Chapter 5

Health Assessment

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Content of the Health History
• Biographical data
• Chief complaint
• Present health concern (or present illness)
• Past history
• Family history
• Review of systems
• Patient profile

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Patient Profile (see Charts 5-2 & 5-3)
• Past life events
• Education and occupation
• Environment; includes support, cultural, and spiritual factors
• Lifestyle: pattern and habits
• Presence of physical or mental disability
• Self-concept
• Sexuality
• Risk for abuse
• Stress and coping

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Cultural Sensitivity
• Cultural beliefs and attitudes must be recognized and
respected.
• Cultural background will influence perception and
reporting.
• Cultural health practices and beliefs related to health
care

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Health Assessment of People with
Disabilities (see Chart 5-4)
• Modify communication as needed:
– Talk with the patient
– Family should not be interpreters
• Modify the physical assessment.
• Need for routine screening and testing

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Genetics in Nursing Practice
• Genetic concepts are important to all steps of the nursing
process.
• Recent advances in this areas
• See Box 5-1

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Physical Assessment
• Usually performed after the health history
• Examiner must wash hands
• Make the patient comfortable
• Assessment must be systematic and organized

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Sequencing of the Assessment
• Skin
• Head and neck
• Thorax and lungs
• Breasts
• Cardiovascular system
• Abdomen
• Genitalia
• Neurologic system
• Musculoskeletal system
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Note:

• The assessment may be modified based on

the person’s presenting problem, age,
general condition, and other factors.

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Assessment Techniques
• Inspection
- include the general appearance of the patient
• Palpation
• Percussion
• Auscultation

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Light and Deep Palpation

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Percussion Technique

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Auscultating the Heart

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Nutritional Assessment
• Clinical examination
• BMI
• Biochemical assessment
• Dietary data
– Food record
– 24-hour recall
– Diet diary
• Cultural and religious considerations

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Clinical Assessment
Indicators of Nutritional Status
• General appearance
• Skin, hair, and nails
• Mouth; includes teeth and gums
• Neck; includes thyroid
• Musculoskeletal
• Abdomen
• Nervous system
• Height and weight
• See Table 5-2 and Table 5-3
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Body Mass Index
• Body Mass Index (BMI) is used to determine who is
overweight.
• BMI = 703 x weight in pounds
height in inches2
• A Body Mass Index of 25 or more is considered
overweight.
• A Body Mass Index of 30 or more is considered obese.

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Copyright © 2008 Lippincott Williams & Wilkins.
Biochemical Assessment
• Serum albumin and globulin
• Serum transferrin
• Retinol-binding protein
• Electrolytes
• Hemoglobin
• Vitamin A and carotene
• Vitamin C
• Urine tests

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Copyright © 2008 Lippincott Williams & Wilkins.
Dietary Data
• Food record
• 24-hour food recall
• Diet diary
• Conducting the Dietary Interview
• Religious and cultural considerations

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Analysis of Data
• Collaborative approach
• Assess in conjunction with clinical indicators and patient
health needs.
• Compare with dietary guidelines.

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Copyright © 2008 Lippincott Williams & Wilkins.
Ethical Considerations Related to Patient
Assessment
• Always explain the purpose of the interview or
assessment, how the information will be obtained, and
how the information will be used.
• Patient right to privacy
• Keep all records secure.
• HIPAA Requirements

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