UNIT 1: INTRODUCTION TO HEALTH
ASSESSMENT CONCEPTS
OBJECTIVES.
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
Identify the basic concepts that you will study in
health assessment course
Differentiate between health, illness, disease and
wellness
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What is the difference between a illness and sickness
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Identify different types of health assessment
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Process of Data collection
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Technique of data collection
 Health:
A state of complete physical, mental &
social wellbeing, not merely the absence of
disease. (WHO def)
 Wellness: Level of wellbeing, a person perceives
of being healthy
 Disease: Alteration of structure and function of
body. ( Dis – ease)
 Illness: A response a person has to a disease.
DEFINITION
The new definition, considers health as a dynamic
state of well being with different levels of
functional abilities at different point in time.
Illness is a response to a disease and sickness is the
individual perception of its illness.
HEALTH ASSESSMENT
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Health assessment is a part of plane care that identifies
the specific need of a person and how those needs will
be addressed by the health care system
It is the evaluation of health status by performing a
physical exam after taking health history.
TYPES OF ASSESSMENT
The four basic types of assessment are
 Initial comprehensive assessment
 Ongoing or partial assessment
 Focused or problem-oriented assessment
 Emergency assessment
DATA COLLECTION
What is a data?
Information, clue, observation, finding, sign and symptom.
Data - complete and accurate.
Type - Subjective and objective
Source – Primary or secondary
SUBJECTIVE DATA
(Interview)
 Biographical information
(name, age, religion,
occupation)
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Chief complain

Present illness
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Past health history

Family history
OBJECTIVE DATA
(directly observed by the
examiner)
 Inspection
 Palpation
 Percussion
 Auscultation
SELF PREPARATION
Anxiety
 Organization
 Mannerisms
 Competence
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EQUIPMENT PREPARATION:
Within reach and ready
 Arranged as per need
 Clean & warm equipment
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PATIENT PREPARATION:
. Introduce yourself
 Comfort
 Bladder empty
ENVIRONMENT
Privacy
 Noise Control
 Adequate light
 Room temperature
 Client position
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TECHNIQUES
Inspection
 Palpation
 Percussion
 Auscultation
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INSPECTION
 Inspection
involves using the senses of vision,
smell, and hearing to observe and detect any
normal or abnormal finding.
PALPATION
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Touch with different parts of hands
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Dorsum / finger / ball of hands
With different degree of pressure
Light: 1-2 cm
 Deep: 4-5 cm
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Light palpation
Deep palpation
PERCUSSION
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
Percussion involves tapping body parts to produce sound
waves.
Sound produced determines the feature of underlying
organ
AUSCULTATION
 Listening
to body sounds with stethoscope
 Used for listening heart sounds, breath
sounds, vascular sounds, and abdominal
sounds
 Use
Diaphragm & bell
GENERAL SURVEY
The general survey includes observation of the client’s
 Physical development
 Gender
 Apparent age as compared to reported age
 Skin condition and color
 Dress and hygiene
 Posture and gait
 Level of consciousness
 Behaviors, body movements.
 Facial expression
 Speech
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GENERAL SURVEY DOCUMENTATION
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Elderly women, oriented to person and place only, appears weak,
unable to stand, skin flushed, pt is shivering.
A 45 years old male, looks younger than his age, skinny, alert,
oriented to x3. appears healthy and in no acute distress, well
groomed, respond appropriately and cooperative. No gross
abnormalities apparent. Posture is erect and comfortable for age.
Gait is rhythmic and coordinated with arms swinging at side.
Young lady of 25 years old seated on wheel chair, constantly
shifting position and picking at the paper on the table.
 Disoriented to time, place and person (require frequent
orientation to the examination process). Eye contact minimal.
Talked throughout the examination.
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Mr. Mohsin, a young male, adult, fair skinned, with moustache
and beard, tall and average built, alert, cooperative and well
groomed, in no apparent distress. Posture is erect and
comfortable for age. Gait is rhythmic and coordinated with arms
swinging at side.
DOCUMENTATION OF PE FINDINGS
Specific – avoid vague terms
 Concise – use short simple words
 Complete entry with date & sign
 Describe observation clearly
 Use standard abbreviations only
 Record exact size, position of lesion.
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THANK YOU