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Nursing Health Assessment
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2. Assessment is refers to systematic
appraisal of all factors relevant to a
client’s health.
Health Assessment components
•Nursing Health History
•Physical Examination
•Records & reports
•Review of lab & diagnostic test results
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11. Nursing Health History
Through the health history, the nurse elicits a
detailed, accurate, and chronologic health record as
seen from the client’s perspective.
Data collection techniques
Provide privacy and comfort for the patient
Greet the client and introduce yourself
Establish a verbal contract with the client that
delineates the purpose of the history taking
session, the client role , and a time limit for the
interview
Ask open- ended questions how may I help you
12. Components of Nursing History
1.Biographical Data
Date & Time
Client’s name, address, telephone #, social ID#.
Name , address, telephone#, of person to contact if
emergency or other situation.
Gender ,race, ethnic origin, religious preference.
Age , birth date, birth place, and marital status.
Occupation and level of education
Health insurance
13. 2. Chief complaints
Identify the client reason for seeking health care.
A brief statement (client own words) for the current
problem.
A description of onset and duration of problem
Present Health History
The history of present health concern or illness is the
single most important factor in helping the health care
team to arrive at a diagnosis or determine the person
needs
A detailed chronologic statement of the
problem, beginning with when the client last felt well
and ending with a description of the current condition.
14. Past Health History
A detailed summary of the person’s past health is an
important part of the database.
Immunization status
Known allergies
Childhood illness
Adult illness
Psychiatry illness
Injuries – burns, fractures, head injuries
Hospitalization
Surgical and diagnostic procedures
Medication history
Use of alcohol and other drugs.
16. Review of systems
Subjective information about what the patient
feels or sees with regard to major systems of
the body
Skin
Rash, itching, change in pigmentation, or
texture, sweating, hair growth and
distribution, condition of nails.
Skeletal
Stiffness of joints, pain, deformity, restriction of
motion, swelling, redness, heat.
Head
Headaches , dizziness, syncope, head injuries.
Eyes
Vision, pain, diplopia, photophobia, blind
spots, itching, burning, discharge, recent changes
in appearance of vision, contact lens
, glaucoma, cataracts.
17. Ears
Hearing acuity, earache, discharge
tinnitus, vertigo.
Nose
Sense of smell, frequency of
colds, obstruction, epistaxis, sinus pain, use of
any nasal spray.
Teeth
Pain, bleeding, swollen, extractions, dentures,.
Mouth and Tongue
Soreness of tongue or buccal
mucosa, ulcers, swelling
Throat
Sore throat, tonsillitis, hoarseness, dysphagia.
Neck
Pain, stiffness, swelling, enlarged glands or
18. Endocrine
Goiter, thyroid
tenderness, tremors, weakness, tolerance to heat and
cold, changes in hat or glove size, changes in skin
pigmentation, libido, bruisability, muscle
cramps, polyuria, polydipsia, polyphagia, hormone
therapy.
Respiratory
Pain in the chest relatioship to
respiration, dyspnea, wheezing, cough, sputum, hem
optysis, night sweats, last chest X-Ray, exposure to
TB.
Cardiac
Presence of pain or distress and
location, palpitations, Orthopnea, edema, cyanosis,
BP, last ECG.
Hematologic
19. Lymph nodes
Enlargement, tenderness,
Gastrointestinal
Appetite and digestion, intolerance to certain
classes of food.
Pain associated with hunger or
eating, eructation, regurgitation, heartburn, na
usea, vomiting, hematemesis.
Regularity of BM, hemorrhoids, jaundice, h/o of
ulcer, gall stones, polyps, tumors
Genitourinary
Dysuria, urgency, frequency, hematuria, nocturia
, polydipsia, poly uria, oliguria, edema of the
face, hesitency , stress incontinence, passage of
stones, h/o STD
20. Neuromuscular
Mental status – orientation to time
, place, person.
Memory – recalling past medical history
Cognitive level
Patient ‘s description of personality
Preseence of
tics, twitching, weakness, paralysis, tremor, In
coordination, fatigue, sensory
loss, temperature, touch, muscle
pain, cramps.
General constitutional symptoms
Fever, chills, malaise, fatigability, recent loss or
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23. PHYSICAL EXAMINATION
General principles:
Physical examination is the second component of a complete
Nursing health assessment.
Examine the client in quiet, warm , well lighted room;
consider privacy and comfort.
Practice and adhere to standard precaution throughout
the entire physical examination.
Assessment techniques:
Inspection
Auscultation
Palpation
percussion
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25. Assessment techniques
Palpation
Temperature Vibration
Texture Position
Moisture Size
Organ size and location Presence of lumps or
Rigidity or spasticity masses
Tenderness, or pain
26. Percussion
Assess underlying
structures for
location, size, density of
underlying organs.
Direct – sinus tenderness
Indirect- lung percussion
Blunt percussion-
organ tenderness
(CVA tenderness)
