HEALTH ASSESSMENT:

AN OVERVIEW
DIANA ROSE D. EMERENCIANA, RN., MAN
 PURPOSE OF NURSING HEALTH
ASSESSMENT
 To collect subjective & objective data to
determine a client’s overall level of
functioning in order to make a professional
clinical judgement
 the mind, body and spirit are
interdependent factors that affect a persons
level of health (Holistic)
 THE
PERSON The
(Therapeutic Disease
Use of Self- (Pathological
Aspect of and Sciences
Nursing “The “ The Cure”
Core”

THE BODY
“The Care”

CORE, CARE AND

CURE MODELS
THE 5 STEP Step 1: Assessment
Complete data? Lab & x-ray?

NURSING Multidisciplinary? What is going on?

What are my patient’s Learning
needs?

PROCESS
Step 2: Diagnosis
Potential Problems?
Step 5: Top 2 Priorities?
Evaluation Two Measurable Outcomes?
Make a Difference?
Modify Plan?
Accomplish
Outcomes?

Step 3: Planning
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Step 4: Involve Patient and Family?
Implementation
Am I Being Effective? Efficient?
Have I Delegated Properly?
 Assessment
Activities During Assessment
1. Collecting Data- This involves gathering information
about the patient, considering the physical,
psychological, emotional, cultural and spiritual factors
that may affect his her health status.
Types of Data
a. Subjective data (Symptoms)
b. Objective data (Signs)
 Assessment
Methods of Collection of Data
A. Interview – it is planned, purposeful conversation
Examples: Collection of data for health history
Admission of patient to a health care facility.
B. Observation
Examples: Use of senses (vision, hearing, touch, smell)
Use of units of measure
Physical examination (IPPA)
inspection,palpation, percussion, auscultation
Interpretation of lab results ( urinalysis,
RBC,WBC,PUS and bacteria)
 Assessment
Sources of Data

A. Primary Source – Patient

B. Secondary Source – Family members and significant
others, patients chart, health team members, related
literature (books, journal, researchers, brochures)
 Assessment
Activities During Assessment
1. Verifying/Validating Data – Making sure your
information is accurate
Example: 1. The patients urine is in dark in color
How to validate dehydration?
2. The patient doesn’t want to take
food at 11:30AM
How to validate?
THE 5 STEP Step 1: Assessment
Complete data? Lab & x-ray?

NURSING Multidisciplinary? What is going on?

What are my patient’s Learning
needs?

PROCESS
Step 2: Diagnosis
Potential Problems?
Step 5: Top 2 Priorities?
Evaluation Two Measurable Outcomes?
Make a Difference?
Modify Plan?
Accomplish
Outcomes?

Step 3: Planning
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Step 4: Involve Patient and Family?
Implementation
Am I Being Effective? Efficient?
Have I Delegated Properly?
 2. Diagnosing
Purpose – To identify the patients health care needs and
to prepare diagnostic statements.

Nursing Diagnosis uses PRS/PES

P- Problem P- Problem
R- relates Focus E- Etiology
S- Signs and symptoms S- Signs and
Symptoms
 2. Diagnosing
Activities of Diagnosing
1. Organizing the Data
Clustering the facts into groups of information
Examples: 1. Data About Patients Nutritional Status
2. Fluid Imbalance Nutrition
a. Subjective data?
b. Objective data?
 2. Diagnosing

2. Compare Data Gathered During Assessment

Against Standards
 Standards are accepted norms, measures, or patient
purposes of comparison

3. Analyzing data after comparing with standards

Example: Passage of frequent watery stool may
lead to dehydration and loss of electrolytes like
potassium and sodium.
 2. Diagnosing

4. Identify gaps and inconsistency in data

5. Determine the patients health problems, health

risks and strengths.

6. Formulate nursing diagnosis statements

 2. Diagnosing

1. Fluid volume deficit related to frequent

passage of stool
2. Inadequate nutrition related to poor oxygen
carrying capacity of the blood
3. Ineffective airway clearance related to:
weak respiratory muscles/thick mucous
secretions
4. Alteration in nutrition: less than body
requirements related to poor apetite.
 2. Diagnosing
Summary of Steps of Nursing Diagnosis
a. Cluster data
b. Compare with standards
c. Make a reasoned conclusion
d. Nursing diagnosis
Alteration in Bowel Elimination (diarrhea)
related to:
food intolerance
irritation
 2. Diagnosing

CORRECT INCORRECT

Acute pain related to physical Acute pain related to mycardial

exertion infarction
Ineffective breathing pattern Ineffective breathing pattern
related to increased airway related to pneumonia
secretion
Diarrhea related to food Diarrhea related to colon
intolerance cancer
THE 5 STEP Step 1: Assessment
Complete data? Lab & x-ray?

NURSING Multidisciplinary? What is going on?

What are my patient’s Learning
needs?

PROCESS
Step 2: Diagnosis
Potential Problems?
Step 5: Top 2 Priorities?
Evaluation Two Measurable Outcomes?
Make a Difference?
Modify Plan?
Accomplish
Outcomes?

Step 3: Planning
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Step 4: Involve Patient and Family?
Implementation
Am I Being Effective? Efficient?
Have I Delegated Properly?
 Outcome Identification

PLANNING

Involves determining beforehand the

strategies or course of actions to be taken
before Implementation of nursing care. To
be effective involve the patient in his
family in giving care
 3. Outcome Identification
Refers to formulating and documenting
measurable, realistic, patient- focused goals. It
provides the basis for evaluating nursing
diagnosis.
Purpose:
1. To provide individual care
2. To promote patient participation
3. To plan care that is realistic and measurable
4. To allow involvement of support
 Outcome Identification
Activities During Outcome Identification
1.Establish priorities
Priority setting involves the following:
a.Life-threatening situations should be given
highest priority
b.Use the principle of ABC's airway, breathing,
circulation); airway should be the highest
priority.
c.Use Maslow's hierarchy of needs; Physiologic
needs are given priority over
 Outcome Identification
Activities During Outcome Identification
d. Consider something that is very important to the
patient.
Ex. Pain, anxiety
e. Patients with unstable condition should be given
priority over those w/ stable conditions.
f. Actual problem take precedence over potential
concern
g. Do assessment before implementation
 Outcome Identification
Activities During Outcome
Identification
1. High priority- those that are potentially
life threatening and require immediate
action
2. Medium priority- those that could result
in unhealthy consequences, such as
physical and emotional impairment but not
life-threatening.
3. Low priority-involve problems that
usually can be resolved easily with minimal
 Outcome Identification
Activities During Outcome
Identification
2. Establish patient's goal and criteria
A patient goal is an educated guess, made
as a broad statement about what will be the
patient's state after intervention is carried out.

Behavioral goals are written to indicate a desired

state. They contain an action verb and a qualifier
that indicate the level of performance that needs
to be achieved.
 Outcome Identification
Activities During Outcome
Identification
Examples of behavioral
Calculate Classify verb used in patient goal
Compare

Draw explain Express Identify

Demonstrate Construct Distinguish
Communicate Describe Define
List Name Maintain
Perform Participate Practice
 Outcome Identification
Activities During Outcome
Identification

1. Outcome criteria are written in a manner

that they answer the questions who, what
are the actions, under what circumstances,
how well and when
 Outcome Identification
Activities During Outcome
Identification

Therefore the characteristic of well

stated-outcome
S-specific
M-measurable
A-attainable
R-realistic
T-time framed
 Outcome Identification
Activities During Outcome
Identification

2. The patient will demonstrate safety

habits when performing ADL's and
prevention injury.

3. The patient will mobilize pulmonary

secretion.
 3. PLANNING

PURPOSES
1. To identify the patient's goals and
appropriate nursing intervention
2. To direct patient care activities
3. To promote continuity of care.
4. To focus charting requirements
5. To allow for delegation of specific
activities.
 3. PLANNING

Activities During Planning

1. Planning Nursing Interventions
To direct activities to be carried out be
the implementation phase
Nursing interventions are "any
treatment based upon clinical judgement
and knowledge
that a nurse performs to enhances patient
outcomes.
 3. PLANNING

Nursing interventions are also called

nursing orders
Nursing interventions are independent,
dependent and
interdependent/collaborative activities that
nurses carry out to provide patient care.
 3. PLANNING
Writing a nursing plan of care

The nursing plan of care is a written

summary of the care that a patient is to
receive.

It is the "blue print of the nursing process.

 3. PLANNING
Writing a nursing plan of care

The plan of care is a step-by-step process.

Evidenced by the following:
1. Sufficient data are collected to
substantiate nursing diagnosis.
2. At least one goal must be stated for
each nursing diagnosis.
3. Outcome criteria must be identified for
each goal.
THE 5 STEP Step 1: Assessment
Complete data? Lab & x-ray?

NURSING Multidisciplinary? What is going on?

What are my patient’s Learning
needs?

PROCESS
Step 2: Diagnosis
Potential Problems?
Step 5: Top 2 Priorities?
Evaluation Two Measurable Outcomes?
Make a Difference?
Modify Plan?
Accomplish
Outcomes?

Step 3: Planning
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Step 4: Involve Patient and Family?
Implementation
Am I Being Effective? Efficient?
Have I Delegated Properly?
 4. IMPLEMENTATION

Putting the nursing care plan into action.

Purpose:
To carry out planned nursing interventions
to help the patient attain goals and achieve
optimal level of health.
 4. IMPLEMENTATION

Activities:
1. Reassessing
2. Set priorities
3. Perform nursing interventions
4. Record actions
 4. IMPLEMENTATION

Requirement of Implementation
1. Knowledge
2. Technical skills
3. Communication skills
4. Therapeutic use of self
THE 5 STEP Step 1: Assessment
Complete data? Lab & x-ray?

NURSING Multidisciplinary? What is going on?

What are my patient’s Learning
needs?

PROCESS
Step 2: Diagnosis
Potential Problems?
Step 5: Top 2 Priorities?
Evaluation Two Measurable Outcomes?
Make a Difference?
Modify Plan?
Accomplish
Outcomes?

Step 3: Planning
What Shall I do?
Interdisciplinary?
Resources and Timeline?
Not Just Technical Care
Step 4: Involve Patient and Family?
Implementation
Am I Being Effective? Efficient?
Have I Delegated Properly?
 5. EVALUATION
Assessing the patients response to nursing
interventions and then comparing the
response to predetermined standards of
outcome criteria
Purpose:
To appraise the extent to which goals and
outcome criteria of nursing care have been
achieved
 5. EVALUATION
Activities
1. Collect the data about the clients response.
2. Compare the patients response to goals and
outcome criteria.
3. Possible judgement
Characteristics of the Nursing Process

1. Problem oriented
2. Goal oriented
3. Systematics
4. Open to accepting new information
5. Interpersonal
6. Permits creativity
7. Cyclical
8. Universal
Benefits of Nursing Process to the Patients

1. Quality to patient care

2. Continuity of care
3. Participation by the patient in their health
care
Benefits of Nursing Process to the for the Nurse

1. Consistent and systematic nursing

education
2. Job satisfaction
3. Professional growth
4. Avoidance of legal action
5. Meeting professional nursing standards
6. Making standards of accreditation of
hospitals.
 The Heart of Nursing Process
1. Knowledge, skills and caring
A. Interpersonal Skills
B. Intellectual Skills
C. Manual Skills
The Heart of Nursing Process
CARING – Willingness and Ability to

Being able to care

Understanding
selves
To be able to understand
others
To be more objective/non
judgmental
 Patient (Boy)

Weight Loss

Increased work pressure Weight loss of 10lbs(4.5kg) over past 2

months
Increased hours spent working 15hrs/day No complains of nausea, vomiting, diarrhea,
or constipation
Decreased ability to sleep Frequently anorexic
Upset over recent divorce; lives alone with Preilllness weight: 164 to 166lbs (78.8 to
no experience in food planning or 74.7kg)
preparation
Weight 155 lbs (69.8 kg), height 5’9 Hemoglobin 13.6mg/ml
(175.3cm)
Triceps skinfold thickness 12.1mm Hematrocrit 40%
Hemoglobin 120g/dl
)
Nursing Diagnosis
1. Knowledge deficit concerning principles of
sound nutrition and meal preparations
2. Ineffective coping with lifestyle changes
and career demands.
3. Alteration in nutrition: less than body
requirements.
4. Ineffective rest/activity pattern related to
excessive work hours and emotional upset
over divorce.
FRAMEWORK FOR HEALTH
ASSESSMENT IN NURSING
 HEAD – TO – TOE FRAMEWORK
 END RESULT OF NURSING
ASSESSMENT
 Nursing diagnosis (wellness, risk or
actual problem) that require nursing
care,
 the identification of collaborative
problems that require interdisciplinary
care,
 identification of medical problems that
require immediate referral
 4 BASIC TYPES OF
ASSESSMENT
1.Initial Comprehensive Assessment
2. On going or partial assessment
3.Focused or problem-oriented assessment
4.Emergency Assessment
INITIAL COMPREHENSIVE
ASSESSMENT
 collection of subjective data about the
client’s perception:
 health of all body parts
 past health history
 family history, and
 lifestyle and health practices
 objective data gathered during step – by
– step physical examination
ONGOING OR PARTIAL
ASSESSMENT
 Data collection occurs after the
comprehensive database is established
 mini overview of the client’s body
system and holistic health pattern as
follow up on health status
 an evaluation of previous findings
FOCUSED OR PROBLEM –
ORIENTED ASSESSMENT
 does not replace comprehensive HA
 performed when comprehensive
database exists for a client who comes to
the health care agency with specific
health concern
 a thorough assessment of a particular
client problem and does not address
areas not related to the problem
EMERGENCY ASSESSMENT
 A very rapid assessment performed in
life – threatening situations needing
prompt treatment
 its purpose is to determine the status of
the client’s life – sustaining physical
functions
4 MAJOR STEPS IN ASSESSMENT
PHASE
1.Collection of Subjective Data
2.Collection of Objective Data
3.Validation of Data
4.Documentation of Data
PREPARING FOR THE
ASSESSMENT
1. Review the client’s medical records
 Biographical data (age, sex, religion,
educational level and occupation)
 Chronic diseases
 Medications
 Allergies
 Previous & current health status
PREPARING FOR THE
ASSESSMENT
2. Keep an open mind and avoid premature
judgement that may alter your ability to
collect accurate data
3. Educate yourself about the client’s
diagnosis or tests performed
4. Reflect on your own feelings regarding
your initial encounter with the client
5. Organize materials needed for the
assessment
COLLECTING SUBJECTIVE DATA
 are sensations or symptoms (pain,
hunger), feelings (happiness, sadness),
perceptions, desires, preferences,
beliefs, ideas, values, and personal
information that can be elicited and
verified only by the client
 To elicit accurate data, use effective
interviewing skills
 MAJOR AREAS OF SUBJECTIVE
DATA
 Biographical information
 History of present health concern: physical
symptoms related to each body part
 Personal health history
 Family history
 Health & lifestyle practices (Risk, nutrition,
activity, relationships, cultural beliefs or
practices, family structure and function,
community environment)
 Review of systems
 Collecting Objective Data
 Direct observation of examiner & SO
 Physical characteristics (skin color,
posture)
 Body functions (HR, RR)
 Appearance (Dress & hygiene)
 Behavior (mood, affect)
 Measurements (BP, Temperature, height &
weight)
 Result of laboratory testing
 COMPARING SUBJECTIVE & OBJECTIVE DATA
SUBJECTIVE OBJECTIVE
Description Data elicited & verified Data directly & indirectly
by the client observed through
measurement
Sources Client; Family & SO; Observations & physical
Client Record; Other assessment findings of the
health care professionals nurse or other health care
professionals;
Documentation of
assessments made in
client record;
Observations made by the
client’s family or SO
 COMPARING SUBJECTIVE & OBJECTIVE DATA

SUBJECTIVE OBJECTIVE
Methods Client interview Observation & Physical
used to Examination
obtain data
Skills Interview & Inspection
needed to therapeutic Palpation
obtain data communication skills; Percussion
Caring ability & Auscultation
empathy;
Listening skills
 Validating Assessment Data
 Ensure that the assessment process is
not ended before all relevant data have
been collected
 Helps to prevent documentation of
inaccurate data
Documenting Data
 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 analysed in
the second step of the nursing process
Analysis of Assessment Data/
Nursing Diagnosis
 second phase of the nursing process
 the nurse analyse & synthesize data to
determine whether the data reveal a
nursing concern(nursing diagnosis);
collaborative concern (collaborative
problem); concern that needs to be
referred to other discipline)
Nursing Diagnosis (North
American Nursing Diagnosis
Association)
 a clinical judgement concerning human
response to health conditions/ life
processes, or a vulnerability to a response,
by an individual, family, group or
community
 provides a basis for selecting nursing
interventions to achieve outcomes for
which the nurse is accountable
Collaborative Problems
 are physiological complications that
nurses monitor to detect their onset or
changes in status (Carpenito, 2017)
Referrals
 occur because nurses assess the whole
(physical, psychological, social, cultural,
and spiritual) client, often identifying
problems that require the assistance of
other health care professionals
Process of Data Analysis
 Identify abnormal data and strengths
 Cluster the data
 Draw inferences and identify problems
 Propose possible nursing diagnoses
 Check for defining characteristics of
those diagnoses
 Confirm or rule out nursing diagnoses
 Document conclusions
Factors Affecting Health
Assessment
1.Culture
2.Family
3.Community
4.Spirituality
 Formulate Nursing Diagnosis
1. Problem: Weight Loss
2. Subjective Data: Severe Diarrhea (up to 8
episodes /day, including some passage of some blood
in stools for past 4 days, anorexic for past 2 months,
resulting in decreased intake, weight loss of 25lb
(11.3kg) over past 2 months, Worried over loss of
school time (college freshmen) also worried about
academic standing, because it affects his scholarship,
complains of fatigue, doesn’t have the energy to
wash or cook, preillness weight 163 lb(73.4kg)
 Formulate Nursing Diagnosis
3. Objective Data: Weight 138 (62.1kg),
height 5’11” (180.3cm), arm circumference
21.3cm, Hemoglobin 100mg/dl, hematocrit
34%.
Thank
You!!!