Introduction to Health
assessment and
Fundamentals
GNUR 238 SPRING 2015
LOYOLA UNIVERSITY CHICAGO
Why Learn Health Assessment?
• Health assessment is a systematic
method of collecting and analyzing
data.
• Utilize the American Nurses
Association’s (ANA) Standards of
Practice, which incorporates the
nursing process.
Components of Health Assessment
• Three primary
components:
oHistory (subjective data)
oPhysical examination
(objective data)
oDocumentation of data
Components of Health Assessment
Data collection
Symptom
Copyright © 2013 by Mosby, an imprint of
Elsevier Inc.
Sign
Clinical
manifestations
Types of Health
Assessment
• Amount of information
gained during a health
assessment depends on
several factors, including:
o Context of care
o Patient need
o Health assessment
skills
Examples: Types of
Assessments
•Types of assessment:
 Comprehensive health




assessment
Problem-based or focused
health assessment
Shift assessment
Episodic
assessment/follow up
assessment
Screening assessment
Documentation of Data
• Improves plan of care
• Legal document of patient’s health status
• Baseline for
o Evaluation
o Changes and decisions related to care
• Must be accurate, concise, and without
bias or opinion
Health
Promotion
Health
Protection
1. Central component of nursing.
2. Begins with health assessment—data
to identify patient’s health status,
practices, and risk factors.
3. Interpretation of data allows the nurse
to target health promotion needs.
Three Levels of Health
Promotion
• Three levels of health promotion/
levels of prevention:
o Primary
o Secondary
o Tertiary
• Nurses provide education and care to
help meet health promotion needs.
Health Promotion and
Health Protection
hhttp://www.healthypeople.gov/2020
Four overarching goals:
•Attain high
quality, longer
lives, free from
preventable
diseases.
•Achieve health
equity, eliminate
disparities, and
improve the
health of all
groups.
•Create
social and
physical
environments
that promote
health for all.
•Promote
quality of life,
healthy
development,
and healthy
behaviors
across all life
stages
Question 1
A mother of three is being seen for a screening assessment.
While planning the initial part of the visit with this patient, the
nurse needs to ensure that:
A. The patient receives a refill for her thyroid medication.
B. The patient is instructed on preventive measures for hypertension.
C. Other family members are present during the interview.
D. Information about the patient’s lifestyle habits is gathered.
Question 2
A nurse is assessing a female teenager. The nurse asks the
young woman to bend over and touch her toes. The nurse
assesses the curvature of the spine as a means of detecting
scoliosis. Assessing the curvature of the spine is an example
of:
A.
B.
C.
D.
Health education
Primary prevention
Secondary prevention
Tertiary prevention
Question 3
3. For which person is a shift assessment
indicated?
a. The person who had abdominal surgery yesterday
b. The person who is unaware of his high serum glucose
levels.
c. The person who is being admitted to a long-term care
facility.
d. The person who is beginning rehabilitation after a knee
replacement.