NUR 097; CHAPTER 1 Introduction to Health Assessment and Social Determinants of Health
Health
- overall well being of body and mind
- relative state in which a person strives to meet their
potential and includes the areas of wellness with the
ultimate goal of improving health and includes
“8 dimensions”
Nursing health assessment
- both a comprehensive health history and a complete
physical examination, which are used to evaluate the
health status of a person
- help nurses identify health problems, establish a
baseline for monitoring changes, and provide a basis
for planning and implementing interventions.
8 DIMENSIONS
1. Physical – how the body works and adapts;
involves factors like exercise, nutrition, and
proper rest
2. Emotional – ability to handle life and its
challenges; involves understanding, expressing,
coping with feelings in a positive way, and a
relationship w/ others
3. Social – supportive relationships with family
and friends; involves feeling a sense of
belonging, connection, and satisfaction in your
interaction w/ others
4. Spiritual – living peacefully, morally, and
ethically; involves a person’s sense of values,
belief, practices, and experiences related to
religion.
5. Environmental – favorable connections to
promote health encompasses the patients
surroundings
6. Intellectual – ability to advance knowledge and
is different for each person; state of keeping
your mind active, engaged, and continuously
seeking new knowledge and challenges
7. Financial – state of having a good and stable
financial situation and having control over your
finances; includes budgeting, saving, avoiding
debt, and planning for long-term goals
8. Occupational – finding satisfaction and
fulfillment in your work or chosen activities;
involves having a sense of purpose,
accomplishment in your professional life,
maintaining a healthy work-life balance,
managing stress related to work, and
continuously developing skills to enhance your
career
1. Health History
Biographical Data - Includes personal information
such as age, gender, occupation, and address.
Chief Complaint or Reason for Seeking Healthcare The primary reason the individual is seeking
healthcare services.
Present Health Status - Information about the
individual's current health condition, symptoms, and
concerns.
Past Medical History - Includes information about
previous illnesses, surgeries, hospitalizations, and
chronic conditions.
Family History - Information about the health status of
close family members.
Social History - Details about lifestyle factors, habits,
and environmental factors that may influence health.
2. Physical Examination
General Appearance - Observations about the
individual's overall appearance, behavior, and hygiene.
Vital Signs - Measurement of basic physiological
parameters such as temperature, pulse, respiratory
rate, and blood pressure.
Head-to-Toe Assessment or Cephalocaudal Assessment
- A systematic examination of each body system,
including inspection, palpation, percussion, and
auscultation.
3. Psychosocial Assessment
Evaluating the patient's mental health, emotional
well-being, and social support systems.
Identifying any factors that may impact the patient's
mental and emotional health, such as stressors,
coping mechanisms, and social relationships.
4. Functional Assessment
Evaluating the patient's ability to perform daily
activities and tasks, including mobility, self-care, and
any limitations they may have.
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NUR 097; CHAPTER 1 Introduction to Health Assessment and Social Determinants of Health
5. Review of Systems (ROS)
Inquiry about Symptoms - Systematically examining
each body system to identify any signs or symptoms
that may be relevant to the patient's overall health.
6. Documentation
Recording all assessment findings accurately and
comprehensively in the patient's health record.
7. Analysis and Interpretation
Synthesizing the collected data to identify patterns,
potential health issues, and areas for further
investigation.
Role of the nurse in assessment
 Nurses deliver care across the lifespan in a variety
of practice arenas
 small sample of the groups served are pediatrics,
geriatrics, medical, surgical, mental health,
maternity, and community health
 Nurses
assess
patient
needs,
develop
interventions, and educate and counsel
individuals, families, groups, and communities
toward higher levels of health and wellness
 Nurses view health as the focus with the patient,
the environment, and the nurse all influencing the
health status of the patient
Assessing the patient by using the eight dimensions is
at the forefront of the nurse’s responsibilities The
nurse conducts a comprehensive assessment covering
physical, mental, emotional, developmental, social,
and spiritual dimensions of the patient.
Physically - signs like changes in vital signs, nausea, or
incontinence are observed.
Mentally - alterations in consciousness and confusion
may be noted.
Emotionally - the nurse explores mood changes,
considering factors like abuse or financial worries.
Developing rapport allows the nurse to address
sensitive issues.
Developmentally - guidance may be needed for
problem-solving or moral understanding.
Socially - the patient may be isolated, and the nurse
suggests self-help groups or resources.
Spiritually - the patient's preferences
interventions, such as connecting with clergy.
guide
Collaborating with the patient ensures partnership in
decision-making - addressing social determinants of
health and promoting long-term healthier lifestyle
outcomes.
NURSING PROCESS
- it is used to identify patient problems; set a goal and
develop an action plan; implement the plan; and
evaluate the outcome
NURSING STEPS ARE:
Assessment
Diagnosis
Planning
Implementation
Evaluation
I.
Assessment - Gather comprehensive information
about the patient's health status through
observations, interviews, and examinations.
Subjective data – information provided by the
patient, often based on their feelings, perceptions, or
experiences.
Examples: Vital signs (e.g., heart rate, blood
pressure), physical examination findings (e.g.,
skin color, respiratory rate), laboratory results,
and diagnostic imaging.
Objective data – observable and measurable
information that can be assessed using the five senses
or through diagnostic tests.
II.
Diagnosis - Identify health issues and their root
causes based on the collected data, leading to the
formulation of nursing diagnoses.
III.
Planning - Develop a tailored care plan by setting
priorities, establishing goals, and determining
specific nursing interventions.
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NUR 097; CHAPTER 1 Introduction to Health Assessment and Social Determinants of Health
IV.
Implementation - Execute the care plan by
carrying out nursing interventions, coordinating
care, and providing patient education.
V.
Evaluation - Assess the effectiveness of the care
plan by measuring outcomes, comparing them
with goals, and making necessary adjustments for
ongoing care.
TYPES OF HEALTH ASSESSMENT
The admission of a new patient to a clinic, hospital,
long-term care facility, or visiting nurse agency usually
requires a comprehensive health assessment
Comprehensive Health Assessment
- A thorough examination of a patient's physical,
psychological, social, and environmental aspects.
-Conducted during initial encounters or periodic
check-ups to provide a holistic view of the patient's
overall health.
Focused or Problem-Oriented Health Assessment
- A follow-up history is a form of a focused assessment
- Targeted and specific, addressing a particular health
concern or set of related issues.
- Performed in response to immediate health
problems, guiding interventions for the specific
identified problem.
Emergency history – is a data collection which focused
on the patient’s emergent problem with a systematic
prioritization of need beginning with the ABCs of
airway, breathing, and circulation
a) Airway - Assess and clear any obstructions.
b) Breathing - Evaluate and provide artificial
ventilation if necessary.
c) Circulation - Check for signs of circulation and
initiate chest compressions if needed. This
sequence is a fundamental guideline for
prioritizing interventions to address lifethreatening issues promptly.
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