Importance of
Health Assessment
DSN
Kevin Dobi, MS, APRN
Copyright © 2013 by Mosby, an imprint
of Elsevier Inc.
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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.
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Three primary components:
 History (subjective data)
 Physical examination (objective data)
 Documentation of data
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Data collection
 Symptom: What the patient feels/communicates
(subjective)
 Sign: Clinical findings (objective) collected during
physical examination
 Clinical manifestations = signs and/or symptoms
collected utilizing inspection, palpation,
percussion, and auscultation
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Improves plan of care
Legal document of patient’s health status
Baseline for
 Evaluation
 Changes and decisions related to care
Must be accurate, concise, and without bias or opinion
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Amount of information gained during a health
assessment depends on several factors, including:
 Context of care
 Patient need
 Expertise of the nurse
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Context of care refers to circumstance or situation
related to health care delivery.
 May be related to the setting or environment.
 May be related to the physical, psychological, or
socioeconomic circumstances involving the patient.
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• Types of assessment:
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Comprehensive health assessment
Problem-based or focused health assessment
Episodic assessment
Screening assessment
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Patient needs vary widely:
 Type of health assessment performed by the nurse is
driven by the patient’s need.
 Nurse must be prepared to conduct appropriate
level of assessment.
 Patient’s age, general level of health, presenting
problems, knowledge level, and support systems are
among the variables that impact patient need.
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Expertise of the nurse is gained with specialization
within a given area of practice:
 A nurse in an adult intensive care unit has expertise
assessing a patient with hemodynamic instability.
 A family nurse practitioner working in a women’s
clinic has expertise in performing routine pelvic
examinations.
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The nurse must analyze and interpret data before
initiating a plan of care.
The outcome of a health assessment is a portrait of the
patient’s physical status, strengths, weaknesses,
abilities, support system, health beliefs, and activities
to maintain health, as well as the patient’s health
problems and available resources to maintain health.
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Organization and clustering of data
 allows problems to be more clearly apparent
Can be based on body system format:
 Cardiovascular, musculoskeletal, etc.
Can be based on conceptual format:
 Oxygenation, perfusion, mobility
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Data analysis, interpretation, and clinical judgment
include:
 Identifying abnormal findings.
 Correctly interpreting findings to select appropriate
plan of care.
 Applying clinical judgment to interpret or make
conclusions regarding patient needs, concerns, or
health problems.
 After understanding the situation, the nurse responds
by determining appropriate interventions.
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Central component of nursing.
Begins with health assessment—data to identify
patient’s health status, practices, and risk factors.
Interpretation of data allows the nurse to target health
promotion needs.
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Health promotion:
 Behavior motivated by desire to increase well-being
and actualize health potential.
Health protection:
 Behavior motivated by desire to avoid illness, detect
illnesses early, and maintain functioning when ill.
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Three levels of health promotion:
 Primary = Preventing disease from developing
through promoting healthy lifestyle.
 Secondary = Screening efforts to promote early
detection of disease.
 Tertiary = Minimizing disability from acute or
chronic illness or injury and allowing for most
productive life within limitations.
Nurses provide education and care to help meet health
promotion needs.
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Framework for health promotion efforts found in
Healthy People 2020:
 http://www.healthypeople.gov/2020/
Managed by U.S. Department of Health and Human
Services.
Objectives address most significant preventable threats
to health with goals to reduce threats.
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Objectives address most significant preventable threats
to health, with goals to reduce threats
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.
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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.
B.
C.
D.
The patient receives a refill for her thyroid medication.
The patient is instructed on preventive measures for
hypertension.
Other family members are present during the interview.
Information about the patient’s lifestyle habits is
gathered.
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The medical-surgical nurse is reviewing the practice related
to a patient who acquired pneumonia while recovering
from a hip replacement. The unit documents this event as
failure to rescue and would like the nurse to develop a
personal professional action plan. This plan will most likely
include:
A.
B.
C.
D.
Reflection on action
Reflection in action
Tertiary prevention of health care-associated infections
Reasoning patterns
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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:
Health education
B. Primary prevention
C. Secondary prevention
D. Tertiary prevention
A.
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