Lec 1 Introduction

HEALTH
ASSESSMENT-I
LEC-1
BSN-3B
INSTRUCTOR: MEERUB SHAKIL
COURSE OBJECTIVES
▪ 1. Systematically assess the health status of an individual by

obtaining a complete health history using interviewing skills
appropriately.
▪ 2. Utilize proper techniques of observation and physical examination
in assessing various body systems.
▪ 3. Differentiate normal from abnormal findings.
▪ 4. Record findings in an appropriate manner.
▪ 5. Demonstrate an awareness of the need to incorporate health
assessment as part of their general nursing practice skills.
▪ 6. Apply knowledge of growth and development, anatomy, physiology,
& psychosocial skills in assessment & analysis of data collected
UNIT 1: Introduction to Health Assessment
Concepts
KEY CONCEPTS:
▪ Health - A dynamic state of complete physical, mental, and social well-
being.
▪ Assessment - The systematic collection and analysis of information to
understand the patient's health status.
▪ Data Collection - Gathering relevant information through various methods
such as interviews, observations, and physical examinations.
▪ Diagnosis - The formulation of nursing diagnoses based on the
assessment data
CONTINUE
▪ Prognosis refers to the predicted course and outcome of a medical condition,

including the likelihood of recovery.
▪ Etiology is the study of the causes or origins of diseases or medical conditions. It
aims to identify the factors, such as genetic, environmental, infectious, or
lifestyle-related, that contribute to the development of a particular health issue.
▪ Signs are objective, observable, and measurable indicators of a disease or
medical condition. They are often identified by healthcare professionals during
physical examinations, tests, or diagnostic procedures. Signs are not influenced
by the patient's feelings or perceptions.
▪ Symptoms are subjective experiences reported by the individual, reflecting their
perception of a health issue. These can include sensations, feelings, or changes
in function that the patient notices. Symptoms may not be directly measurable
by others and rely on the individual's description of their experience.
INTRODUCTION TO HEALTH ASSESSMENT
Nursing – the protection, promotion, and optimization of health

and abilities, prevention of illness and injury; alleviation of
suffering through the diagnosis and treatment of human
responses and advocacy in the care of individuals, families,
communities, and populations” American Nurses Association
(2010).
Emphasis is placed on “diagnosis and treatment of human
responses” based on “accurate client assessment”, including how
effective nursing interventions are “to promote health and prevent
illness and injury”
To accomplish this pertinent and comprehensive
data collection, the nurse:
 Collects data in a systematic and ongoing process

 Involves the patient, family, other health care providers, and
environment, as appropriate, in holistic data collection
 Prioritizes data collection activities based on the patient’s immediate
condition or anticipated needs of the patient or situation
 Uses appropriate evidence-based assessment techniques and
instruments in collecting pertinent data
 Uses analytical models and problem-solving tools
 Synthesizes available data, information, and knowledge relevant to the
situation to identify patterns and variances
 Documents relevant data in a retrievable format
Overview of Nursing Process (ADPIE)
o Health assessment is more than just gathering information

about the health status of the client. It is analyzing the data,
making judgments about the effectiveness of nursing
interventions, and evaluating client care outcomes.
o Each step of the nursing process depends on the accuracy of
the preceding step. Evaluation involves examining all the
previous steps, it especially focuses on achieving desired
outcomes. The arrow between assessment and evaluation
goes in both directions because they are ongoing processes
as well as separate phases. When the outcomes are not as
anticipated, the nurse needs to revisit all the steps, collect
new data, and formulate adjustments to the plan of care
TYPES OF HEALTH ASSESSMENT
▪ Comprehensive Assessment: In-depth and detailed examination of

the patient's overall health.
▪ Focused Assessment: Targeted examination to address specific
health concerns or issues.
▪ Ongoing/Continuous Assessment: Continuous monitoring of the
patient's health status over time.
▪ Emergency Assessment: Rapid assessment in emergency
situations to identify life-threatening issues.
STEPS OF HEALTH ASSESSMENT
The assessment phase of the nursing process has four major steps:
1. Collection of subjective data
2. Collection of objective data
3. Validation of data
4. Documentation of data
DOCUMENTING DATA
Documenting Health Assessment Data
POINT-1
Importance of accurate documentation in
nursing practice
POINT-2
Utilizing a problem-oriented approach to
document findings
POINT-3
Clear and concise documentation aids in
communication among healthcare professionals
PROCESS OF DATA ANALYSIS
1. Identify abnormal data and strengths.

2. Cluster the data.
3. Draw inferences and identify problems.
4. Propose possible nursing diagnoses.
5. Check for defining characteristics of those diagnoses.
6. Confirm or rule out nursing diagnoses.
7. Document conclusions
ANY QUESTIONS?
THANK YOU

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HEALTH

▪ 1. Systematically assess the health status of an individual by

▪ Prognosis refers to the predicted course and outcome of a medical condition,

Nursing – the protection, promotion, and optimization of health

 Collects data in a systematic and ongoing process

o Health assessment is more than just gathering information

▪ Comprehensive Assessment: In-depth and detailed examination of

1. Identify abnormal data and strengths.

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