Health Assessment Midterm 1 Notes
“We recommend that you review the assigned chapters to ensure that you have a general understanding
of the structure and function,the components of the physical exam and normal expected findings
across the lifespan, including respiratory and breast.
if you are preparing for labs by watching online lectures, reading chapters, reviewing online content,
completing worksheets and cue cards and doing the quizzes, you are well on your way to being prepared
for this test!”
- Assessment is the collection of subjective and objective data about a patient’s health
- Subjective data consist of information provided by the affected individual.
- Objective data include information obtained by the health care provider through physical
assessment, the patient’s record, and laboratory studies.
- The nursing process has six phases: assessment, diagnosis, outcome identification,
planning, implementation, and evaluation.
- Critical thinking is the multidimensional thinking process needed for sound diagnostic
reasoning and clinical judgement. Seventeen critical thinking skills have been identified, including
- Every examiner needs to collect four kinds of databases based on the clinical situation.
- A complete (or total health) database includes a complete health history and a full physical
- An episodic (or problem-centred) database is used for a limited or short-term problem. It is
smaller in scope and more targeted than the complete database.
- A follow-up database evaluates the status of any identified problem at regular intervals to
follow up on short-term or chronic health problems.
- An emergency database calls for rapid collection of data, which commonly occurs while
performing life-saving measures.
- The concept of health has expanded and is based on the practice model used.
- The biomedical model of Western medicine views health as the absence of disease. It focuses
on collecting data on biophysical signs and symptoms and on curing disease.
- The behavioural model extends beyond treating disease to include primary and secondary
prevention with emphasis on changing behaviour and lifestyle.
- The socioenvironmental model encompasses the biomedical and behavioural models and
incorporates sociological and environmental aspects of health.
- Social determinants of health are the social, economic, and political conditions that
shape the health of individuals, families, and communities.
Session 2 Critical Thinking/ Health Promotion/ Culture/ Interviewing/ Health History Ch. 1 – 5 resources Phys. Examination
- End goal is to explore interviewing techniques required to obtain a health history
- Following online activities (quizzes and SLS, and EMR), lab, and assessments, your
understanding should be:
- 1. Review the concepts of health, health promotion, and disease prevention
- 2. Articulate an understanding of the basic characteristics of culture and its impact on the
- 3. Explain the significance of transcultural considerations and how it influences the
- 4. Explain how the interview is similar to forming a contract between yourself and the client
- 5. Demonstrate a complete interview utilizing the steps of therapeutic interviewing
- 6. Articulate limitations and barriers to the interviewing process
- 7. Describe strategies needed when interviewing clients with special needs
- Learning to conduct systematic assessments is integral to developing confidence in clinical
abilities and capacity to respond effectively to patients’ needs (Jarvis 2014)
- The method of moving from novice to becoming an expert practitioner is through critical
- All nurses start as novices, when clear-cut rules are needed to guide actions
- Critical thinking is the means by which nurses learn to assess and modify, if indicated, before
- The process of enabling people to increase control over, and to improve their health (WHO,
- Primary prevention – People and populations are prevented from becoming ill, sick or injured
in the first place
- Secondary prevention – Early detection of disease, before symptoms emerge
- Tertiary prevention – Prevetion of complications when a condition or disease is present or
has progressed (Jarvis, 2014) Cultural and social considerations in Health Assessment
- When working with other cultures, the goal is to understand and develop a plan of care based
on client’s values
- Nurses are responsible for asking the client about their health practices, values and beliefs
- Cultural competence is the ability to communicate between and among cultures and to
demonstrate skill in interacting with and understanding people from cultures other than your own
- The two primary components of a health assessment are the health history and physical
- Collection of assessment data is the first step in the nursing process and an expectation of
nurses in clinical practice
- The nurse and the client use this data to create a plan to promote health, prevent disease,
resolve acute health issues, and to minimize limitations of chronic health problems
- The purpose of the health history is to obtain subjective data from the client
Three phases of an interview: 3. Analyze your own negative feelings
1. Introductory phase (Introduce the 4. Your style is governed by your own personal
interview.) life experiences
2. Working phase (Gather data, start with 5. Practice conversations, observe behaviour,
open-ended questions asking for narrative validate responses
information, then use closed questions asking 6. Be expressive, consistent, open, and truthful
for specifics in short.)
3. Summary and closure phase (signal that
the interview is ending and summarize what
you learned during the interview.) Interviewing traps
1. Providing assureance/reassurance
2. Giving unwanted advice
Rules of effective interviewing 3. Using authority
1. Create a pleasant atmosphere 4. Using avoidance language
2. Gather information prior to the interview 5. Engaging in distancing
3. Develop a good rapport 6. Using professional jargon
4. Set the tone for the interview 7. Using leading and biased questions
5. Form effective questions
6. Take notes
7. Explain what information you seek, how long Sensitive topics:
interview will last 1. Alcohol use/abuse
2. Drug use/abuse
8. Write a history guideline
9. Explain that you will be writing down 3. Physical violence
information during the interview 4. Sexual history
5. Death and dying
Practice interviewing Techniques
1. Be aware of what you are saying/how you Lab outcomes:
say it 1. Active listening, open-ended and close-
ended questions, appropriate use of
2. Be aware of body language nursing/medical terminology, use of SOLER 2. Development of a therapeutic relationship 6. Cultural competency
3. Accurate completion of a comprehensive
health history assessment tool
5. Accurate documentation
The Complete Health History
- The purpose of the Health history is the collect subjective data (what the patient says)
- For sick patients the health history is detailed and chronological; for all patients it is a
screening tool for abnormal symptoms, health problems, and concerns
- The Health History gathers data into 8 categories:
- First, collect biographical data, such as the patient’s name, address, and date of birth as well
as language and communication needs.
- Second, note the source of the history, which is usually the patient, but may be
someone else, such as a relative or interpreter.
- Third, obtain the reason for seeking care, formerly known as the chief complaint. In the
patient’s own words, briefly describe the reason for the visit.
- Fourth, record the present health or history of present illness. For a well patient, briefly
note the general state of health. For a sick patient, chronologically record the reason for
seeking care. When a patient reports a symptom, perform a symptom analysis. If you find it
helpful, use the mnemonic PQRSTU to do this. PQRSTU stands for Provocative or palliative,
Quality or quantity, Region or radiation, Severity scale, Timing, and Understanding the
patient’s perception of the problem.
- Fifth, investigate past health events, such as illnesses, injuries, hospitalizations, and
allergies as well as current medications.
- Sixth, gather a family history to help detect health risks for the patient. To aid in this
process, draw a family pedigree or genogram.
- Seventh, perform a review of systems to evaluate the past and present health of each
body system, double-check for significant data, and assess health promotion practices. For
each body system, assess for symptoms and health-promoting behaviours.
- Finally, perform a functional assessment, including activities of daily living, such as
bathing dressing, toileting, eating, walking, housekeeping, shopping, cooking, and other
- When obtaining a child’s health history, use the same structure you would use for an adult,
but make pertinent modifications or additions. Additions include:
- A prenatal and perinatal history,
- The parents’ description of the present problem,
- Any childhood illnesses or accidents,
- Immunization data,
- A developmental overview,
- And a nutritional history.
When taking the health history of an adolescent, the HEEADSSS framework of interviewing
minimizes stress. To foster trust, follow the adolescent’s lead with an attitude of openness and
When taking an older adult’s health history, also ask additional questions. For example, explore
changes in activities of daily living that may result from the aging process or chronic illness.
Remember that the impact or burden of a disease may be more important to an older adult than
the actual disease diagnosis or pathology. So be sure to record the patient’s reason for seeking
care, not your assumption about the problem. (SLS > Simulation Scenarios > Scenario 3-1, Nursing Assesment in EMR under Sc. 3-1)
Session 3 – Mental Status, Substance Abuse, Assessment Techniques,
Interpersonal Violence and Nutrition
- State the purpose of a mental status assessment and list the four components (ABCT).
- Define the behaviours that are considered in an assessment of a person's mental status.
- Demonstrate history taking and examination techniques appropriate for mental status
- Review the components of obtaining vital signs and height & weight measurement.
- Review normal ranges of temperature, pulse, respiratory rate, blood pressure and oxygen
- List the information considered in each of the four areas of a general survey: physical
appearance, body structure, mobility, and behaviour.
- Describe the components of a nutritional clinical examination.
- Compute body mass index, % DBW and waist - to - hip ratios and explain their significance.
- Consider how culture and growth & development impact assessment findings.
- Recognize deviations from established normative values.
- Explain the following assessment techniques: inspection, palpation, percussion and
- Describe the importance of screening all clients for domestic violence.
- Mental status is the degree of competence that a person shows intellectual, emotional,
psychological, and personality functioning
- Consciousness, language, mood and affect, orientation, attention, memory, abstract
reasoning, thought process, though content, and perceptions all need to be considered
- Consciousness, language use, attention span, and abstract thinking ability develop over time
and must be considered from a developmental perspective when examining infants and children
- Slower response time may affect new learning
- The full mental status examination is a systematic check of emotional and cognitive
- Full mental status exam would be conducted if family express concern about a person’s
behaviour, if a cerebral pathological condition or aphasia is observed, or if symtoms of psychiatric
mental illness are noted (be aware of pre-existing illnesses and medications as factors) - A B C T – Appearance, Behaviour, Cognition, Thought processes are the 4 main
components addressed during a mental status assessment
- Appearance: posture, body movements, dress, grooming and hygiene
- Behaviour: Level of consciousness, facial expression, speech (quality, pace, articulation,
word choice), mood and affect
- Cognitive functions: Orientation, attention span, recent/remote memory, new learning – the
four unrelated words test, judgement
- Thought processes: Thought processes, thought content, perception, screening for suicidal
- Lastly, perform mini mental status exam
- The Mini Mental Examination is a quick and easy means of assessing cognitive function (not
mood or thought process), can be used for both initial measurement and serial measurement to
follow a pt. overtime
- Detects dementia and delirium, and differs organic disorders from psychiatric illnesses
- Focus of the mental status assessment in infants and children is on the behavioural, cognitive,
and psychological development of the child in coping with their environment
- The ABCT components may be used for adolescents and aging adults
- To help prevent and minimize the harmful effects of substance use, and to develop health
promoting nursing practice that accounts for a range of substance use, the social and health
effects of substance use, and the root causes of substance use. This is relevant to assessment of
every patient, regardless of whether they appear to have problems with substance use. (Jarvis,
- Refers to a visual examination of the body, including body movement and posture
- Data obtained by smell also included in inspection
- Concentrated observation of the client as a whole, then of each body system
- Always comes first
- Involves the use of the nurse’s hands to feel texture, size, shape, consistency, and location of
certain parts of the client’s body and to identify areas the client reports as tender or painful
- Palpation follows and confirms areas noted during inspection
- Applies sense of touch to assess: texture, temperature, moisture, organ location/size, swelling,
vibration, pulsation, rigidity, spasticity, crepitation, lumps, masses, tenderness, pain
- Fingertips: skin texture, swelling, pulsatility and lumps
- Grasping action of fingers: position, shape and consistency of organ or mass - Dorsa of hand and fingers: skin temperature
- Base of fingers: vibration
- Bimanual: use of both hands to envelope certain body parts
- Perform light palpation before deep palpation
- abdomen is assessed in this order: Inspection, auscultation, percussion, and palpation
- 5 percussion tones are produced by tapping the plexor on the pleximeter
- Tones allow examiner to evaluate size, borders, and consistency of some internal organs, to
detect tenderness, and to determine the extent of fluid in a body cavity
- Percussion is tapping the person’s skin with short, sharp strokes to assess underlying structures
- Yields palpable vibration and sound depicting location, size and density of underlying organ
- Percussion is used to: map location/size of organ; assess density of a structure; detect abnormal
mass; elicit pain; elicit deep tendon reflex
- Percussion may be replaced with diagnostic tests (bladder scanner or chest xray)
Percussion Note Origin Sound Example
Tympany Enclosed Air Drum like Stomach Air in Bowel
Resonance Part Air & Solid Tissue Hollow Normal Lung
Hyper-Resonance More Air Booming Lung with Emphysema
Dullness More Solid Thud Sound Liver, Spleen, Heart
Flatness Very Dense Tissue Flat Muscle, Bone
- The act of listening to sounds within the body, commonly uses stethoscope
- Listening to sounds produced by the body
- Of the stethoscope, the bell is held lightly against the client’s skin, and the diaphragm is held
firmly against the client’s skin
- Occurs at the onset of most exams when initial data is collected before examining specific
- Physical appearance, body structure, mobility and behaviour are types of information
- Symptom analysis, screening for reported pain, can be completed by PQRSTU method or the
method - P – Provocative or palliative
- Q – Quality or quantity
- R – Regional or radiation
- S – Severity scale (0-10)
- T – Timing, onset
- U – Understanding of the patient’s perspective
- Types of abuse:
- Consequences of violence:
- Challenges to screening for abuse:
- Effective responses to screening: Putting safety first; Making connections; Offering more
than band-aid solution; Doing no harm; Listening in a nonjudgmental and accepting manner;
Having a high index of suspicion for abuse; Assessing and intervening collaboratively
- Screening of child abuse is not recommended
- Reporting is mandatory in most provinces
- Food and fluid are the basic biological needs
- Nutrition assessment not typically done in isolation, usually part of general exam
- Nutrition exam includes: anthropometric measurements, biochemical tests, and nutrition-
- Areas in which rapid turnover of epithelial tissue occurs: skin, hair, mouth, lips, and eyes – are
the nutritional deficiencies readily available; but these signs many be non-nutritional in origin, so
lab testing is required for accurate diagnosis
- **Understand clinical signs for various nutritional deficiencies in Table 11-4
Derived weight measures
- Percent ideal body weight: current weight/ideal weight x100
- Percent usual body weight: current weight/usual weight x 100
- BMI: weight (kg)/height(m2)
- Waist-to-hip ratio assesses body fat distribution; obese persons with greater proportion of fat
in the upper body (especially in abdomen) have android obesity; obese persons with most of fat in
the hips/thighs have gynoid obesity; waist circumference/hip circumference
- A WC > 89 cm (35 in) in women and >102 cm (40 in) in men increases risk of cardiovasc