HEALTH ASSESSMENT

ASSESSMENT
 Systematic and continuous collection,
organization, validation and documentation of
data
 The first step in the nursing process
 It is focus on a client’s response to a health
problem
Purposes of Assessment
 To establish a data base about a client’s
physical and emotional well being,
intellectual functioning, social relationships
and spiritual condition
 To determine the client’s functional abilities
and the absence and presence of dysfunction
 To form a therapeutic interpersonal
relatioship with the client
Types of Assessment
 Initial
 Comprehensive
 Problem-focused
 Ongoing
 Emergency
 Time-lapsed
Data Collection
 Process of gathering information about a
client’s health status
 Database – all information about a client
 Types of data:
1. Subjective
2. Objective
Data Collection
 Sources of Data:
1. Primary
2. Secondary
 Support people
 Clients records
 Health care professionals
 Literature
 Results of laboratory and diagnostic tests
 Medical history and physical examination
Methods of Data Collection
 Observation – to gather data by using the
senses
 Interview – a planned communication or
conversation with a purpose
 Preparation:
1. review the client’s medical records
2. conversations with other health team members
3. research of the presenting medical diagnosis
Methods of Data Collection
 Two approaches in interview:
1. directive/structured/formal
2. nondirective/unstructured/informal
 Interview Questions:
1. closed-ended
2. open-ended
3. focused
Methods of Data Collection
 Stages of Interview:
1. Introduction/Opening
2. Working/Body
3. Closure/Closing
Method of Data Collection
 Health History
- a review of the client’s functional health
patterns prior to the current contact with a
health care agency
- used in developing plan of care and
formulating nursing interventions
Components of Nursing Health History
 Demographic information
 Reason for seeking health care
 Perception of health status
 Previous illness, hospitalization, and surgeries
 Client/Family medical history
 Immunization/exposure to communicable
disease
 Allergies
Components of Nursing Health History
 Current medications
 Developmental level
 Psychosocial history
 Values and beliefs
 Sociocultural history
 Activities of daily living
 Review of systems