Health Assessment
Ms. Bushra Ikram
Lecturer (FUCN)
By the end of the unit, learners will be able to:
 Discuss the need for health assessment in general nursing
practice.
 Explain the concepts of health, assessment, data
collection, and diagnosis.
 Explain the purposes of Health assessment
 Identify types of health assessments
 Explain the steps of Health assessment
 Document health assessment data using a problem
oriented approach.
Objective
2
As a professional nurse, you will constantly observe
situations and collect information to make nursing
judgments.
 Hospital, clinic, home, community, or long-term care
 We are conduct many informal assessments every
day.

Health Assessment in Nursing
3

Defines nursing as “the protection, promotion, and
optimization of health and abilities, prevention of
illness and injury, alleviation of suffering through the
diagnosis and treatment of human responses and
advocacy in the care of individuals, families,
communities and populations.”
Concepts of Health
4
Emphasis is placed on “diagnosis and treatment of
human responses”
based on
“accurate client assessments,” including how effective
nursing interventions are “to promote health and
prevent illness and injury.”


“The registered nurse collects comprehensive data of
the patient’s health or situation”
Concepts of Health Conti…
5
The nurse should be
• Collects data in a systematic and ongoing process
• Involves the patient, family, other health care
providers, and environment, as appropriate, in holistic
data collection.
• Prioritizes data collection based on the patient’s
immediate condition, or anticipated needs of the patient
or situation.
Conti…
6
• Uses appropriate evidence-based assessment
techniques and instruments in collecting relevant
data
• Documents relevant data in a retrievable format
• The registered nurse, derives the diagnosis or issues
based on assessment data
Conti…
7
• Validates the diagnoses or issues with the client,
family, and other healthcare providers.
• Documents diagnoses or issues in a manner that
facilitates the determination of the expected
outcomes and plan

Nursing process begins with the complete ,accurate
health Assessment.
Conti…
8





Establish the nurse patient relationship
Gather data about the patient general health status.
Identify the patient strengths.
Identify actual and potential Health problems
Establish a base for the Nursing process
Purpose of Health Assessment
9
1.
2.
3.
4.
5.
Initial comprehensive assessment
Ongoing or partial assessment
Focused or problem-oriented assessment
Emergency assessment
Time-Lapsed assessment
Each assessment type varies according to the
amount and type of data collected.
Types of Health Assessments
10
1 Initial Comprehensive Assessment
 An initial comprehensive assessment involves collection
of subjective data about the client’s perception of his or
her health of all body parts or systems.
 General Survey
 Past health history
 Family history
 lifestyle
 Health practices
Initial Comprehensive Assessment
11
Objective data gathered during a step-by-step
physical examination.
 Performed shortly after admittance to hospital
 Total health assessment (subjective and objective
data) is needed.
 Performed to establish a complete database for
problem identification and care planning.

Conti…
12
2. Ongoing or Partial Assessment
 An ongoing or partial assessment of the client consists
of data collection that occurs after the comprehensive
database is established.
 This consists of a mini-overview of the client’s body
systems and holistic health
patterns as a follow-up
on health status.
Ongoing Assessment
2/27/2019
Health Assessment/ M. Imran
13
3. Focused or Problem-Oriented Assessment
 It is performed when a comprehensive database exists for a
client who comes to the health care agency with a specific
health concern
 A focused assessment consists of a thorough assessment of a
particular client problem and does not cover areas not related
to the problem.
 For example, if your client, John , tells you that he has pain
you would ask him questions about the character and location
of pain, onset, relieving and aggravating factors, and
associated symptoms.
Focused or Problem-Oriented Assessment
14


Emergency assessment:
An emergency assessment is a very rapid assessment
performed in life-threatening situations.
◦ Choking, cardiac arrest, drowning
An example of an emergency assessment is the
evaluation of the client’s airway, breathing, and
circulation (known as the ABCs) when cardiac arrest
is suspected.
 The major and only concern during this type of
assessment is to determine the status of the client’s
life sustaining physical functions.

Emergency Assessment
15
Time Lapsed assessment
 Several months after initial assessment
 Performed to compare the patient’s current status to
baseline data obtained earlier
 Performed to reassess the health status and make
necessary revision in plan of care.

Time Lapsed assessment
16
17

The assessment phase of the nursing process has four major
steps
1. Collection of Data
subjective data collection
objective data collection
2. Validation of data
3. Organization of data
4. Documentation of data

Although there are four steps, they tend to overlap and you
may perform two or three steps concurrently. For example, you
may ask your client, Jane Q., if she has dry skin while you are
inspecting the condition of the skin. If she answers “no,” but
you notice that the skin on her hands is very dry, validation
with the client may be performed at this point.
STEPS OF HEALTH ASSESSMENT
18
COLLECTING SUBJECTIVE DATA
Subjective data are sensations or symptoms (e.g.,
pain, hunger)
 Feelings (e.g., happiness, sadness), perceptions,
desires, Preferences, beliefs, ideas, values, and
personal information that can be elicited and verified
only by the client

19
Biographical information (name, age, religion,
occupation)
• History of present health concern: Physical symptoms
related to each body part or system
(e.g.skin,HEENT,neck and , abdomen)
• Personal health history
• Family history
• Health and lifestyle practices (e.g., health practices
that put the client at risk, nutrition, activity,
relationships, cultural beliefs or practices, family
structure and function, community environment)

Conti…
20
The examiner directly observes objective data. These
data include:
• Physical characteristics (e.g., skin color, posture)
• Body functions (e.g., heart rate, respiratory rate)
• Appearance (e.g., dress and hygiene)
• Behavior (e.g., mood, affect)
COLLECTING OBJECTIVE DATA
21
Measurements (e.g., blood pressure, temperature,
height, weight)
 Results of laboratory testing (e.g., platelet count, xray findings)
 This type of data is obtained by general observation
and by using the four physical examination
techniques: inspection, palpation, percussion, and
auscultation.

COLLECTING OBJECTIVE DATA
22
This is done along with subjective and objective data.
 It serves to ensure that the assessment process is not
ended before all relevant data have been collected,
and helps to prevent documentation of inaccurate
data.
 What types of assessment data should be validated,
the different ways to validate data, and identifying
areas where data are missing are all parts of the
process.

VALIDATING ASSESSMENT DATA
23
Uses a written or computerized format that organizes
data systematically.
 Maslow's Hierarchy needs
 Body system models
 Gordon’s Functional health patterns

Organizing data
24
It forms the database for the entire nursing process
and provides data for all other members of the health
care team.
 Thorough and accurate documentation is vital to
ensure that valid conclusions are made when the data
are analyzed in the second step of the nursing
process.

DOCUMENTING DATA
25
2/27/2019
Health Assessment/ M. Imran
26
Problem –oriented approach
27
28
29