Health Assessment Data Collection & Nursing Documentation

Data Types Collected During Health Assessment

  • Two fundamental categories

    • Subjective data

    • What the patient says, feels or complains of (≙ symptoms)

    • Gathered mainly through the health interview

    • Objective data

    • What the nurse observes or measures (≙ signs)

    • Includes physical‐examination findings plus investigative tests (e.g.

      • X-rays

      • MRI, CT, Ultrasound scans

      • Laboratory values, urinalysis)

  • Four “classes” of databases built from the above data

    1. Complete / Comprehensive database

    • Head-to-toe, “A to Z” review

    • Used for routine admission, full annual physicals, community screenings

    1. Emergency database

    • Rapid, focused questions or observations only on life-threatening issues

    • Automobile crash example: no lengthy history, immediate ABCs (Airway, Breathing, Circulation)

    1. Problem-based (a.k.a. Episodic) database

    • Limited to a single issue, one body system, or one cue complex

    • E.g. an isolated boil / wound with no broader complaints

    • Still requires “red-flag” thinking (large boil → consider diabetes)

    1. Follow-Up / Review database

    • Reassessment of a previously identified problem (wound checks, suture removal, chronic disease follow-ups)

Techniques for Collecting Objective Data

  • Inspection – visual observation

  • Palpation – using touch to assess texture, temperature, tenderness, masses

  • Percussion – tapping to elicit sound & vibration

  • Auscultation – listening (stethoscope) to heart, lungs, bowel, vessels

  • Additional modalities routinely classed under objective findings

    • Radiology (X-ray, MRI, CT, ultrasound)

    • Endoscopy, ECG, spirometry, etc.

Definitions Refresher

  • Symptoms = subjective complaints

  • Signs = objective findings

  • Think “S-patient, S-subjective; S-symptom” vs. “S-seen, S-sign”

Critical Thinking Emphasis

  • "A good nurse is a critical-thinking nurse."

  • Constantly correlate history, physical exam & diagnostics

  • Move from data collection → pattern recognition → clinical reasoning

Course Roadmap (Week-by-Week)

  • Week 1 Health interview + intro to objective data & nutritional assessment

  • Week 2 HEENT (Head, Eyes, Ears, Nose, Throat)

  • Week 3 Breasts & regional lymphatics; Thorax & lungs

  • Week 4 Heart, neck vessels, peripheral / lymphatic system

  • Week 5 Abdomen, anus/rectum & prostate; genitourinary system

  • Week 6 Musculoskeletal system

  • Mid-semester break: Week 8

  • Post-break Neurological system + advanced health issues

Assessment & Assignment Details

  • Assignment 1 due: 08/17/202508/17/2025

  • Quiz: scheduled immediately before semester break

  • Marking criteria emphasise

    • Cover page + rubric attached

    • APA citation style (out of 8080 marks)

  • Reference requirements for “Exceeds Expectation”

    • ≥ 55 total references

    • ≥ 44 must be primary research articles

    • Acceptable web domains: .edu, .org, .com (access via Digital Library or Google Scholar)

    • Textbook references ≤ 20232023 editions (prefer 20162016+ latest JBI or similar)

Nursing Assessment Form – Core Elements

  • Administrative/Biodata section

    • Hospital name, ward, date & mode of admission

    • Patient & father’s name, biodata ID

    • Provisional / admitting diagnosis

  • Vital signs block

    • Weight, Temperature, Pulse, Respirations, Blood Pressure

    • Urinalysis findings

    • Previous hospitalisations

  • Past Medical / Surgical History

    • Diabetes, asthma, hypertension, medications, allergies, transfusions

  • Nursing Observations

    • Speech & hearing clarity

    • Personal habits & nutrition

    • Skin integrity & lesions

    • Home status / social supports

    • Immunisation status

    • Patient-expressed concerns & identified needs

  • Functional Pattern Review (aligns with Gordon’s patterns)

    • Nutrition & hydration

    • Elimination

    • Personal hygiene

    • Exercise, mobility & body alignment

  • Special Orders / MD directives

    • NPO, fluid restrictions, diets (e.g. 1,8001{,}800-kcal diabetic, 2,0002{,}000 kcal, low-salt)

  • Patient Education, Referrals & Discharge Planning

    • Document teaching provided & services arranged

  • Progress Notes

    • Nurses & physicians chart consecutively in same record → need for clarity & accuracy

Nursing Diagnosis Framework (NANDA-I)

  • Use NANDA-I 2018–2020 list until local taxonomy developed

  • Examples mentioned in lecture

    • Ineffective Infant Eating Dynamics

    • Risk for Metabolic Imbalance Syndrome (common in diabetes / malnutrition)

    • Energy Field Imbalance

    • Risk for Unstable Blood Pressure (applicable in dehydration, hemorrhage, sepsis etc.)

  • NANDA categories sorted by functional domain (Nutrition, Elimination, Activity/Rest, Perception/ Cognition, etc.)

  • Choose diagnosis that matches collected cues; use PES format (Problem–Etiology–Signs/Symptoms)

Documentation Tips & Ethical Considerations

  • Start typing patient histories early; include

    • Family history & genogram

    • Full Review of Systems

    • Functional health patterns

    • Identified problems & nursing diagnoses

  • Reference all sources ethically (APA, avoid plagiarism)

  • Ensure confidentiality when handling forms & electronic records

  • Reflect on real-world implications: accurate data entry drives safe care, interdisciplinary communication & quality metrics

Practical Reminders

  • Carry blank assessment forms on clinical rotations

  • Practice the four objective techniques on each body system weekly

  • Link each abnormal finding to possible pathologies discussed later in course

  • Keep a running index of NANDA diagnoses for quick selection during clinical write-ups