NCM 101 HEALTH

ASSESSMENT
DIANNA ROSE BELEN, RN, LPT
 INTRODUCTION TO HEALTH
ASSESSMENT

• Case Study
Mrs. Gutierrez, age 52, arrives at the
clinic for diabetic teaching. She
appears distracted and sad,
uninterested in the teaching. She is
unable to focus, and paces back and
forth in the clinic wringing her hands.
What should the nurse suspect of Mrs.
Gutierrez?
• Nursing – 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. (Nursing:
Scope and Standards of Nursing Practice
(American Nurses Association (ANA), 2010)
• -Nursing Scope and Standards of
Practice Standard 1 – The RN collects
comprehensive data pertinent to the
patient’s health or situation. (ANA
p.21)
• -Nursing Scope and Standards of
Practice Standard 2 – The RN analyses
the assessment data to determine the
diagnosis or issues.
 ASSESSMENT: STEP ONE OF THE
NURSING PROCESS

•Assessment is the first and

most critical phase of the
nursing process.
PHASES OF THE NURSING PROCESS

Phase Title Description

I Assessment Collecting subjective and
objective data
II Diagnosis Analyzing subjective and objective
data to make a professional
nursing judgment (nursing
diagnosis, collaborative problem,
or referral)
III Planning Determining outcome criteria and
developing a plan
IV Implementation Carrying out the plan

V Evaluation Assessing whether outcome criteria

have been met and revising the
plan as necessary
 FRAMEWORK FOR HEALTH
ASSESSMENT IN NURSING

• A nursing framework helps to organize

information and promotes the collection of
holistic data.
• The questions asked in each physical
systems focus on that particular body system
and are broken down into four sections:
• History of Present Health Concern
• Personal Health History
• Family History
• Lifestyle and Health Practices
• The end result of a nursing assessment
is the formulation of nursing diagnoses
to know:
• nursing care
• identify collaborative problems requiring
interdisciplinary care
• identify medical problems that require
immediate referral
• client teaching for health promotion.
 USING EVIDENCE TO PROMOTE
HEALTH AND PREVENT DISEASE

• There are many models used to

analyze health promotion and
disease prevention.
• Two of the major models are:
• The Health Belief Model (Becker &
Rosenstock)
• The Health Promotion Model (Pender)
 THE HEALTH BELIEF MODEL

• based on three concepts:

• the existence of sufficient motivation;
• the belief that one is susceptible or
vulnerable to a serious problem;
• the belief that change following a
health recommendation would be
beneficial to the individual at a level
of acceptable cost.
THE HEALTH PROMOTION MODEL

• also focused on behavioral outcomes.

• Pender proposes that individual
characteristics and experiences (prior
related behavior and personal biologic,
psychological, and cultural factors) affect
behavior-specific cognitions and affect
(perceptions of benefit, barriers, self-
efficacy, and activity-related affect; as well
as interpersonal and situational influencers),
which in turn yield the level of commitment
to a plan.
TYPES OF HEALTH ASSESSMENT

• Initial comprehensive
assessment
• Ongoing or partial assessment
• Focused or problem-oriented
assessment
• Emergency assessment
STEPS OF HEALTH ASSESSMENT

• Four major steps:

• 1. Collection of subjective
data
• 2. Collection of objective data
• 3. Validation of data
• 4. Documentation of data
PREPARING FOR THE ASSESSMENT

• review the client’s medical record.

• keep an open mind and to avoid
premature judgments
• Use this time to educate yourself about
the client’s diagnoses or tests
performed.
• (laboratory manual, textbook, or
electronic reference resource, such as
a smart phone application)
• Once you have gathered basic data
about the client, take a minute to
reflect on your own feelings regarding
your initial encounter with the client.
• Remember to obtain and organize
materials that you will need for the
assessment.
 STEP 1 COLLECTING SUBJECTIVE
DATA

• Subjective - 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.
 CASE STUDY

• As the assessment progresses, the nurse learns

through the interview with Mrs. Gutierrez that she
has no appetite and no energy. She feels as though
she wants to stay in bed all day. She misses her
sisters in Mexico, and cannot do her normal
housekeeping or cooking. The nurse thinks that Mrs.
Gutierrez is probably suffering from depression. But
when the nurse asks Mrs. Gutierrez what she
believes is causing her lack of appetite and low
energy, Mrs. Gutierrez says she was shocked when
her husband was hit by a car. He could not work for
a month.
STEP 2 COLLECTING OBJECTIVE DATA

• This type of data is obtained by

general observation and by using the
four physical examination techniques:
• Inspection
• Palpation
• Percussion
• Auscultation
 STEP 3 VALIDATING ASSESSMENT
DATA

• crucial part of assessment that often

occurs along with collection of
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.
 STEP 4 DOCUMENTING DATA

• Documentation of assessment data is an

important step of assessment because 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.
 CASE STUDY

• Consider Mrs. Gutierrez, introduced at the

beginning of the chapter, to help illustrate
the reason for seeing the client in context.
The nurse continues to listen to Mrs. Gutierrez
and learns that she is also suffering from
“susto.” Mrs. Gutierrez states that a few days
in bed will help her recover her soul and her
health. The nurse decides to reschedule the
diabetic teaching for a later time and
provide only essential information to Mrs.
Gutierrez at this visit.
 QUESTIONS

• The nursing process is utilized to:

A. Provide a systemic, organized and
comprehensive approach to meeting the
needs of clients.
B. Encourage the family to make decisions
regarding patient's care.
C. Increase involvement of allied healthcare
professionals in decision-making
D. None of the above
• Objective data might include:
A.Chest pain.
B.An evaluation of BP
C.Complaint of dizziness
D.None of the above
• The following is the most important
purpose of documentation except
A.For Communication
B. For Reimbursement
C.For Quality assurance
D.To provide comfort
• Subjective data might include:
A.Heart rate
B.Oral temperature of 37.7 C
C.Pain Scale of 4/10
D.Poor hygiene
• A teenage girl spends most of her free time with
friends or at school. Sharing their concerns about
this behaviour with the school nurse, the parents are
worried about their child seeming to draw away
from them. The nurse's best reply is:
A. "You should really keep better track of your child.
It's hard to tell what kinds of trouble they may be
getting into.
B. "Use stricter guidelines for curfew and punishment
if curfew is broken."
C. "Is it possible that your child might be taking
drugs?"
D. "Independence is really important for this age
group. Try to be extra attentive when your child
does spend time at home."