Nursing Health Assessment Foundations and Data Collection

What is the primary purpose of a nursing health assessment?

1. Collect data pertinent to the patient's health status (subjective + objective).

2. Identify deviations from normal.

3. Discover patient strengths, limitations, and coping resources.

4. Pinpoint problems.

5. Build a rapport/therapeutic relationship with the patient and family.

6. Provide an essential foundation for the care of the patient.

What are the two main components of a health assessment?

1. Health History

2. Physical Examination

What key procedural and safety steps must a nurse take before beginning an assessment?

1. Introduce yourself.

2. Use standard precautions (hand hygiene, gloves).

3. Identify the patient using 2 identifiers (name and birthdate; check patient armband).

4. Provide privacy.

5. Explain the procedure to the client.

6. Make use of teaching opportunities.

What is the difference between primary and secondary sources of data?

• Primary Source: Information directly from the patient.

• Secondary Source: Information from family members, close friends, primary care provider (PCP), and medical records.

Differentiate between subjective data and objective data.

• Subjective Data: Verbal statements from the patient, including their feelings, perceptions, and self-report of symptoms.

• Objective Data: Signs detected by the nurse during the physical examination (what the nurse sees, hears, and measures).

What are the key components of a complete Health History?

1. Chief Complaint (main reason they are here; what is wrong)

2. Details of Present Illness (onset, activities at onset, aggravating/relieving factors)

3. Past Health History

4. Family History

5. Personal and Social History

6. Review of Systems

What are the three frameworks for organizing a physical examination?

1. Head-to-Toe: Organized, comprehensive, or ongoing partial health assessment.

2. Body Systems: Focused on specific body systems (e.g., cardiovascular).

3. Functional Health Patterns: Focuses on the effects of health or illness on quality of life, using a holistic approach (physical, social, emotional, spiritual).

Functional Health Patterns: Define Activity and Rest and give example diagnoses.

• Definition: Ability to engage in necessary or desired activities and obtain adequate sleep/rest.

• Examples: Decreased Activity Tolerance, Impaired Mobility, Ineffective Sleep Patterns.

Functional Health Patterns: Define Circulation and give example diagnoses.

• Definition: Ability to transport O₂ and nutrients necessary to meet cellular needs.

• Examples: Decreased Cardiac Output, Imbalanced Blood Pressure, Risk for Shock.

Functional Health Patterns: Define Comfort and give example diagnoses.

• Definition: Ability to control or maintain comfort.

• Examples: Acute Pain, Chronic Pain Syndrome.

Functional Health Patterns: Define Elimination and give example diagnoses.

• Definition: Ability to excrete waste (bowel, bladder).

• Examples: Impaired Urinary Continence, Impaired Gastrointestinal Mobility.

Functional Health Patterns: Define Food/Fluid and give example diagnoses.

• Definition: Ability to maintain intake of and utilize nutrients and liquids.

• Examples: Excessive Fluid Volume, Inadequate Nutritional Intake.

Functional Health Patterns: Define Health Management and give example diagnoses.

• Ability to incorporate and act on information to achieve a healthy lifestyle.

• Examples: Inadequate Health Knowledge, Ineffective Health Management Behaviors.

Functional Health Patterns: Define Neurosensory and give example diagnoses.

• Definition: Ability to perceive, integrate, and respond to internal/external cues.

• Examples: Acute or Chronic Confusion, Impaired Memory.

Functional Health Patterns: Define Respirations and give example diagnoses.

• Definition: Ability to provide and use oxygen to meet physiological needs.

• Examples: Ineffective Airway Clearance, Impaired Gas Exchange.

Functional Health Patterns: Define Roles/Relationships and give example diagnoses.

• Definition: Ability to accomplish role development and establish/maintain relationships.

• Examples: Caregiver Burden, Impaired Verbal Communication, Ineffective Role Performance.

Functional Health Patterns: Define Safety and give example diagnoses.

• Definition: Ability to provide/promote a safe environment.

• Examples: Risk for Falls, Risk for Infection, Pressure Injury.

Functional Health Patterns: Define Self-Care and give example diagnoses

• Definition: Ability to perform activities of daily living (ADLs).

• Examples: Self-Care Deficit, Decreased Self-Care Abilities.

Functional Health Patterns: Define Self-Perception/Concept and give example diagnoses.

• Definition: Ability to develop and use skills and behaviors understanding own attitudes and beliefs.

• Examples: Disrupted Body Image, Inadequate Self-Esteem.

Functional Health Patterns: Define Sexuality and give an example diagnosis.

• Definition: Ability to meet requirements or characteristics of male/female role.

• Example: Impaired Sexuality Function.

Functional Health Patterns: Define Stress Management and give example diagnoses.

• Definition: Preventing or adapting to life's changes, managing response to stressors.

• Examples: Anxiety, Maladaptive Coping.

Functional Health Patterns: Define Values/Beliefs and give example diagnoses.

• Definition: Ability to use personal values and beliefs.

• Examples: Moral Distress, Impaired Spiritual Well-Being.

What environmental and patient preparation steps are needed for a physical exam?

• Adequate lighting and a quiet, comfortable environment.

• Provide privacy by draping the patient with a sheet and visualizing only one body section at a time.

• Explain assessments before performing them.

• Keep hands and stethoscope warm.

• Never feel or listen over clothes.

• Use standard precautions with body fluids, wound drainage, or open lesions.

What additional considerations should a nurse keep in mind before beginning an exam?

• Ensure patient has sensory aids available (glasses, hearing aids).

• Offer the patient the restroom before starting.

• Observe verbal and nonverbal cues.

• Be genuine, respectful, and show empathy.

What are the components of the General Survey?

• General appearance and behavior

• Vital signs

• Height and weight

What is the standard order of the 4 cardinal physical assessment techniques?

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

What is the order of techniques for an Abdominal Assessment and why does it change?

1. Inspection

2. Auscultation

3. Percussion

4. Palpation

• Reason: Palpation and percussion can disrupt or alter normal bowel sounds and motility, so auscultation must precede them.

What are key principles of Inspection?

• Close, careful visualization of the person and each body system.

• Note general appearance and symmetry (side-to-side comparison).

• Always look and observe before touching.

• Ensure warm hands.

Which hand surfaces are used for specific palpation assessments?

• Fingertips: Fine touch

• Dorsum (back of hand): Temperature

• Palmar or Ulnar surface: Vibration

What clinical findings are evaluated during Palpation?

• Presence of lumps, masses, rigidity, and spasticity.

• Patient verbal and nonverbal cues (e.g., grimacing, guarding, discomfort).

What is Percussion and what is its clinical purpose?

• Tapping the body with fingertips to produce sound waves.

• Evaluates organ size, borders, and detects the presence of air or fluid in underlying tissue

What does Tympany sound like and where is it normally found?

• Sound: High-pitched, drum-like.

• Location: Hollow organs (e.g., stomach, bowels).

Percussion: What does Resonance sound like and where is it normally found?

• Sound: Low-pitched.

• Location: Normal, healthy lung fields.

Percussion: What does Hyperresonance sound like and when is it heard?

• Sound: Low-pitched, loud, and booming.

• Clinical Examples: Lung hyperinflation, COPD, Pneumothorax.

Percussion: What does Dullness sound like and when is it heard?

• Sound: Thud-like and muffled.

• Clinical Examples: Dense solid organs (liver) or fluid-filled lungs (pneumonia).

Percussion: What does Flatness sound like and where is it normally found?

• Sound: Soft and short.

• Location: Muscle and bone.

• What is the stethoscope's Diaphragm used for?

• Used for high-pitched sounds.

• Evaluates: Blood pressure, normal heart sounds, lung sounds, and abdominal/bowel sounds.

• What is the stethoscope's Bell used for?

• Used for low-pitched sounds.

• Evaluates: Vascular sounds (bruits) and abnormal heart sounds/murmurs.

Lifespan Considerations: Newborn and Infant

• Keep covered to prevent heat loss.

• Involve parents throughout the exam.

Lifespan Considerations: Toddler and Preschooler

• Involve parents.

• Explain procedures in simple, age-appropriate terms.

• Use role-playing / medical play to decrease anxiety.

Lifespan Considerations: School-Age Child and Adolescent

• Ensure proper draping and privacy.

• Give honest, straightforward answers to questions.

Lifespan Considerations: Adult and Older Adult

• Prepare client for all procedures and maintain strict Prepare client for all procedures and maintain strict privacy.

• Keep client warm (older adults chill easily).

• Accommodate limitations in flexibility, joint movement, or positioning.