Introduction to Health Assessment

Why Learn Health Assessment?

Components of Health Assessment

Three primary components:

History (subjective data)

Physical examination (objective data)

Documentation of data

Components of Health Assessment

Data collection

Symptom: What the patient feels/communicates (subjective)

Sign: Clinical findings (objective) collected during physical examination

Clinical manifestations = signs and/or symptoms collected utilizing inspection, palpation, percussion, and auscultation

Documentation of Data

How do I know which Health Assessment to Do?

ØContext of Care

ØPatient Needs

ØHealth Assessment Skills

Context of Care

§Circumstance or situation related to health care delivery.

Setting or environment

Physical

Psychological

Socioeconomic

Expertise of the nurse

Patient Needs

Experience of the Nurse

Expertise of the nurse is gained with specialization within a given area of practice:

A nurse in an adult intensive care unit has expertise assessing a patient with hemodynamic instability.

A family nurse practitioner working in a women’s clinic has expertise in performing routine pelvic examinations.

Types of Health Assessment

ØComprehensive health assessment

ØProblem-based or focused health assessment

ØEpisodic assessment

ØShift assessment

ØScreening assessment

Clinical Reasoning and Judgment

The nurse must analyze and interpret data before initiating a plan of care.

Health assessment provides information on the patient’s

vPhysical status

vHealth problems (comorbidities)

vStrengths

vWeaknesses

vAbilities

vSupport system

vHealth beliefs

vAccess to resources

vActivities to maintain health

Data Organization

Analysis, Interpretation, and Clinical Judgment

Health Promotion and
Health Protection

Definitions of Health Promotion and Health Protection

Three Levels of Health Promotion

Health Promotion and
Health Protection