Nursing Assessment

1. Kimberly Carillo, RN
Kristine Mae Fernandez, RN
Regeine Tepanero, RN

2. After 2 hours and 30 minutes of interactive class
discussion and film showing, the graduate school
students of MAN 211c will be able to:
Define the Nursing Health History
Identify the purpose of the Nursing Health History
Differentiate Subjective Data and Objective Data
Utilize the guidelines in obtaining nursing history when
doing the Interview
Identify the components of the nursing history
Demonstrate the Skills used in Physical Examination

3. ...the systematic collection of subjective data (stated by
the client) and objective data (observed by the nurse)
used to determine a client's functional health pattern
status.
...these data assist the nurse in identifying nursing
diagnoses and/or collaborative problems.

4. Characteristic Subjective Objective
Description Data elicited & verified
by the client
Data directly or indirectly
observed through
measurement
Sources Client
Family & Significant
Others
Client Records
Other Health Care
Professionals
Observations & PA
findings of the nurse or
other health care
professionals
Documentation of
assessments made in
client record
Observations made by
the client’s family or
significant others

5. Characteristic Subjective Objective
Methods used to obtain
data
Client Interview Observation and Physical
Examination
Skills needed to obtain
data
Interview
Therapeutic
communication skills
Caring ability
Empathy
Listening Skills
Inspection
Palpation
Percussion
Auscultation
Examples “ I have a headache”
“Hindi ako gutom”
Respirations 16 cpm
BP 180/100, apical pulse
80, irregular
X-ray film reveals
fractures

6.  Phases of the Nursing Interview
 Specific Communication Techniques

7. Nursing Interview
...is a communication process that focuses on the client's
developmental, psychological, physiological,
sociocultural and spiritual responses that can be
treated with nursing and collaborative interventions.

8. Introductory
Phase
Working
Phase
Summary/
Closing
Phase

9. 
Introduce yourself & your role

Explain purpose of interview

Explain the purpose of note-taking, confidentiality
and type of questions to be asked.

Provide comfort, privacy and confidentiality.
Introductory Phase

10. 
Facilitate clients comments about major biographical
data, reason for seeking health care, and functional
health pattern responses.

Use critical thinking skills to:

listen for and observe cues

interpret and validate information received from the
client

Collaborate with client to identify problems and
goals

The approach for facilitation may either be free-
flowing or structured depending on time and data
needed
Working Phase

11. 
Summarize information obtained from working
phase

Validate problems and goals with the client

May discuss possible plans to resolve the problems
identified

Allow the client time to express feelings, concerns
and questions.
Summary/ Closing Phase

12.  Types of Questions to use
 Types of Statements to use
 Helpful Hints
 Communication Styles to Avoid
 Specific Age Variations
 Emotional Variations

13.  Use open-ended questions (What, How, Which)
 Use close-ended questions in obtaining facts on
specific information
 Use a laundry list (scrambled words) approach to
obtain specific answers

14.  Explore all data that deviate from normal with the
following questions:
 “What alleviates or aggravates the problem?
 “How long has it occurred?”
 “How severe is it?”
 “Does it radiate?”
 “When does it occur?”

15.  Rephrase or repeat your perception of the client’s
response to reflect or clarify information shared
 Encourage verbalization of client by saying “Yes, ” or
“I agree,” or nodding
 Describe what you observe in the client

16.  Accept the client; display a non-judgmental attitude
 Use silence to help both you and the client reflect
and reorganize thoughts
 Provide client with information as questions and
concerns arise

17.  Excessive/Insufficient eye contact
 Doing other things while taking history
 Biased or Leading questions
 Relying on memory to recall information
 Recording all the details
 Rushing the Client
 Reading questions from history form

18.  For ages from birth up to 14 years old clients history
should be validated for reliability with the
responsible SO.
 Assess hearing acuity; with loss, speak slowly, face
the client, and speak on the side on which hearing is
more adequate.
 Speak loudly only if with hearing deficit
 Use direct eye contact

19.  Angry Client:
 Approach in a calm, reassuring, in-control manner.
 Allow ventilation of client’s feelings
 Avoid arguing and provide personal space
 Anxious Client:
 Approach with simple and organized information
 Explain your role and purpose
 Manipulative Client
 Provide structure and set limits

20. Client Profile
Developmental
History
Gordon’s
Functional
Health Patterns
History of
Present Illness
Past Health
History
Review of
Systems
Physical
Assessment
Client Profile
The purpose of the client profile is to
determine biographical client data and to
obtain an overview of past and present
medical diagnoses and treatment that may
alter a client’s response.
Developmental History
The purpose of the developmental history
is to determine the physical, cognitive, and
psychosocial development to assess
developmental delays.
Gordon’s Functional Health Patterns
a guide for establishing a comprehensive
nursing data base. These 11 categories
make possible a systematic and
standardized approach to data collection,
and enable the nurse to determine the 11
aspects of health and human function.
History of Present Illness
a framework for approaching patient
complaints in a problem oriented fashion.
The patient initiates this process by
describing a symptom. It falls to you to
take that information and use it as a
springboard for additional questioning
that will help to identify the root cause of
the problem.
Past Health History
Patient’s other Health Problems aside
from his/her chief complaint
Review of Systems
To better define the likely causes of a
presenting symptom
(Meaning it’s highly subjective)
Physical Assessment
Uses 4 Basic Techniques for Assessment:
Inspection
Palpation
Percussion
Auscultation

21. Marjorie Gordon (1987) proposed functional health
patterns as a guide for establishing a comprehensive
nursing data base. These 11 categories make possible a
systematic and standardized approach to data
collection, and enable the nurse to determine the
following aspects of health and human function:

22. Health Perception and Health Management.
Data collection is focused on the person's perceived
level of health and well-being, and on practices for
maintaining health. Habits that may be detrimental to
health are also evaluated, including smoking and
alcohol or drug use. Actual or potential problems
related to safety and health management may be
identified as well as needs for modifications in the
home or needs for continued care in the home.

23. Nutrition and Metabolism
Assessment is focused on the pattern of food and fluid
consumption relative to metabolic need. The adequacy
of local nutrient supplies is evaluated. Actual or
potential problems related to fluid balance, tissue
integrity, and host defenses may be identified as well as
problems with the gastrointestinal system.
Elimination.
Data collection is focused on excretory patterns (bowel,
bladder, skin). Excretory problems such as
incontinence, constipation, diarrhea, and urinary
retention may be identified.

24. Activity and Exercise.
Assessment is focused on the activities of daily living
requiring energy expenditure, including self-care activities,
exercise, and leisure activities. The status of major body
systems involved with activity and exercise is evaluated,
including the respiratory, cardiovascular, and
musculoskeletal systems.
Cognition and Perception.
Assessment is focused on the ability to comprehend and use
information and on the sensory functions. Data pertaining to
neurologic functions are collected to aid this process.
Sensory experiences such as pain and altered sensory input
may be identified and further evaluated.

25. Sleep and Rest.
Assessment is focused on the person's sleep, rest, and
relaxation practices. Dysfunctional sleep patterns,
fatigue, and responses to sleep deprivation may be
identified.
Self-Perception and Self-Concept.
 Assessment is focused on the person's attitudes toward
self, including identity, body image, and sense of self-
worth. The person's level of self-esteem and response to
threats to his or her self-concept may be identified.

26. Roles and Relationships.
Assessment is focused on the person's roles in the world
and relationships with others. Satisfaction with roles,
role strain, or dysfunctional relationships may be
further evaluated.
Genogram - A genogram is a pictorial display of a
person's family relationships and medical history.

27. Sexuality and Reproduction.
Assessment is focused on the person's satisfaction or
dissatisfaction with sexuality patterns and reproductive
functions. Concerns with sexuality may he identified.
Coping and Stress Tolerance.
Assessment is focused on the person's perception of stress
and on his or her coping strategies Support systems are
evaluated, and symptoms of stress are noted. The
effectiveness of a person's coping strategies in terms of stress
tolerance may be further evaluated.
Values and Belief.
Assessment is focused on the person's values and beliefs
(including spiritual beliefs), or on the goals that guide his or
her choices or decisions.

28. Overview of Skills

29. Inspection
Palpation
Percussion
Auscultation

30. Inspection
•Definition:
•Inspection is using the senses of vision, smell, and hearing to
observe the condition of various body parts, including any
deviations from normal.
•Technique:
•Expose the parts being observed while keeping the rest draped
•Always look before touching
•Use good lighting
•Provide warm room for examination
•Observe color, size, location, texture, symmetry, odors and
sounds.

31. Inspection
Palpation
Percussion
Auscultation

32. Inspection
Palpation
•Definition:
•Is touching and feeling body parts with your hands to determine
the following characteristics:
•Texture
•Temperature
•Moisture
•Motion
•Consistency of structures

33. Inspection
Palpation
•Technique:
•Examiner’s fingernails should be short
•Most sensitive parts of the hand should be used to detect various
sensations
•Fingertips: Fine discriminations, pulsations
•Palmar Surface: Vibratory sensations (e.g. thrills, fremitus)
•Dorsal Surface: Temperature
•Light palpation precedes deep palpation
•Tender areas are palpated last

34. Inspection
Palpation
Percussion
Auscultation

35. Percussion
Auscultation
•Definition:
•Is tapping a portion of the body to elicit tenderness or sounds
that vary with the density of underlying structures.
•Technique:
•Direct Percussion: To elicit tenderness or pain
•Indirect Percussion: To elicit one of the following sounds over the
chest or abdomen:

36. Percussion
Auscultation
•Technique: (cont’d)
•Resonance: Heard over part air and part solid
•Hyperresonance: Heard over mostly air
•Tympany: Heard over air
•Dullness: Heard over more solid tissue
•Flatness: Heard over very dense tissue

37. Inspection
Palpation
Percussion
Auscultation

38. Auscultation
•Definition:
•Is listening for various breath, heart, vasculature, and bowel
sounds using a stethoscope.
•Technique:
Purpose Technique
Diaphragm To detect high-
pitched sounds
Press firmly on body
part
Bell To detect low-pitched
sounds
Press lightly over
body part

39. Inspection
Palpation
Percussion
Auscultation