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Health Assessment
Introduction and overview to Health Assessment
Definitions
Assessment: - The first and most important step of the nursing process, assessment
involves collecting all the relevant information needed to solve a health problem. All
the remaining steps of this process depend heavily on the accuracy of this information.
-Is the collection of data about an individual’s health state?
-Gathering Data (Types of data):
NO. Subjective data
1- What the person say about
themself during history taking?
Subjective data
What you as the health professional observe
by inspect, palpate, percussed and
auscultate?
2- Symptom.
signs
3- Example: When our patient (or Example: Objective data, or signs, can be
his family or friends) provides verified. If a patient complains of a sore arm,
information you can't verify by for example, you may see a red, swollen area
observation or measurement, that feels warm. Although his complaint of
consider it subjective data — in pain is subjective, the redness, warmth, and
short, symptoms. A patient's swelling that you observe are objective signs
complaint of pain would be an of his health problem.
example of a symptom
- Method of assessment?
A- Health history (subj. Data).
B- Physical assessment (obj. Data).
A- Health history (subj. Data): Systematic collection of subjective data which
stated with client. It is a current collection of organized information unique to an
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individual. Relevant aspects of the history include biographical, demographic,
physical, mental, emotional, sociocultural, sexual, and spiritual data.
-Phases of taking health history:
The health history have two phases:
The interview phase: Establishing The Interview Setting
Before taking a health history, make sure the setting is quiet and private and that
the patient is comfortable. Sit facing the patient, about 3' to 4' (about 1 m) from
him.
The recording phase: record any information taken form the patient during the
interview, record should be done after the interview is end.
- Types of Nursing Health History:
Complete health history: taken on initial visits to health care facilities.
Interval health history: collect information in visits following the initial data
base is collected.
Problem- focused health history: collect data about a specific problem.
Complete Health History
Unlike the medical health history, the nursing health history takes a holistic approach,
focusing on the patient's illness and his responses to it. During the health history, you'll
establish a rapport with your patient and collect important information on how the
illness affects him and his family and what educational needs they have. This
information then helps you direct your plan of care and initiate discharge planning.
Frequently, you may find that the subjective data you collect during the health history
tells you more about the patient's health status than the physical examination.
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Components of the Health History
1- Biographical data
Begin by asking the patient his name, address, telephone number, birth date, age,
birthplace, Social Security number, race, nationality, religion, and marital status. Also
find out the names of anyone living with the patient, the name and telephone number
of the person to call in an emergency, and the patient's usual source of health care.
2- Chief Complaint and History of Present Illness
The nurse begins the history by investigating the patient’s chief complaint. The patient
is asked to describe in his or her own words the problem or reason for seeking care.
Examples of chief complaints:
Chest pain for 3 days.
Swollen ankles for 2 weeks.
Fever and headache for 24 hours.
The nurse then asks for more information about the present illness, according to the
following manner:
 N Normal: Describe your normal baseline. What was it like before this symptom
developed?
 Onset: When did the symptom start? What day? What time? Did it start suddenly
or gradually?
 P Precipitating and palliative factors: What brought on the symptom? What
seems to trigger it—factors such as stress, position change, or exertion? What were
you doing when you first noticed the symptom? What makes the symptom worse?
What measures have helped relieve the symptom? What have you tried so far? What
measures did not relieve the symptom?
 Q Quality and quantity: How does it feel? How would you describe it? How much
are you experiencing now? Is it more or less than you experienced at any other time?
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 R Region and radiation: Where does the symptom occur? Can you show me? In
the case of pain, does it travel anywhere such as down your arm or in your back?
 S Severity: On a scale of 1 to 10, with 10 being the worst ever experienced, rate
your symptom. How bad is the symptom at its worst? Does it force you to stop your
activity and sit down, lie down, or slow down? Is the symptom getting better or
worse, or staying about the same?
 T Time: How long does the symptom last? How often do you get the symptom?
Does it occur in association with anything, such as before, during, or after meals?
-or according to the following manner:
 Onset, duration, precipitating factors.
 Frequency.
 Associated symptoms.
 Alleviating/ aggravating factors
 Relieving factors.
 Time.
3- Medical history
-Past medical history: (DM, HT, CVD, HF, RD, RD).
-Past surgical history: (appendectomy) (how and why this done).
-Past medication: (any drug use to treated the chronic diseases)
4- Past Health History
When assessing the patient’s past health history, the nurse inquires about childhood
illnesses such as rheumatic fever as well as previous illnesses such as pneumonia,
tuberculosis, thrombophlebitis, pulmonary embolism, MI, diabetes mellitus, thyroid
disease, or chest injury. The nurse also asks about occupational exposures to
cardiotoxic materials.
Finally, the nurse seeks information about previous cardiac or vascular surgeries and
any previous cardiac studies or interventions.
5- Current Health Status And Risk Factors
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As part of the health history, the nurse queries the patient about use of prescription and
over-the-counter medications, vitamins, and herbs. It is essential to ask the patient
about drug allergies, food allergies, or any previous allergic reactions to contrast
agents. The nurse inquires about use of tobacco, drugs, and alcohol. The nurse also
asks about dietary habits, including usual daily food intake, dietary restrictions or
supplements, and intake of caffeine containing foods or beverages. The patient’s sleep
pattern and exercise and leisure activities also are noted.
6- Family History
The nurse asks about the age and health, or age and cause of death, of immediate family
members, including parents, grandparents, siblings, children, and grandchildren.
7- Social History
 Occupation:
o Occupational status (full-time, part-time, retired).
o Importance of work to his/her self-image (mild, moderate, high).
 Housing:
o Residence (Urban or Rural).
o House property (owns, rents).
o Home environment facilities (heating, cooling, lightening, cooking
facilities, others).
 Safety and security burden:
o Occupational exposure to health hazards (excessive noises, pollution,
toxic chemicals/vapors, injuries, infectious agents, others).
o Home exposure to health hazards (excessive noises, pollution, toxic
chemicals/vapors, injuries, infectious agents, others).
o Community exposure to health hazards (excessive noises, pollution, toxic
chemicals/vapors, injuries, infectious agents).
 Socio-economic status:
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Note the adequacy of personal and/or family income to meet requirements for
housing, food, clothing, education, recreation in term of adequate, adequate to
some extent, inadequate.
 Diet:
o Nutritional status (body mass index**, condition of the mouth and teeth,
ability to swallowing, appetite, digestion, adequacy of food intake
including basic four).
o Is there any health conditions/diseases influence the usual dietary
practices (peptic ulcer, DM, nausea and vomiting, hyperacidity, renal
diseases, heart diseases, hypertension, loss of consciousness, abnormal
openings, others).
o Therapeutic diet (nothing by mouth, I.V. fluids, liquid diet, soft, low
sodium, low protein, low carbohydrate, high protein, low fat, high
carbohydrate, prudent diet, tube feeding).
**: body mass index calculated through the following formula:

BMI= Weight/ Height (m)2
 Exercises:
o Record the type, intensity, duration, frequency, factors affecting the
patient participation in regular exercises.
 Sleep:
o Usual number of hours per 24-hour period
o Factors interfering with sleep (pain, orthopnia, others).
- Use of supportive aids (analgesics, sedatives, back rub, taking warm drinks,
taking warm bath, quite environment).
 Drugs and alcohol use:
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o Use of illicit drugs (type, amount, rout of administration, and how long).
o Smoking (type, how much, and how long).
o Alcohol (how much, and how long).
 Social support:
 Is the patient receive social support? (In term of yes or no).
 Who/what are his/her primary sources of support? (Father, mother,
brothers, sisters, friends).
 To what extent does he/she want these individuals to be involved in his/her
care?

Katz Index of Independence in Activities of Daily
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8- Review of systems:
The nurse can asking the patient about all the body systems problems from general to
specific.
- Guidelines for Taking Nursing History:
Private, comfortable, and quiet environment.
Allow the client to state problems and expectations for the interview.
Orient the client the structure, purposes, and expectations of the history.
Communicate and negotiate priorities with the client
Listen more than talk.
Observe non-verbal communications e.g. "body language, voice tone, and
appearance".
Review information about past health history before starting interview.
Balance between allowing a client to talk in an unstructured manner and the need
to structure requested information.
Clarify the client's definitions (terms & descriptors)
Avoid yes or no question (when detailed information is desired).
Write adequate notes for recording?
Record nursing health history soon after interview.
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