1.HA-THEORY-STUDENT.pptx

Health Assessment is an organized
systematic assessment of Human Body
which involves the use of one’s senses to
determine the general physical and
mental conditions of the body by
collecting both subjective and objective
data.

 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 activities based on the patient's immediate
condition, or anticipated needs of the patient or situation,
 Uses appropriate evidence- based assessment techniques and instruments in
collecting pertinent data.
 Uses analytical models and problem-solving tools
 Synthesizes available data information and knowledge relevant to the
situation to identify patterns and variances.
 Validates diagnosis or issues with the client, family and other health care
providers when possible and appropriate.
 Document relevant data.

Physical Assessment has been an integral part of Nursing since the
days of FLORENCE NIGHTINGALE.
1800
1900
Nurses relied on
their natural
sense the clients
face, body will be
observed.
Palpation
Was used to
measure pulse
rate.
Case finding
Control of
Communicable
Diseases and
Routine use of
Nursing Skills
1930
1949
Nurses were hired
To conduct pre-
employment
Health history and
Physical examination
For companies
Acute care nurses
Plan of care was
established
1950
1989
Nurses' role in
holistic assessment
Demand for
documentation of
client assessment
Nurses was
responsible for
assessing and
validating.
Nurse specialist
1990
present

 An accurate and timely health assessment provides foundation for
nursing care & intervention.
 Go for comprehensive assessment.
 The health assessment process should include data collection,
documentation and evaluation of the client’s health status.
 All documents should be objective, accurate, clear, concise,
specific and current.
 It should be practiced in all settings whenever there is nurse-client
interaction.
 Information gathered should be communicated to other health
care professional.
 Keep the confidentiality.

 In today’s litigious society, you must be ever vigilant when engaging
in nursing practice. Documentation issues have previously been
addressed. Equally important is how you execute the nursing
assessment. Establishing a trusting and caring relationship is the
primary element in avoiding malpractice claims.
 While performing each step in the physical assessment process,
you need to inform the patient of what to expect, where to expect
it, and how it will feel. Protests by the patient need to be addressed
prior to continuing the examination. Otherwise, the patient may
claim insufficient informed consent, sexual abuse, or physical
harassment.
 All assessments and procedures, including any injury that was
caused during the physical assessment, must be completely
documented. The institutional policy regarding patient injury in the
workplace must be followed.

 You are doing blood pressure screening at a health fair. You take the blood pressure
of a middle-aged man.Your reading is 170/100.
 You are working in the emergency department (ED) when a father comes in with his
9-year-old daughter. He states that she fell off her bike and hit her head but did not
lose consciousness. But she has a terrible headache and feels sick.
 You are making a postpartum follow-up visit to the home of a young mother who
had her first baby 2 days ago.
 You are making an initial hospice visit to a 74-yearold woman with pancreatic cancer.
CASE SCENARIOS
What do you do?
Where do you begin?
You begin with assessment. How well you perform your
assessment will affect everything else that follows.
You will ask questions, and you will use four of your senses to
collect data. This chapter introduces you to the assessment
process.

Nursing is the diagnosis and treatment of human responses to actual or potential
health problems. Diagnosis and treatment are achieved through a process,
called the nursing process, that guides nursing practice. The nursing process is a
systematic problem-solving method that has five steps:
1 ASSESSMENT
2 NURSING DIAGNOSIS
3 PLANNING
4 IMPLEMENTATION
5 EVALUATION

The nursing process is used
 to identify, prevent, and treat actual or potential health problems and
promote wellness.
 It provides a framework in which to practice nursing.
 it is as a continuous, circular process that revolves around your
patient.
 You begin with assessment
 collect data
 cluster the data
 formulate nursing diagnoses
 develop a plan of care
 determine the goals and expected outcomes
 Implement your plan
 then evaluate it.
 Then you will begin the nursing process again.

Your message here
DYNAMIC AND
CYCLIC
PATIENT CENTERED
GOAL DIRECTED
FLEXIBLE
PROBLEM ORIENTED
Your message here
COGNITIVE
ACTION ORIENTED
INTERPERSONAL
HOLISTIC
SYSTEMATIC
CHARACTERESTIC OF A NURSING PROCESS

TYPES OF ASSESSMENT
FOUR BASIC OF ASSESSMENT ARE:
1. Initial Comprehensive assessment
2. Ongoing or partial assessment
3. Focused or problem-oriented assessment
4. Emergency Assessment

TYPES OF ASSESSMENT
1. Initial Comprehensive assessment
 A COLLECTION OF SUBJECTIVE DATA ABOUT
PATIENTS' PERCEPTION OF HER HEALTH OF ALL
BODY PARTS OR SYSTEM.
 PAST HEALTH HISTORY, FAMILY HISTORY AND
LIFESTLE AND PRACTICES.
 OBJECTIVE DATA GATHERED DUTING A STEP-
BY-STEP PHYSICAL EXAMINATION.

TYPES OF ASSESSMENT
2. Ongoing or partial assessment
 CONSIST OF A DATA COLLECTION THAT OCCURS AFTER THE
COMPREHENSIVE DATABASE IS ESTABLISHED.
 CONSIST OF THE MINI- OVERVIEW OF CLIENTS BODY SYSTEM
AND HOLISTIC HEALTH PATTERN AS A FOLLOW UP ON HIS
HEALTH STATUS
 THIS TYPE OF ASSESSMENT IS USUALLY PERFORMED TO
DETECT ANY NEW PROBLEM
 IT IS USUALLY PERFORMED WHENEVER THE NURSE OR
ANOTHER HEALTH CARE PROFESSIONAL HAS AN ENCOUNTER
WITH THE PATIENT

TYPES OF ASSESSMENT
3. Focused or problem-oriented assessment
 Consist of a thorough assessment of a
particular client problem and does not cover
areas not related to the problem.
 A specific health concern

TYPES OF ASSESSMENT
1. Emergency Assessment
 A rapid assessment performed in a life-
threatening situation.
 An immediate diagnosis is needed to provide
prompt treatment.

FOUR MAJOR
STEPS
1.COLLECTION OF
SUBJECTIVE DATA
2. COLLECTION
OF OBJECTIVE
DATA
3.VALIDATION OF
DATA
4.DOCUMENTATION
OF DATA

Communication is a process of sharing information
and meaning, of sending and receiving messages. The
messages we communicate are both verbal and nonverbal.
FACTORS THAT INFLUENCE COMMUNICATION
1.Nonverbal Messages
Is an important source of data. Often, the nonverbal message
being sent is more accurate than the verbal one. So, examine
both your nonverbal behavior and your patient’s. Be conscious
of your beliefs and values and do not let them influence your
verbal or nonverbal communication. Nonverbal behavior
includes vocal cues or paralinguistics, action cues or kinetics,
object cues, personal space, and touch.

2. Cultural Considerations
Cultural communication patterns need to be
considered when obtaining a health history. Culture
can influence every aspect of communication, so
consider not only the language but also the vocal,
action, and object cues, personal space, and touch.
Use of touch as a means of communication also
varies with culture.
3. Verbal Communication Skills
Effective interviewing skills evolve through practice and
repetition. They encourage patients to further expand initial
brief answers and also help redirect patients who wander from
topic.

Affirmation/Facilitation.
Acknowledge your patient’s
responses through both verbal
and nonverbal communication
to reassure him that you are
paying attention to what he is
saying.
Silence. Although silence is
difficult to maintain at times, it can
be very effective at facilitating
communication. Periods of silence
allow your patient to collect her or
his thoughts before responding and
help prevent hasty responses that
may be inaccurate.
Clarifying. If you are unsure or confused
about what your patient is saying, rephrase
what she said and then ask the patient to
clarify. Use phrases like “Let me see if I have
this right,” or “I want to make sure I’m clear on
this, "or “I’m not sure what you mean.”
Restating. Restating the patient’s main idea
shows him that you are listening, allows you to
acknowledge your patient’s feelings,and
encourages further discussion.It also helps clarify
and validate what your patient has
said and may help identify teaching needs. F

Patient Interview Communication Techniques
Active Listening. Pay attention,
maintain eye contact, and really
listen to what your patient tells you
both verbally and nonverbally. As
you listen, keep in mind what you
are telling your patient nonverbally.
Active listening conveys interest
and acceptance.
Broad or General Openings.
This technique is effective when
you want to hear what is
important to your patient. Use
open-ended questions such as,
"What would you like to talk
about?”
Reflection. Allows you to acknowledge your
patient’s feelings, encouraging further discussion.
When your patient expresses a thought or feeling,
you echo it back, usually in the form of a
question. For example, if the patient states, "I am
so afraid of having surgery, "your
response would be, "You're afraid of having
surgery?”
Humor. Humor can be very therapeutic
when used in the right context. It can
reduce anxiety, help patients cope more
effectively, put things into perspective,
and decrease social distance.

Informing. Giving information
allows your patient to be involved
in his or her healthcare decisions.
An example would be explaining
the postoperative course and the
importance of coughing and deep
breathing to your patient
preoperatively
Focusing. allows you to hone in on a
specific area, encouraging further
discussion. Examples include: “You said
your mother and sister had breast
cancer?” or “Do you do BSE, and have you
ever had a mammogram?” In this case,
you have identified a risk factor and a
potential area for health education
Redirecting. Redirecting your patient helps
keep the communication goal-directed. It is
especially useful if your patient goes off on a
tangent. To get your patient on track again, you
might say, “Getting back to what brought you to
the hospital . . .”
Sharing Perceptions. With this
technique, you give your interpretation of
what has been said in order to clarify
things and prevent misunderstandings.
You may need to question your patient if
there is a discrepancy in the message
sent. For example, you might say,“You
said you weren’t upset, but you’re crying.”

Identifying Themes. Identifying
recurrent themes may help your
patient make a connection and focus
on the major theme. For example, you
might say, "From what you’ve told me,
it sounds like every time you were
discharged from the hospital to home
you had a problem.”
Sequencing Events. If your patient is
having trouble sequencing events, you may
need to help her or him place the events in
proper order. Start at the beginning and work
through the event until the conclusion. You
might say, “What happened before the
problem started? “Then what happened?”
“How did it end?”
Suggesting. Presenting alternative ideas gives your
patient options. This is particularly helpful if the patient is
having difficulty verbalizing his or her feelings. Suggesting
is also a good teaching tool. For example, if the patient
says, “I’ve tried so hard to lose weight, but I can’t,” you
might say, “Have you tried combining diet
and exercise?”

Presenting Reality. If your patient seems to be exaggerating or
contradicting the facts, help her or him reexamine what has already
been said and be more realistic. For example, if she or he says, "I
waited all day for someone to answer my call light, "you might
respond, "All day?”
Summarizing. Summarizing is useful at the conclusion of a major section
of the interview. It allows the patient to clarify any misconceptions you may
have. For example, you might say, “Let me see if I have this
correct: You came to the hospital with chest pain,
which started an hour ago, after eating lunch.”

Always be aware of the messages you are sending your patient, both verbally and
nonverbally. How you respond is critical in establishing the nurse-patient relationship.
Qualities that help establish and maintain this relationship include genuineness,
respect, and empathy.
■ Genuineness: Be open, honest, and sincere with your patient. Your patient can detect
a less-than-honest response or inconsistencies between your verbal and your nonverbal
behavior.
■ Respect: Everyone should be respected as a person of worth and value. You need to
be nonjudgmental in your approach. You may not always agree with your patient’s
decisions or like or approve of his or her behavior, but everyone needs to feel accepted
as a unique individual.
■ Empathy: Empathy is knowing what your patient means and understanding how she
or he feels. Showing empathy acknowledges your patient’s feelings; shows acceptance,
care, and concern; and fosters open communication. Phrases that recognize your
patient’s feelings help build a trusting relationship—for example, “That must have been
very difficult for you.”

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