Types of Assessment

Initial Assessment – after admission

Focused Assessment – focus on
particular needs.
Time-lapsed Assessment several
months after initial assessment
- reassessment
Emergency- rapid assessment to
client who is experiencing a life
threatening problems/crisis.
Health Assessment Interview – time
limited verbal interaction between
between the nurse and the patient.
* collect specific information regarding
the patient and patient’s health status.
3 stages of interview
Orientation Phase
-nurse and patient establish trust and
get to know one another
-introducing, explanation of the purpose
and establish goal
- client begin to feel comfortable talking
with the nurse
- nonverbal behavior conducive to the
nurse-client relationship
*eye contact head nodding
*sit facing pts. touch
*smiling lean forward
Working Phase
-time for gathering information on
client’s health status, health history
and biographical
- reasoning for seeking health care
Closed-ended question –question that
can be answer briefly or with one word
response.
*frequently answerable with yes or no
ex: have you been hospitalized
before?
Open-ended question- encourage client
to elaborate about a particular
concern/problem.
ex: how do you typically deal with your
asthma attack?
Focused Question- asked to obtained
information that is more specific about
a problem or condition.
- usually begin with words such as
describe, explain , tell
Termination Stage
last stage of interview process
which information is summarize
and validated as well as planning
for future interview.
HEALTH HISTORY- provides the
subjective database for your
assessment allowing you to see
your patient through his eyes.
PURPOSE:
*provide subjective data base
*identify patient strength
*identify patient health problems both
actual and potential
*identify support
*identify teaching needs, discharge
needs and referral needs.
 HEALTH HISTORY CONSIST:
*Biographical Data
patient’s name occupation
age contact person
gender health insurance
birthday race
birth place religion
marital status address
education SSS number
*Chief Complaints/ reason for
seeking health care
*Present Health History
major health concern
*Past Health History
to identify any health factors from the
past that may have a direct relationship
to your patient current health status
assess childhood illness immunization
hospitalization allergies
surgeries medication
serious injuries recent travel
*Family History
provides clues to genetically linked or
familial disease that may be risks factor
for your patients.
*Psychosocial History
gives a picture of your patient’s
health promotion and preventive
pattern.
*Activities of Daily Living
*Review of Systems- provides a
comprehensive assessment to
determine your patients psychological
status
*Psychological Profile
 *Psychological Profile
health practice developmental task
health belief sexuality pattern
nutritional pattern emotional health
activity pattern status
recreational pattern self-concept
rest/sleep pattern support
personal habits role and relation-
socioeconomic status ship
occupational/environmental risk factors
religious/cultural influence
FUNCTIONAL ASSESSMENT
measures a person’s self-care ability
in the areas of general physical
health or absence of illness.
This includes the following:
* activities of daily living – ADL
- bathing, dressing, eating, walking
*instrumental activities of daily living-
IADL’s or those needed for
independent living such as house-
keeping, shopping, cooking, nutrition
home environment, daily laundry,
 using the telephone, managing finances,
social relationship. Self-concept and
coping stress.
*KATZ INDEX OF INDEPENDENCE IN ADL
commonly referred as KATZ ADL
has appropriate instrument to assess
functional status as a measurement of
patient’s ability to perform ADL
indecently.
 6 functions for older adult
bathing transferring
dressing continence
toileting feeding
Score- yes / no for independence
6 indicates full function
4 indicates moderate impairment
2 less indicates severe functional
impairment
KATZ Instrument Activities of Daily
Living
*heavy housework
*shopping
*managing finances
*telephoning
Barthel Activities of Daily Living Index
consist of 10 items that measures a
person's daily functioning specifically
the ADL and mobility.
*feeding
* moving from wheelchair to bed and
return
*grooming
*transferring to and from a toilet
*bathing
*walking on level surface
* going up and down stairs
*dressing
*continence of bowel and bladders
Highest the score the more
“independent” the person
independence means the person
needs no assistance at any part
of the task.
Additional Information for Health
History for Pediatric Patients
*reason for seeking care
*present health or history of present
illness
*past health
*labor and delivery
*post natal status
*childhood illness
*serious accidents or injuries
*serious or chronic illness
- age of onset, is it treated, any
complication
*operations or hospitalization
*immunization
*allergies
*medication - family history
*developmental history
-growth
-milestone
-current development
_nutritional history
Additional information for health
history in pregnancy
*age
*family history
*women’s medical history
*women’s past obstetrical history
*woman’s present obstetrical history
Gravida- woman who is or has been
pregnant, regardless of pregnancy
of the number of fetuses.
Para- refers to the past pregnancies
that have reached viability
Nulligravida- woman who is not now and
never has been pregnant .
Primigarida- woman pregnant for the first
time.
Multigravide- woman who has been pregnant
more than once.
Nullipara- woman who has never completed
a pregnancy to the period of viability
(capability of living 24 weeks)
Primipara- woman who has completed one
pregnancy to the period of viability
regardless of the number of infants
delivered and regardless of the infant’s
live or stillborn.
 Multipara- woman who has completed two
or more pregnancies to the stage of viability
*date of the last menstrual period (LMP)
*estimated date of birth , expected date of
confinement,/ delivery .
*signs and symptoms
*rest and sleep pattern
*activity and employment
*sexual activity
*diet history
*psychosocial status
 Steps of Health Assessment
A-Collection of subjective data through
interview and health history.
*biographical data
*reasoning for seeking health care
*chief complaint
*history of:
- present illness
-past health history
- family health history
-current medication
-life style
-developmental level
- psychosocial history
B. Collection of Objective Data
a. physical examination
-preparation-
*environment –adjust for the
equipment placement.
-rooms need to be quiet, warm
clean, well ventilated, well
lighted
-all equipment's should be
working/functioning
*positioning
it is important to consider client’s
energy level and privacy.
client’s who is weak may require
assistance with positioning
uncomfortable and embracing positions
should not be maintained for longer
periods
examination should be organizes so
that several body system can be
assessed with the client in one position.
different positions
sitting position
supine position
dorsal recumbent position
Sims position
prone position
lithotomy position
knee-chest position
Technique
4 specific diagnostic technique in
physical assessment
* inspection *percussion
*palpation *auscultation

assessment of the abdomen

*inspection *percussion
*auscultation *palpation