HEALTH ASSESSMENT RLE: Always verify information from the
LESSONS 1-2 client (allergies).
Health Assessment Don't be prejudiced as a nurse (this will
A systematic method of collecting and alter your ability to collect accurate
analyzing data for the purpose of data); prepare your mindset to be
planning patient-centered care. objective in your dealings with the
client.
Nursing Process Educate yourself about the client's
Is an evidence-based, five step health condition/diagnosis/previous
scientific method used to ensure that tests/unfamiliar diagnosis/tests.
the patient is assessed, diagnosed, and After gathering data, reflect on
receives continuity of care across personal feelings.
appropriate healthcare providers and Prepare and organize necessary
departments. materials and equipment to be used.
Hollistic Care Needs The assessment phase of the nursing
VPI. process has four major steps:
1. Collection of subjective data
Assessment 2. Collection of objective data
The first foundational step. 3. Validation of data
It is a collection of comprehensive data 4. Documentation of data
pertinent to the patient’s health and/or
situation. 1. COLLECTING SUBJECTIVE DATA
Subjective Data is verbal or written
Components of Health Assessment information provided by the patient or
1. Conducting health history interview. their family. This data is compiled
2. Performing a physical examination. through interviews, ongoing
3. Review other data from health record if assessments, admissions processes,
available. and questionnaires.
4. Documentation. Subjective Data are sensations or
symptoms (e.g., pain, hunger),
Purpose of Nursing Health Assessment feelings (e.g., happiness, sadness),
To collect holistic (physiological, perceptions, desires, preferences,
psychological, sociocultural, beliefs, ideas, values, and personal
developmental, & spiritual data) information that can be elicited and
subjective and objective data to verified only by the client.
determine a client’s overall level of To elicit accurate subjective data,
functioning in order to make a learn to use effective interviewing skills
professional clinical judgement. with a variety of clients in different
settings.
Preparing for the Assessment The major areas of subjective data
Review previous medical record if any. include:
Biographical information (name, physical therapists, dietitians, social
age, religion, occupation). workers) observed about the client.
History of present health Observations noted by the family or
concern: Physical symptoms significant others about the client.
related to each body part system
(eyes and ears, abdomen). Comparing Subjective and Objective
Personal health history. Data
Family health history. VPI.
Health and lifestyle practices
(e.g., health practices that put the 3. VALIDATING ASSESSMENT DATA
client at risk, nutrition, activity, Validation of Assessment data is a
relationships, cultural beliefs or crucial part of the assessment that
practices, family structure and often occurs along with collection of
function, community environment). subjective and objective data.
Subjective Data can be collected from It serves to ensure that the assessment
two sources: process is not ended before all relevant
1. Primary source data have been collected, and helps to
2. Secondary source prevent documentation of inaccurate
data.
2. COLLECTING OBJECTIVE DATA What types of assessment data should
The examiner directly observes be validated, the different ways to
objective data. These data include: validate data, and identifying areas
Physical characteristics (e.g., where data are missing are all parts of
skin color, posture). the process.
Body functions (e.g., heart rate,
respiratory rate). 4. DOCUMENTING DATA
Appearance (e.g., dress, hygiene). Documentation of assessment data is
Behavior (e.g., mood, affect). an important step of assessment
Measurements (e.g., blood because it forms the database for
pressure, temperature, I weight). the entire nursing process (baseline for
Results of laboratory testing evaluation and continuity of care).
(e.g., platelet count, x-ray findings). Will be available with other health care
It is obtained by general observation professionals involved in the care.
and by using the four physical It must be complete, accurate, &
examination techniques: (IPPA) descriptive (improves the plan of care
INSPECTION and prevent repetition of the same
PALPATION information from the patient).
PERCUSSION Serves as a legal permanent record/
AUSCULTATION document of the patient's health
Client's medical/health record, which is situation at the time of appointment.
the document that contains information It must be accurate, concise, without
about what other health care bias or opinions, and at the point of
professionals (i.e., nurses, physicians, care.
EHR = ELECTRONIC HEALTH RECORD II. WORKING PHASE
SYSTEM Elicit the client's comments about
Is a digital collection of personal health biographical data, reasons for seeking
information that can be shared by all care, history of present health concern,
health care providers. past health history, family history,
To integrate the documentation of care health and lifestyle practices, and
across participating health systems. review of systems.
Use critical thinking skills to listen for
GUIDELINES FOR OBTAINING A and observe cues, and to interpret and
NURSING HEALTH HISTORY validate information received from the
Professional interpersonal and client.
interview skills are necessary to Collaborate with the client to identify
obtain a valid nursing health history. problems and goals.
The nursing interview is a The approach used for facilitation may
communication process that focuses on be either free flowing or more structure
the client's developmental, with specific questions, depending on
psychological, physiologic, sociocultural, available time and type of data needed.
and spiritual responses that can be
treated with nursing and collaborative III. SUMMARY & CLOSURE PHASE
interventions. Summarize information obtained during
There are three basic phases, the working phase and validate
explained below by describing the roles problems and goals with the client.
of the nurse and the client during each Begin to discuss possible plants to
phase. resolve the problems (nursing
I. Introductory Phase diagnoses and collaborative problems).
II. Working Phase Allow client time to express feelings,
III. Summary & Closure Phase concerns, and questions.
I. INTRODUCTORY PHASE
Introduce yourself and describe your
role (ie. RN, student, etc.).
Address the client with surname.
Explain the purpose of the interview to
the client (ie. To collect data to
understand the client’s needs, and to
plan nursing care).
Explain the purpose of note-taking,
confidentiality, and the type of
questions to be asked.
Provide comfort, privacy, and
confidentiality.