I.
Introduction to Health Assessment & The Nursing Process
A. Core Definitions
Health: "A state of complete physical, mental, and social well-being and not merely the
absence of disease or infirmity" (WHO) .
Health Assessment: A systematic data gathering process (health history + physical
exam) to evaluate overall health status and facilitate a nursing care plan .
B. The Nursing Process (ADPIE) This is the problem-solving process nurses use . 1.
Assessment: Gathering subjective and objective data. 2. Diagnosis: Identifying the
problem based on data (nursing focus). 3. Planning: Devising a course of action and
setting goals. 4. Implementation: Executing the plan. 5. Evaluation: Determining if
goals were met.
C. Types of Data | Type | Description | Examples
Subjective (Symptoms) | Described only by the patient; what they tell you. | Dizziness,
pain (quality), fear, nausea.
Objective (Signs) | Observed and measured by the nurse/monitor. | BP, heart rate,
pallor, diaphoresis, lab results.
D. Symptom Assessment Mnemonic: OLD CARTS
Onset
Location
Duration
Characteristics
Aggravating factors
Relieving factors
Treatments
Severity
II. Interviewing and Communication
A. Motivational Interviewing (OARS) Evidence-based method to enhance the nurse-
patient relationship.
Open-ended questions
Affirmation
Reflective listening
Summarize and teach back
B. Phases of the Interview
1. Pre-interview: Self-reflection, reviewing records, setting goals, adjusting the
environment (private/comfortable).
2. Introduction: Establish rapport (greet by name/title), establish agenda (chief
complaint).
3. Working: Invite the patient's story (active listening), identify emotional cues (NURS:
Naming, Understanding, Respecting), generate diagnostic hypotheses.
4. Termination: Summarize points, discuss plan of care, review follow-up.
C. Adapting to Specific Patients
Silent Patient: Watch for non-verbal cues; silence may mean they are collecting
thoughts .
Talkative Patient: Let them talk for 5-10 mins, then focus on what is most important;
set limits .
Crying Patient: Offer tissues, accept the emotion, be supportive .
Language Barrier: Use qualified interpreters (not family, to ensure confidentiality and
accuracy); speak directly to the patient, not the interpreter .
III. The Health History
A. Types of Assessments
Comprehensive: New patients; provides baseline and fundamental knowledge.
Focused/Problem-Oriented: Established patients/urgent care; restricted to a specific
body system.
Emergency: Focused on emergent problems (ABCs).
B. Components of Comprehensive Adult Health History
1. Identifying Data
2. Chief Complaint (Quote the patient's own words)
3. History of Present Illness (HPI)
4. Past History (Allergies, Meds, Childhood/Adult illnesses)
5. Family History
6. Review of Systems (ROS)
7. Health Patterns
C. Obstetric History (The Pregnant Client)
Gravidity: Total number of pregnancies (including current).
Parity: Pregnancies reaching viability (24 weeks).
GTPAL System:
o G: Gravida (Total pregnancies)
o T: Term (37+ weeks)
o P: Preterm (20-37 weeks)
o A: Abortion (Loss before viability/20 weeks)
o L: Living children.
Naegele’s Rule (EDC Calculation):
o Formula: LMP - 3 months + 7 days + 1 year.
o Example: LMP Nov 1, 2017 -> EDC August 8, 2018 .
IV. Pain Assessment (The 5th Vital Sign)
A. Definition: Pain is subjective; it is whatever the patient says it is.
B. Theories of Pain
Pattern Theory: Pain is perceived when stimulus is intense.
Specificity Theory: Specific receptors for specific stimuli (Nociceptors,
Thermoreceptors, Mechanoreceptors, Chemoreceptors).
Gate Control Theory: A "gate" in the spinal cord (substantia gelatinosa) controls pain
transmission.
Affect Theory: Pain is emotional; intensity depends on the value of the affected organ.
Parallel Processing: Physiologic and cognitive/emotional processing occur on different
fibers.
C. Types of Pain
Cutaneous: Surface/skin.
Somatic: Deep (muscles, joints, bones).
Visceral: Organ pain (abdomen/thorax).
Referred: Felt in an area distant from the injury site.
Intractable: Resistant to cure.
Phantom: Felt in a missing body part (amputation).
D. Assessment Tools
PQRSTU: Provoking, Quality, Region/Radiation, Severity, Timing, Understanding.
Wong-Baker FACES Scale: Often used for children.
V. Nutrition & Hydration
A. BMI Calculation & Classification
Formula: $Weight (kg) / Height (m)^2$
Classifications:
o Underweight: < 18.5
o Normal: 18.5 – 24.9
o Overweight: 25.0 – 29.9
o Obesity Class I: 30.0 – 34.9
o Extreme Obesity: ≥ 40 B. Assessment Signs
Pale membranes: Possible anemia.
Dry membranes/Poor turgor: Dehydration.
Ascites (abdominal swelling): Possible protein deficiency.
Bowing tibias: Vitamin D deficiency (Rickets).
C. Health Promotion
Sodium: RDA is < 2400 mg/day (1 tsp). For hypertension/African-Americans, limit to
1500 mg .
Exercise: 30 mins moderate activity on most days.
VI. Vital Signs (Cardinal Signs)
A. Temperature
Regulator: Hypothalamus.
Heat Loss Mechanisms: Radiation (waves), Evaporation (sweat), Conduction (direct
contact), Convection (air movement).
Fever Patterns:
o Continuous: Constantly high.
o Intermittent: Rises and falls to normal/subnormal (e.g., Malaria).
o Remittent: Fluctuates but stays above normal.
o Relapsing: Fever days alternating with normal days.
Conversions:
o F to C: $(F - 32) \times 5/9$
o C to F: $(C \times 9/5) + 32$
B. Pulse
Adult Normal Rate: 60–100 bpm.
Sites: Radial (common), Carotid (CPR), Apical (most accurate, 5th ICS midclavicular
line), Pedal (foot circulation).
Abnormalities:
o Tachycardia: >100 bpm.
o Bradycardia: <60 bpm.
o Pulse Deficit: Difference between Apical and Radial pulse rates.
C. Respiration
Adult Normal Rate: 12–20 breaths/min.
Control Center: Medulla Oblongata.
Abnormalities:
o Bradypnea: <10 bpm.
o Tachypnea: >20 bpm.
o Orthopnea: Ability to breathe only while upright.
o Cheyne-Stokes: Rhythmic waxing/waning of depth with apnea periods (often before
death).
o Kussmaul’s: Deep, rapid (Diabetic Ketoacidosis).
D. Blood Pressure
Definition: Force of blood against arterial walls.
Normal: 120/80 mmHg.
Pulse Pressure: Systolic - Diastolic (Normal: 30-40 mmHg).
Common Errors:
o Cuff too narrow: False HIGH reading.
o Cuff too wide: False LOW reading.
o Arm below heart level: False HIGH reading.
o Arm above heart level: False LOW reading.