Health Assessment Lecture

Week 1: Introduction, Unit 1

 What is Nursing?
o emphasis is placed on “diagnosis and treatment of human responses”, accurate
client assessments, how effective nursing interventions are
 The Nurse
o Collects data in an ongoing process
o prioritizes needs or situation appropriate evidence based assessment techniques
and instruments
 Focus of Health Assessment
o Collect holistic subjective: physiological, psychological, sociocultural,
developmental, spiritual, family, and community> all factors of a patient

 Nursing vs. Medical Assessment

 The Nursing Process:

o Assessment: objective data: what we see, subjective: what the patient tells us,
what we can’t prove. we’re collecting data in this step. What are the priorities?
Mind, body, soul.
o Diagnosis: make a judgement and come up with a plan, compare clinical finding
with normal and abnormal variation, interpret data, hypothesize, validate
diagnosis, document it. Based on assessment. Right here right now problems?
Potential Problems? We create the nursing assessment.
o Planning: determine outcome criteria and plan, what do we need to do to fix it?
Goal development. Specific, Measurable, Attainable, Realistic, Timely. SMART
GOALS
o Implementation: execute/carry out plan, Collab w/ colleagues and use evidence
based interventions (change the client’s outcome, action)
o Evaluation: progress, use ongoing assessment, is it working? May have to revise
the plan.
 Disease Prevention
o Health Belief Model: what people believe determines behavior
o Health Promotion Model: empowers people to increase control of health. Ex:
Exercising
o Disease Prevention: specific population and individual based interventions. Ex:
Covid Vaccine, Flu Vaccine
 Types of Health Assessment:
o Initial Comprehensive Assessment: Collection of subjective data, past medical
history, lifestyle, first interaction and covers wide range of issues
o Ongoing or partial assessment: data collection continues after the initial
comprehensive database. Next day, we’d do an ongoing
o Focused/Problem Oriented Assessment: Thorough assessment of a particular
client problem, doesn’t cover areas not related to the problem. Ex: cough, focus
on nose and throat, not abdomen.
o Emergency Assessment: Very rapid, performed in life threatening situations,
collect all data and performing life sustaining measures.

 Steps of Health Assessment:

1. Collection of subjective and objective data
2. Validate Data: Identify abnormal data and cluster data, propose a diagnosis
3. Document Data
4. Preparation
5. Review clients record
6. Review status with other health care team members
7. Educate about client’s diagnosis and test performed

 Subjective Data: anything patient says

o Includes:
 Family or personal history, lifestyle, health practices, deceptions, desires,
beliefs, ideas, values, personal info, review of systems
 Biographical data: name, address, phone number, DOB
 History of Present Illness: why are you here? Detailed description of the
concern (COLDSPA)

 Personal Past Health History: Immunizations, allergies, medications

  Family Health History: Health Problems within family Ex: Heart Disease,
alcoholism
 Review of Systems (ROS): skin, hair, nails, eyes, ears, mouth, throat,
nose, thorax lungs, breasts, heart, genitalia, trouble breathing, dry mouth,
abdomen
 Lifestyle: What do you do in a normal day? Do you Exercise? Have
prescribed medications? Education Background? Stress?
Pain and Nauseas are things that we can’t prove, so we can act on them.

 Interview Phase for Subjective Data (3 phases)

o Pre-introductory: medical records, discuss with other members, consults,
o Introductory: explain the purpose, discuss types of questions asked, the reason
for taking notes, assure the client that confidential info will remain confidential,
introduce yourself, make sure client is comfortable and has privacy, develop trust
o Working: Collect the bulk of Subjective Data, reason for seeking care, history/
past health history, family history, review of body systems from head to toe,
lifestyle and health assessments, listen and observe cues, use critical thinking
skills
o Summary/ Closing: summarize info, validate problem, identify, and discuss
plans, see if client has any questions

 PQRSTU Mnemonic:
o Provactive/ Palliative factors/Pattern: what makes pain better or worse?
o Quality: open ended questions, tell me about your pain, (sharp, dull, throbbing)
o Region/ Radiation: show me where the pain is (location)
o Severity: Ask child to rate pain, use a pain scale, consistently use the same pain
tool (scale of 1-10)
o Timing: is it constant, intermittent, continuous, combination? Certain times of
day or activities, locations? When did it first began? Do meds help? If so, pain
level after?
o U: How does the pain affect you?

 Interview Communication
o Nonverbal: appearance, demeanor, facial expression, attitude, silence, listening
~AVOID: distraction and distance, standing, excessive or insufficient eye contact
o Verbal: open ended and close ended questions, laundry list (list of descriptors.
Choose from list how they’re feeling), rephrasing: increase our level of accuracy,
well placed phrases (tell me more, mhmm), inferring (educate guess), provide info
 ~AVOID: rush interview, reading into the questions

 Special Considerations for Interviews:

o Gerontologic Variations: speak clearly, simple terms, avoid medical jargon,
show respect
o Cultural Variations: be aware of variations and have knowledge
o Emotional Variations:
o Anxious Client: who we are, what’s our goal, our purpose, quite forward and
precise, decrease external stimuli, calm atmosphere
o Angry Client: DON’T MATCH ENERGY, remain calm and in control, let them
vent and don’t argue or touch them, we may need help from other HCP, keep
space
o Depressed Client: Express interest in understanding client, don’t be overly
upbeat
o Manipulative Client: set limits, boundaries, difference b/w manipulation and a
reasonable request
o Seductive Client: set limits, encourage client to use appropriate methods, let
them know its inappropriate, if it continues have a witness and report behavior to
supervisor
o Sensitive Issues: beware of your own biases, ask questions and don’t be
judgmental

Key Points:
~health assessment divided into 4 steps
~4 types of nursing assessment
~nursing health assessment differs from other professional health care assessments
~assessment is the most CRITICAL

Key Points of Chapter 2:

~Subjective data is KEY, get as much as possible
~Interviews include verbal & nonverbal communication,

Chapter 3:
Objective Data

 WE obtain it
o Physical Characteristics, appearances, behavior, lab test, body functions
 Physical Exam: prepare yourself, practice and assess feelings and anxiety
 Inspection: use of eyes, use of vision, what can I see?
o good lighting, look and observe before touching, note characteristics, compare
appearance, they aren’t in the out and open, private space
 Palpation: use of touch, done with index and middle finger. Abdominal need four fingers,
never use your thumb for anything
o light palpitation: barely touch
o moderate: slight
o deep: push all the way down
o bimanual:
 Percussion: tapping, certain sounds should be made on body
 Auscultation: eliminate distracting noise, explain what we’re listening to, don’t apply too
much pressure, listen to skin and not on top of clothes
o Diaphragm: larger part of stethoscope
o Bell: smaller part of stethoscope
o earpieces down
 Standard Precautions
o Hand Hygiene
o Gloves
o Mask, eye protection, face shield
o Gown
o Linen: occupational health and blood-borne pathogens
o Patient Care Equipment: patient placement

 Client Approach and Preparation

o Explain Procedure and establish nurse-client relationship
o respect desires and requests
o explain the importance of exam
o leave room while patient changes
o explain positions and why you may change them
o begin exam w/ less intrusive procedures
o provide necessary container in case of need of sample

Key Points:
Is the patient okay?
Objective data is essential core
 Chapter 4:
Validating & Documenting Data
 Validation: verification that subjective and objective data are reliable and accurate.

 Methods of Validation
o Repeat assessment
o clarify data with client
o verify with other professional
o compare objective with subjective

 Documentation: if it’s not documented, then it’s not done.

o Provides source of assessment data
o ensures info about client ad family is accessible to health team
o establish basis for diagnosis, helps diagnose new problems, constitutes a
permanent legal record

 Documenting Data:
o nonerasable ink
o use correct grammar and phrases
o record data findings, not how they were obtained
o don’t document before assessment
o don’t use normal, normal changes per person.

 Assessment Forms:
~

 Verbal Communication:
o ISBARR (Identify, situation, background, assessment, recommendation, read
back orders)
 Identify. State the team member’s name and title.
 Situation. Provide the circumstances that have required the
communication to occur.
 Background. Provide the background data regarding the client to assist
the provider with familiarity.
 Assessment. Provide the most recent set of vital signs or other data
relevant to the communication.
 Recommendations. Provide any suggestions that may be helpful to the
situation.
 Read back orders. Repeat the orders that are given and clarify anything
that is unclear.
o allows us to communicate face to face, phone to phone, provide and validate data
and what was received

Key Points:
Is data reliable and accurate?
Validating documentation provides record of care.

Chapter 5
Diagnosis: Data Analysis
 Steps:
~Step One: identify strengths (ex: exercise) and abnormal data (ex: elevated BP)
~Step Two: cluster data
~Step 3: Draw inferences; potential diagnosis, “hunches”
~Step 4: propose possible diagnosis
~high risk potential
~Step 5: defining characteristics using NANDA, compare findings to NANDA
~Step 6: Confirm or rule out any diagnosis, validate with client or HCP
~Step 7: document diagnosis

 Nursing Diagnosis: clinical judgement about potential health problems and life
assessments
~Actual Diagnosis: a real problem exists based on assessment data
~PES:
~(P)roblem: NANDA label
~(E)tiology: what problem is related to
 ~(S)igns and symptoms
~Risk Diagnosis: at risk if we don’t intervene
~Syndrome diagnosis: group of diagnosis, similar interventions

 Collaborative Problems
 Prioritization: what should be addressed first?
~First level: Airway, Breathing, Circulation, Vital sign concerns
~Second Level: Mental status changes, Acute pain, Untreated medical problems,
Abnormal lab values

Key Points:
7 steps of data analysis
Expertise: knowledge and experience
Week 2: Assessing Psychosocial Development, Violence, Culture
 Erikson’s Developmental Stages: 8 stages of the life span
Adolescent Identity vs role Peers, emotional Confused, nonfocused Devotion
confusion independence from and fidelity
parents, same as others
but unique, abilities
and goals, several
identities into one,
friendships mean much,
trying to fit in
Young adult Intimacy vs isolation Friends, lovers, Loneliness (no friends, Affiliation
spouses, community, partners), poor and love
networking, work relationships
relationships, where is
your focus?
Middle-aged adult Generativity vs Younger generation, Shallow involvement Production
stagnation family, community, w/ the world in and care
mentoring, helping general, selfish, little
others, “giving back”, psychosocial growth,
priority is their family opinions don’t matter,
stuck in the same place
Older adult Ego integrity vs All mankind, reviewing Regret, discontent, Renunciation
despair one’s life, acceptance pessimism, despair and wisdom
of death, acceptance of (haven’t done
worth, “Have I done anything, they’re not
everything I’ve wanted accepted, don’t want to
to do?” die)

 What is Domestic Violence?

o Types of Family Violence
 Physical: hitting, pushing, shoving (anything that involves touch that hurts
someone)
 Psychological: threats, humiliation, intimidation, talking down on
someone, stalking (verbal or actions)
 Economic: controlling resources, spending money w/o knowledge or
abuse, controlling money (no access to finances)
  Sexual abuse: no consent, violence after sex (any unwanted or coerced
sex)
o Categories of Family Violence
 Long Term Consequences of Child Abuse
o Other Types of Violence
 School violence (bullying and punking)
 Hate crimes
 Human trafficking
 War crimes
o Nursing Assessment of Family Violence
 All childbearing women from ages 14-46 should be screened for IPV even
w/o obvious signs of abuse.
 Nurses are mandatory reporters of abuse
 Examine your feelings, beliefs, and biases. Leave them at the door.
o Collecting Subjective Data
 Create safe environment
 Establish trust
 Don’t interrupt
 Show empathy
 We report suspicions w/ children: bruises/burns in different stages,
constantly coming into the facility
o Physical Exam
 Children: make sure they’re comfortable, parents could also be abused
 Danger assessment, safety plan
 Validation- document accurate data
 Remember they may choose to return home
 All clients may not disclose information

 Assessing Culture
o What is Culture?
 US is made up of many cultures. It is learned, shared, associated w/
adaptations to environment
 We must recognize that people have their own cultural beliefs that they
believe is right.
o Interview modifications
 Communication: time, space, eye contact, body language, gender roles,
silence, touch
o Cultural Competence (Sensitive)
 Awareness: what are my beliefs?
  Knowledge: be knowledge of ones in my area
 Skill: collect relevant and cultural data
 Encounter: being able to engage
 Desire: self-motivation to be culturally aware

 Assessing Spirituality, Religion, and Health.

o Spirituality and religion are important factors that can influence decisions and
outcomes.
o Religion: rituals, practices, and experiences that involve a search for the sacred
(God, Allah, etc.)
o Spirituality: a search for the meaning of life
o A person’s beliefs about the cause and meaning of suffering and pain affect the
illness
o Religion and spirituality can increase sense of well-being in the face of chronic
diseases management, can be powerful coping mechanisms.
o Religions can negatively affect health
 Christians: rely on prayers, rarely seek mainstream medical care
 Jehovah Witness: don’t accept blood transfusions.
 P.L.E.A.S.E
o P
o L
o E- Events leading to illness or injury
o A-Allergies and types of reactions (hives, swelling)
o S-symptoms or chief complaint, why did they come in (nail beds blue, out of
breath, why are you here?)
o E- Each prescribed medication, OTC meds, herbal supplements
 Introduce yourself: “Hello, my name is Dierra George and I’ll be your student nurse. Is
it okay if I ask you a few questions?”
 Information/Plan; Go through chart, how long have they been there, any specialties,
physicians
 Medical Record: Paper chart or electronic chart, review it and make sure you understand
what’s going on with the patient, why were they diagnosed with it? Never print the chart,
history, meds, must write it down, no pictures.
 Time and Place: Safe and private environment, hospital room, closed space, it’s okay to
ask questions in front of family
 Seating: 2 to 3 feet apart from client, be mindful of verbal and nonverbal cues
 Pain: Ask clients are you experiencing pain and rate it if so, document it. May not be a
good time to conduct interview. Pain is the 5th VS
 Transgenders: Ask about hormones, reassignment, will affect how they’re cared for
 Physical or Sensory Disability: have the right people there
 Directive Interview: gain detailed info about client’s condition, close ended questions,
easily documented (How often do you exercise, have you had the flu vaccine, what
causes you to become short of breath, how old are you?)
 Nondirective Interview: client controls pace, ask open ended questions. (Please describe
the chest pain, tell me about the voices you’re hearing, what brought you in today?)
 Use words that are easy for the average patient to understand. (Instead of diabetes, high
blood sugar)
 Avoid “Why” (Why haven’t you took your medication, why aren’t you eating right)
Instead, “Is there anything that is stopping you?”
 With older people, don’t change the topic so quickly. Complete one topic before moving
to the next.
 Always document in clients’ own words. Chief complaint or presenting problem. Instead
of client states, use “I am having lower back pain”. Interpret and validate response,
summarize it.
 History or Present Illness: establishes a baseline for clients
o Document in chronological order the appearance of the manifestations connected
with the reason for seeking care.
o Any other signs or symptoms that may support their visit.
o Childhood Illnesses: are there any?
o Chronic Illness: (6 months or more) asthma, diabetes, seizures, heart disease,
hepatitis
o Hospitalizations: when, why, where, duration
o Surgery: what, when, and where, complications, outcome
o Immunizations: do you have them all?
o Allergies: Foods, medications, environmental or contact triggers, latex
o Current medications (medication reconciliation): accurate list of prescribed
medications including herbs
o Family History: Immediate family, can impact patient’s health, 3 generations
o Obstetrical:
 Gravida: total # of pregnancies experienced
 Term: # of pregnancies that were carried to within 2 weeks of due date
 Preterm: pregnancies delivered more than 2 weeks before due date
 Abortion: spontaneous (miscarriage) or induced (therapeutic)
 Living: current number of living children
o OLD CARTS
 O- Onset: When symptoms began
 L-Location: where are the symptoms
 D-Duration: how long have they been there
 C-Characteristics: what it looks like, what It feels like (burning, aching)
  A-Aggravating/ Alleviating: what improves it or worsens it?
 R-Related: other symptoms related
 T-Treatments: treatments that have been tried
 S-Severity: how severe are they
 Functional Assessment
o What can they do, what are they doing?
o Comfortable being yourself and social settings
o How do they see themselves in a functional role?
o Self-esteem, role performance, body image, personal identity
o Exercise, mobility issues, navigate home and environment
o Sleep: naps, sleep patterns, assistance with falling asleep
o FICA: spirituality
 Faith: spiritual traditions
 Influence:
 Community: religious or spiritual community
 Address: preferences (catholic, Muslim, Jehovah witness)

Week 3: Interviews

o Pre-introductory: medical records, discuss with other members, consults,

address biases, private location, past medical history
o Introductory: explain the purpose, discuss types of questions asked, the reason
for taking notes, assure the client that confidential info will remain confidential,
introduce yourself, make sure client is comfortable and has privacy, develop trust
 Hello, my name is, I’ll be your student nurse, how are you
doing today
 Ill be doing an assessment is that okay
o Working: Collect the bulk of Subjective Data, reason for seeking care, history/
past health history, family history, review of body systems from head to toe,
lifestyle and health assessments, listen and observe cues, use critical thinking
skills
 COLDSPA, OLD CARTS
 Can you tell me whats going on
 What brought you in today
o Summary/ Closing: summarize info, validate problem, identify, and discuss
plans, see if client has any questions
 I want to confirm that your pain is blah blah.. and were doing XYZ
 Can you confirm everything that I said?
  Do you have any questions?
Mock Interview w/ Miss Tolden
 Good morning, my name is, ill be your student nurse, im from PVAMU, is it okay if I can
work with you
 Part of my assignemtn is an interview for about 10-15 minutes, its confidential, my
instructor will see the video, is that okay>
 Can you confirm your name and DOB
 Can you provide your gender and your gender at birth
 What pronouns do you use?
 Can you give me your ethnicity or nationality? Are you married?
 Whats your educational level? Your employment level?
 Do you live with anyone or significant others? Care givers?
 Any drug allergies? Latex?
 Whats your reason for coming in today?
 Are you comfortable with this institution? is this your first time here?
 Can you describe your pain or characteristics
 COLDSPA
 Do you take any meds on a daily bases?
 Any OTC
