Chapter 1
Introduction to Health
Assessment
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Learning Objectives:
❖ Define health and health assessment.
❖ Explain the components of the health assessment.
❖ Define the nurse’s role in assessment.
❖ Explain the nursing process.
❖ Define subjective and objective data.
❖ Describe the phases of the nurse--patient interview.
❖ Explain the four types of histories and when each is used.
❖ Describe and obtain the components of a comprehensive
health history.
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Health
❖Relative state in which a person strives to meet
their potential and includes the areas of wellness
with the ultimate goal of improving health
❖Includes the “eight dimensions”
❖Is not solely the absence of disease or eating right
p. 4
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The “Eight Dimensions” of Wellness
p. 4
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Health Assessment #1
❖Definition: The processes used to evaluate the
health status of a person
❖Systematic data collection that provides information
to facilitate a plan to deliver the best care
❖Consists of:
o 1st component: Comprehensive health history
o 2nd component: Complete physical examination
p. 5
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Purpose of Health Assessment
❖Determine a patient’s health status
❖Determine the patient’s risk factors
❖Determine the need for health education
❖Develop a nursing plan of care
p. 8
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The Nursing Process
❖The overall goals:
o Extrapolate the findings
o Prioritize the findings
o Formulate the plan of care
o Implement the plan of care
p. 4
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1st component: Health History
❖Past medical history
❖Past physical issues
❖Past psychological issues
❖Social history
❖Cultural history
❖Spiritual beliefs
❖Environmental influences
❖Developmental level
p. 5
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2nd component: Physical Examination
❖Structured head-to-toe examination
❖Identify changes in patient’s body systems
❖Unusual or abnormal findings may support history
data or trigger new questions
❖Document all findings in a clear, concise manner
❖Collate all information with medical records
p. 5
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Health Assessment #2
❖Each person needs a complete health assessment
❖Ideally done on admission
❖Circumstances may delay the completion; should be
completed once situation allows
o A critically ill patient coming into the ER—wait
until patient is stable to complete
o A patient with a professional relationship with
the nurse—just need updates
o A patient with dementia may require
supplemented information from family p. 6-7
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Nursing vs. Medical Assessments
❖Nursing ❖Medical
o Focus on diagnoses o Focus is on the
and treatment of diagnoses and
the actual or treatments of the
potential human disease
responses
o Identifies many
contributing factors
to the individual’s
health and wellness
p. 7
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Health Assessment #3
❖Nurse detects areas of concern requiring immediate
attention
❖Nurse uses findings to decide the areas that take
precedence
❖Health promotion and disease prevention are
essential areas of patient education
p. 7-8
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Healthy People 2030
❖Framework that identifies risk factors, health
issues, and diseases of concern in the United States
❖Goals and objectives serve to improve the health of
individuals and communities
❖Overall goal is to increase quality of life by creating
guidelines for a healthy lifestyle
❖Promotes health and disease prevention as it
improves the quality and length of a person’s life
❖Data provided by U.S. Department of Health and
Human Services ([Link])
p. 8
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The Role of the Nurse in Assessment #1
p. 8-9
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Role of the Nurse in Assessment #2
❖Use findings and decide in which areas patient
needs the most care
❖Deliver care across the lifespan
❖Promote health and prevent disease
❖Educate and counsel individuals, families, groups,
and communities
❖Determine what affects the patient’s health
❖Focus on health and goals of the patient
p. 8-11
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Role of the Nurse in Assessment #3
❖Oversee the holistic care of each patient
❖Collect data
❖Make decisions about what information will impact
patient safety and quality of care
❖Identify what is important on a daily basis for each
patient
❖Carefully watch and listen to the patient to
determine what additional questions to ask
❖Watch for subtle changes in the patient
p. 8-11
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Role of the Nurse in Assessment #4
❖Rely on skills in accurate health history taking and
physical assessment
❖Use the “eight dimensions” to assess the patient
❖Use information detected in the assessment to work
with the patient to enhance quality of life
❖Learn to detect a change in patient to enable
providing best care
❖Take advantage of teaching opportunities that
present themselves during health assessments
❖Continually reassess the patient for changes in order
to achieve the best results
p. 8-11
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Assessment
❖Gathering subjective and objective data via health
history and physical examination
❖Instrumental in devising a care plan
❖Key points and relevant pieces of information are
clustered together
❖Preliminary problem list is formulated
❖Assessment phase continues throughout entire
patient encounter
pp. 16-17
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Types of Patient Data
❖Subjective—Symptoms ❖Objective—Signs
o What patient tells you o What you observe
o History (from chief o Measurable data (i.e.,
complaint through physical examination
review of systems) findings, laboratory and
radiologic results)
pp. 14-15
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Examples of Patient Data
❖Mrs. G is a 54-year-old ❖Mrs. G is an older,
veteran who reports overweight White
pressure over her left female, who is pleasant
chest “like an elephant and cooperative. Height
sitting there” which 5’4”, weight 150 lb, BMI
radiates to her left neck 26, BP 160/80 right
and arm. arm, sitting, HR 96 and
regular, respiratory rate
24 and regular,
temperature 97.5˚F
oral.
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Subjective Data #1
❖OLD CART
o Onset
o Location
o Duration
o Characteristic symptoms
o Associated manifestations
o Relieving factors
o Treatment
pp. 16
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Subjective Data #2
❖Onset
o When the sign or symptom began
❖Location
o Where the sign or symptom is located?
❖Duration
o How long the sign or symptom has been present
pp. 16
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Subjective Data #3
❖Characteristic symptoms
o What the symptom feels like, how it is
described, and the severity
❖Associated manifestations
o What else is happening when the patient
experiences the sign(s) or symptom(s)
pp. 16
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Subjective Data #4
❖Relieving factors
o Anything the patient has tried to relieve the
symptom
❖Treatments
o Any interventions the patient has previously
tried
pp. 16
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OBJECTIVE DATA
o Information gathered from the physical
examination and the laboratory test.
o What the nurse detects during the examination .
o Measurable data.
o Factual and descriptive.
o Also known as “signs”.
pp. 14
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Chapter 3
Interviewing and Communication
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Introduction
❖Primary goal: improve the well-being of the patient
❖Threefold purpose:
o Establish a trusting and supportive relationship
o Gather information
o Offer information
pp. 39-40
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Process of Interviewing
❖ Health history format
o Structured framework for organizing patient
information in written, electronic, or verbal form
o For communicating with other health care providers
o Identifies specific information to be obtained
❖ Interviewing process
o Demands communication and relational skills
o Ability to elicit accurate information
o Interpersonal skills to respond to patient’s feelings
and concerns
pp. 40-41
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Phases of Interviewing#1
❖Pre-interview: set the stage
❖Introduction: put patient at ease, establish trust
❖Working: obtain patient information
❖Termination: summarize, discuss plan of care
pp. 42-51
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Phases of Interviewing#2
▪ Phase 1: Pre-interview
▪ Setting the stage for a smooth interview.
▪ Plan the interview, review patient’ records, set goals for
interview, get ready to take brief notes.
▪ Phase 2: Introduction
▪ Putting the patient at ease and establishing trust.
▪ Greet the patient and establish rapport.
pp. 42-51
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Phases of Interviewing#3
▪ Phase 3: Working Phase
▪ Obtaining patient information.
▪ Invite the patient’s story by asking about the
patient’s foremost concern.
▪ Phase 4: Termination
▪ Summarize important points and discuss
plans.
pp. 42-51
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Therapeutic Communication Techniques
❖Active listening ❖Reassurance
❖Guided questioning ❖Summarizing
❖Nonverbal ❖Transitions
communication
❖Empowering the patient
❖Empathic responses
❖Validation
pp. 51-56
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Chapter 4
The Health History
Copyright © 2018 Wolters Kluwer · All Rights Reserved
Types of Patient Health Histories
❖Comprehensive health assessment
o Admission of new patient
❖Focused or problem-oriented assessment
o Returning patient
❖Follow-up history
o Problem or treatment evaluation
❖Emergency history
o Focused on emergent problem
pp. 70-71
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Comprehensive or Focused?
❖Comprehensive ❖Focused
o New patients in all o Established patients,
settings especially routine or
urgent care visits
o Provides fundamental
and personalized o Focused concerns or
knowledge symptoms
o Strengthens nurse– o Assesses symptoms
patient relationship restricted to specific
body system
o Provides baseline
o Creates platform for
health promotion
pp. 70-71
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The Comprehensive Adult Health History
#1 (seven components)
❖Identifying data and source of the history
❖Chief complaint(s)
❖History of present illness (HPI)
❖Past history
❖Family history
❖Review of systems
❖Health patterns
pp. 72
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The Comprehensive Adult Health History
#2
❖Initial information
o Date and time of history
o Identifying data: age, gender, birth date, marital
or relationship status, occupation, other as
appropriate
▪ Source of history
o Reliability
pp. 72
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The Comprehensive Adult Health History
#3
❖1. Chief complaint(s)
o Make every attempt to quote the patient’s own
words
o If there are no complaints, report goals
❖2. History of present illness (HPI)
o Chronologic account of problem(s)
o Onset of problem(s)
o The setting in which it developed
o Its manifestations
o Any treatments pp. 74
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The Comprehensive Adult Health History
#4
❖3. HPI: Key elements
o Seven attributes of each principal symptom
(OLD CART or OPQRST)
o Self-treatment by patient or family
o Past occurrences of the symptom(s)
o Pertinent positives and/or negatives from the
review of systems
o Risk factors or other pertinent information
related to the symptom
pp. 74
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The Comprehensive Adult Health History
#5
❖4. Past history: Five (5) key elements
A.) Allergies
▪ Medication, food, insects, environmental factors
▪ Include specific reaction to each allergen
B.) Medications
▪ Prescriptions
▪ Over-the-counter
▪ Home remedies
▪ Vitamins, mineral, or herbal supplements
▪ Oral contraceptives
▪ Medications borrowed from family members or friends
pp. 75-76
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The Comprehensive Adult Health History
#6
❖ Past history: key elements—(cont.)
C.) Childhood illnesses
▪ Measles, rubella, mumps, whooping cough,
chickenpox, rheumatic fever, scarlet fever, polio
▪ Chronic conditions (e.g., asthma)
D.) Adult illnesses
▪ Medical
▪ Surgical
▪ Accidents
▪ Psychiatric
pp. 76
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The Comprehensive Adult Health History
#7
❖ Past history: key elements—(cont.)
E.) Health maintenance
▪ Immunizations
▪ Screening tests
▪ Safety measures
▪ Risk factors
➢ Tobacco
➢ Environmental Hazards
➢ Substance abuse
➢ Alcohol pp. 76
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Alcohol and Drugs
❖Misuse of alcohol or drugs often directly contributes
to symptoms
❖Should routinely ask about current and past use of
alcohol or drugs, patterns of use, and family history
❖Include adolescents and older adults in assessing for
drug or alcohol misuse
❖Assess what patient considers alcohol
pp. 77
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The Comprehensive Adult Health History
#8
5. Family history
pp. 79
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The Comprehensive Adult Health History
#9
❖ Family history—(cont.) o Asthma or lung
disease
o HTN
o Headache
o CAD
o Seizure disorder
o Cholesterol
o Mental illness
o Stroke
o Suicide
o Diabetes
o Substance abuse
o Thyroid or renal
disease o Cancer and the site
o Arthritis o Genetic diseases
o Tuberculosis o Allergies
pp. 79-80
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The Comprehensive Adult Health History
#10
❖6. Review of systems
o Address each body system, from head to toe
o Most questions pertain to symptoms
o May uncover problems patient has overlooked
o Do not use medical terms
pp. 80
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Review of Systems
❖General ❖Peripheral vascular
❖Skin ❖Urinary
❖HEENT ❖Reproductive
❖Neck ❖Musculoskeletal
❖Breasts ❖Psychiatric
❖Respiratory ❖Neurologic
❖Cardiovascular ❖Hematologic
❖Gastrointestinal ❖Endocrine
pp. 81-83
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The Comprehensive Adult Health History
#11
❖7. Health patterns
o Self-perception/self-concept
o Value-belief
o Activity-exercise
o Sleep-rest
o Nutrition
o Role-relationship
o Coping-stress-tolerance
pp. 83-84
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Documenting the Health History
❖Form of documentation is frequently computerized
❖Must be accurate and thorough
pp. 88
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