, which is in contact with
the body surface being percussed.
§ Blunt percussion: Percussion which ulnar surface of the hand or fist is
used in place of the fingers to strike the body surface, either directly or
indirectly.

Percussion sound:

i. Resonance: A hollow sound

ii. Hyper resonance: A booming sound.
iii. Tympani: A musical sound or drum sound like that produced by stomach.
iv. Dullness: Thud sound produced by dense structures such as liver, and
enlarge spleen, or a full bladder.
v. Flatness: An extremely dull sound like that produced by very dense
structures such as muscle or bone.
 Auscultation: It is listening to sounds produced inside the body. These include
breath sound, heart sound, vascular sounds and bowel sounds.
It is used to detect the presence of normal and abnormal sounds and to assess
them in terms of loudness, pitch, quality, frequency and duration.
 ASSESSMENT SEQUENCING

a) Cephalocaudal Approach-Head to Toe Assessment

PHYSICAL EXAMINATION

VITAL SIGN:

Date Temp ( F) Pulse (/min) Respiration(/min) BP (mm of Hg) SpO2

19/12/11 100 F 82/min 22/min 114/78 100

GENERAL APPERANCE:

Body image :
Health :
Activity :

MENTAL STATUS:

 Consciousness :
 Look :

POSTURE

 Body curves :
 Movement :

SKIN CONDITION:

 Color :
 Texture :
 Temperature :
 Lesions :

HEAD & FACE:

 Scalp :
 Face :

EYES:

 Eyebrow :
 Eye lashes :
 Eyelids :
 Eye balls :
 Conjunctiva :
 Sclera :
 Pupils :
 Vision :
EAR:

 External ear :
 Hearing :

NOSE:

 External nares :
 Nostrils :

MOUTH & PHARYNX:

 Lips :
 odour of the mouth :
 Teeth :
 Mucus membrane :
 Tongue :

NECK:

 Lymph node :
 Thyroid gland :
 Range of motion :

Mouth:

 Lips :
 Odour of the mouth :
 Teeth & Gum :
 Mucus membrane :
 Tongue :
Chest
 Inspection : breast, chest expansion, scars, lesion
 Palpation : tenderness
 Percussion :
 Auscultation : lung and heart

Abdomen

 Inspection : shape, lesions, pigmentation, scars, distension hernia

 Auscultation : bowel sounds
 Palpitation : tenderness, organomegaly, any palpable mass
 Percussion note : tympani, dull
 Appetite : good/ poor
 nausea/ vomiting/heart burn :
 Bowel :frequency/melaena
 bowel sound :
 Rectum : Presence of haemorrhoids

Genital and rectum:

 Bladder & Bowel Pattern :

Extremities:

 Palpate arterial pulses :

 Observe capillary refill :
 Evaluate edema :
 Assess joint mobility :
 Measure strength :
 Deep tendon reflexes :

b) Body system approach- examine all body systems

GENERAL APPERANCE:
Body image :
Health :
Activity :

MENTAL STATUS:
 Consciousness :
 Look :

POSTURE
 Body curves :
 Movement :

Integumentary System :

 Color :
 Texture :
 Temperature :
 Lesions :
 Edema :

Respiratory System :

 Thorax :
 Breath sound :
 Presence of cough/Hemoptysis :
 Percussion notes :
 Presence of mass/tenderness :

Cardiovascular system :
 Peripheral pulse :
 Heart sounds :
 Neck vein distention :

Lymphatic system :

 Lymph node enlargement :

Gastrointestinal system:

Mouth:

 Lips :
 Odour of the mouth :
 Teeth & Gum :
 Mucus membrane :
 Tongue :

Abdomen

 Inspection : shape, lesions, pigmentation, scars, distension hernia

 Auscultation : bowel sounds
 Palpitation : tenderness, organomegaly, any palpable mass
 Percussion note : tympani, dull
 Appetite : good/ poor
 nausea/ vomiting/heart burn :
 Bowel :frequency/melaena
 bowel sound :
 Rectum : Presence of haemorrhoids

Urinary system : Retention/incontinence

Musculoskeletal system :

 Range of motion :
 Joint tenderness/pain :
 Presence of any edema, scars, lesions, deformities:

Nervous system :

 Facial expression :
 Level of consciousness :
 Memory : Recent, Remote, Immediate
 Orientation : Time, Place, person
 Assessment of cranial nerves :
 Assessment of sensation :

Endocrine and genital reproductive:

 Male:
 Female:

c) Review of system approach: examine only particular area affected

 According to person illness which system is affected that system examination do in
detail.

Ex. Mr. X has complaint of chest pain, palpitation and felling restlessness so for this
patient cardiovascular system examination will do in detail.
 o Sources of data:
a.) Primary sources: data directly gathered from the client using interview and physical
examination.
b.) Secondary sources: data gathered from the client’s family members, significant others,
client medical record/ chart, others member of health team and related care literature/
journals.

B. Validation of data:
The act of double checking or verifying data to confirm that it is accurate and complete. Validation
of data is the process of confirming or verifying that the subjective and objective data collected are
reliable and accurate.
Steps of validation include:
-Deciding whether the data require validation.
-Determining ways to validate the data and
-Identifying areas where data are missing.
Failure to validate data may result in premature closure of the assessment or collection of
inaccurate data.
Purposes of Data Validation
 Ensure that data collection is complete
 Ensure that objective and subjective data agree
 Obtain additional data that may have been overlooked
 Avoid jumping to conclusion
 Differentiate cues and inferences
Data Requiring Validation
Not every piece of data you collect must be verified. For example: you would not need to
verify or repeat the client’s pulse, temperature, or blood pressure unless certain conditions
exist. Conditions that require data to be rechecked and validated include:
• Discrepancies or gaps between the subjective and objective data.
For example, a male client tells you that he is very happy despite learning that he has
terminal cancer.
 Discrepancies or gaps between what the client says at one time and then another
time.
For example, your female patient says she has never had surgery, but later in the
interview she mentions that her appendix was removed at a military hospital when
she was in the navy
 Findings those are very abnormal and inconsistent with other findings.
For example, the client has a temperature of 104oF degree. The client is resting
comfortably. The client’s skin is warm to touch and not flushed.
Methods of validation
 Recheck your own data through a repeat assessment. For example, take the client’s
temperature again with a different thermometer.
 Clarify data with the client by asking additional questions. For example: if a client is
holding his abdomen the nurse may assume he is having abdominal pain, when
actually the client is very upset about his diagnosis and is feeling
 Verify the data with another health care professional. For example, ask a more
experienced nurse to listen to the abnormal heart sounds you think you have just
heard.
  Compare you objective findings with your subjective findings to uncover
discrepancies. For example, if the client state that she “never gets any time in the sun”
yet has dark, wrinkled, suntanned skin, you need to validate the client’s perception of
never getting any time in the sun

C. Organizing data
The nurse uses a written or computerized format that organizes the assessment data systematically.
The format may be modified according to the client's physical status.
 Maslow’s Basic Needs:
Abrahm maslow who put forward the hierarchy of human needs is the best way used for the
organization of data in the nursing process. His model got the world’s attention because of his
high value in health care.

 Body System Model

The Body systems model (also called the medical model or review of systems) focuses on the
client’s major anatomic systems. The framework allows nurses to collect data about past and
present condition of each organ or body system and to examine thoroughly all body systems
for actual and potential problems.

 Gordon’s Functional Health Patterns:

The client’s strengths, talents and functional health patterns are an integral part of the
assessment data. An assessment of functional health focuses on client’s normal function and
his or her altered function or risk for altered function.
1. Health perception-health management pattern.
2. Nutritional-metabolic pattern
 3. Elimination pattern
4. Activity-exercise pattern
5. Sleep-rest pattern
6. Cognitive-perceptual pattern
7. Self-perception-concept pattern
8. Role-relationship pattern
9. Sexuality-reproductive pattern
10. Coping-stress tolerance pattern
11. Value-belief pattern

D. Recording/documentation of data
To complete the assessment phase, the nurse records client's data.
Accurate documentation is essential and should include all data collected about the client's health
status.
Data are recorded in a factual manner and not interpreted by the nurse.
E.g.: the nurse record the client's breakfast intake as" coffee 240 mL. Juice 120 mL, 1 egg". Rather
than as "appetite good".

Purposes of documentation
1. Provides a chronological source of client assessment data and a progressive record of
assessment findings that outline the client’s course of care.
2. Ensures that information about the client and family is easily accessible to members of
the health care team; provides a vehicle for communication; and prevents fragmentation,
repetition, and delays in carrying out the plan of care.
3. Establishes a basis for screening or validation proposed diagnoses.
4. Acts as a source of information to help diagnose new problems.
5. Offers a basis for determining the educational needs of the client, family, and significant
others.
6. Provides a basis for determining eligibility for care and reimbursement. Careful recording
of data can support financial reimbursement or gain additional reimbursement for
transitional or skilled care needed by the client.
7. Constitutes a permanent legal record of the care that was or was not given to the client.
8. Provides access to significant epidemiologic data for future investigations and research
and educational endeavors.

Guidelines for documentation

 Document legibly or print neatly in un erasable ink
 Use correct grammar and spelling
 Avoid wordiness that creates redundancy
 Use phrases instead of sentences to record data
 Record data findings, not how they were obtained
 Write entries objectively without making premature judgments or diagnosis
 Record the client’s understanding and perception of problems
 Avoid recording the word “normal” for normal findings
 Record complete information and details for all client symptoms or experiences
 Include additional assessment content when applicable
 Support objective data with specific observations obtained during the physical examination
 Nursing Assessment
Assessment is the first stage of the nursing process in which the nurse should carry out a complete
and holistic nursing assessment of every patient's needs, regardless of the reason for the encounter.
Usually, an assessment framework, based on a nursing model is used.
The purpose of this stage is to identify the patient's nursing problems. These problems are expressed
as either actual or potential. For example, a patient who has been rendered immobile by a road traffic
accident may be assessed as having the "potential for impaired skin integrity related to immobility".
I. Nursing health history- a structure interview design to collect specific data and to obtain a
detail health record of a client.
Components of nursing health history.
▶ Biographic data:
▶ Chief complaint
▶ History of present illness
▶ Past health history
▶ Family history
▶ Review of systems
▶ Life style
▶ Social data
▶ Psychological data
II. Psychological And Social Examination
Spiritual health (is religion important? If so, in what way? What/who provides a sense of
purpose?)
Intellectual health (cognitive functioning, hallucinations, delusions, concentration, interests,
hobbies etc
III. Physical examination
A nursing assessment includes a physical examination: the observation or measurement of
signs, which can be observed or measured, or symptoms such as nausea or vertigo, which can
be felt by the patient.
The techniques used may include Inspection, Palpation, Auscultation and Percussion in
addition to the "vital signs" of temperature, blood pressure, pulse and respiratory rate, and
further examination of the body systems such as the cardiovascular or musculoskeletal
systems
IV. Documentation of the assessment
The assessment is documented in the patient's medical or nursing records, which may be on
paper or as part of the electronic medical record which can be accessed by all members of the
healthcare team.
V. Assessment Tools
A range of instrument has been developed to assist nurse in their assessment role. These
include:
The index of independence in activities of daily living
§ Activities of daily living (ADLs) are "the things we normally do in daily living
including any daily activity we perform for self-care (such as feeding ourselves,
bathing, dressing, grooming), work, homemaking, and leisure."
§ The Barthel index: The Barthel Index consists of 10 items that measure a person's
daily functioning specifically the activities of daily living and mobility. The items
include feeding, moving from wheelchair to bed and return, grooming, transferring to
 and from a toilet, bathing, walking on level surface, going up and down stairs,
dressing, continence of bowels and bladder.
§ The general health questionnaire
§ Mental health status examination: The Mental Status Exam (MSE) is a series of
questions and observations that provide a snapshot of a client's current mental,
cognitive, and behavioural condition.

Summary
Today we learnt about health assessment, its definition, types, importance of health assessment, steps of
health assessment and nursing assessment in detail.

Conclusion
Assessment is the first and most critical step of nursing process. Accuracy of assessment data affects all
other phases of the nursing process. A complete data base of both subjective and objective data allows the
nurse to formulate nursing diagnosis, develop client goals, and intervenes to promote heath and prevent
disease.
Bibliography
1. Brar kaur navdeep, “TEXTBOOK OF ADVANCE NURSING PRACTICE”1st edition,2015,
jaypee publication,new delhi;India;p.p no.613-622.
2. Basheer Shabir, “A CONCISE TEXT BOOK OF ADVANCED NURSING PRACTICE” 1st
Edition,2013,emmess
3. Black M. Joyce and Jane Hokenson Hawk,”.MEDICAL SURGICAL NURSING VOLUME 1”
11th edition 2014;published by Elsevier;New Delhi;Pg No.50-55
4. Brunner and Suddarth,ʺTEXTBOOK OF MEDICAL SURGICAL NURSING,VOL. 1”;
12th edition 2010;Published by Wolters Kluwer;New Delhi;India;Pg no.108-117.

Net reference:
1. http://en.health assessmentWikipedia.org
2. http;//en.datavalidationwikipedia.org.
3. http;//en.healthassessment.slideshare122345