HEALTH

ASSESSMENT
TYPES OF HEALTH ASSESSMENT
• Initial comprehensive assessment
• Ongoing or partial assessment
• Focused or problem-oriented assessment
• Emergency assessment

STEPS OF HEALTH
ASSESSMENT
1. Collection of subjective data
2. Collection of objective data
3. Validation of data
4. Documentation of data
 COLLECTING COLLECING
SUBJECTIVE OBJECTIVE
DATA DATA
Subjective data are sensations or symptoms This type of data is obtained by
(e.g., pain, hunger), feelings (e.g., happiness, general observation and by using
sadness), perceptions, desires, preferences, the four physical examination
beliefs, ideas, values, and personal techniques: inspection, palpation,
information that can be elicited and verified percussion, and auscultation.
only by the client.

Biographical information (name, age, Physical characteristics (e.g., skin color,

religion, occupation) posture)
History of present health concern: Body functions (e.g., heart rate,
Physical symptoms respiratory rate)
related to each body part or system Appearance (e.g., dress and hygiene)
(e.g., eyes and ears, Behavior (e.g., mood, affect)
abdomen) Measurements (e.g., blood pressure,
Personal health history temperature, height, weight)
Family history Results of laboratory testing (e.g.,
Health and lifestyle practices platelet count, x-ray findings)
PATIENT POSITIONING

supine position lateral

used for general examination or recumbent (left
physical assessment. or right)
This position makes it
easier to access a
patient's right/left
side..

prone position
The prone position is used primarily
to assess the hip joint. The back can
also be assessed with the client in this
position. Clients with cardiac and
respiratory problems cannot tolerate
this position.
PATIENT POSITIONING

lithotomy position
Commonly used for knee-chest position
vaginal examinations Is assumed for a
and childbirth. gynecologic or rectal
examination.

Knee-chest position
can be lateral or
prone.
PATIENT POSITIONING

Fowler’s position Trendelenburg’s

Used for patients who
position
Patients can benefit
have difficulty
from this position
breathing because in
because it promotes
this position, gravity
venous return.
pulls the diaphragm
downward allowing
Used to provide
greater chest and lung
postural drainage of
expansion.
the basal lung lobes.
HEALTH HISTORY ASSESSMENT "SAMPLE"
S -Symptoms patient's chief complaints
seeking to know what type of allergic
A -Allergy reaction they experienced

M -Medications prescribed, OTC drugs, herbal meds, etc...

seeking to know the previous
P -Past Medical History state of health and previous
illness

L -Last Oral Intake seeking what are the last oral intakes
of the client

E -Events leading up to
the illness or injury events leading up to the
illness or injury.
 FAMILY HISTORY ASSESSMENT
"BALD CHASM"
B -Blood pressure C -Cancers
A -Arthritis H -Heart disease
L -Lung disease A -Alcoholism
D -Diabetes S -Stroke
M -Mental health
disorders
 SIGNS vs. SYMPTOMS

sign symptoms
Is objective and discovered Is subjective, observed and
by the healthcare experienced by the patient,
professional during an and cannot be measured
examination. directly.

something I can detect sYMptom is something only

even if patient is hYM jnows about.
unconscious.
 PAIN ASSESSMENT "OPQRSTUV"
O -Onset
P -Provoking or Palliating factors
Q -Quality
R -Region and Radiation
S -Severity
T -Time&Treatment
U -Understanding&Impact
V -Values
CLASSIFICATION OF PAIN
according to duration and etiology according to location

Acute pain usually associated Cutaneous pain

with a recent injury (skin or subcutaneous tissue)
Chronic usually associated with a
nonmalignant specific cause or injury Visceral pain
pain: and described
constant pain that
as a (abdominal cavity, thorax,
cranium)
persists for more than 6
months
Deep somatic pain
Cancer pain often due to the
(ligaments, tendons, bones,
compression of peripheral blood vessels, nerves)
nerves or meninges or
from the damage to these
structures following
surgery, chemotherapy,
radiation, or tumor growth
and infiltration
according to location whether it is other types of pain
perceived at the site of the pain
stimuli Neuropathic pain
caused by damage or injury to the
Radiating nerves that transfer information
perceived both at the source and between the brain and spinal cord
extending to other tissues from the skin, muscles and other
parts of the body.
Referred
perceived in body areas away from
the pain source
Intractable pain
A type of pain that can't be

Phantom pain controlled with standard medical

care because of its high resistance
can be perceived in nerves left by a
to pain relief.
missing, amputated, or paralyzed
body part.
 DIMENSIONS OF PAIN
Physical Sensory
effect of anatomic structure and qualitative and quantitative
physiologic functioning on the descriptions of pain
experience of pain
Sociocultural
Behavioral effect of social and cultural
verbal and nonverbal behaviors backgrounds on the experience
associated with pain of pain

Cognitive Affective
thoughts, beliefs, attitudes, feelings and emotions that result
intentions, and motivations from pain
related to the experience of pain

Spiritual
ultimate meaning and purpose
attributed to pain, self, others,
and the divine
PAIN RATING SCALE
WARNING SIGNS OF CANCER "CAUTION US"
C -Change in bowel or bladder habits
A -A sore that does not heal
U -Unusual bleeding or discharge
T -Thickening or lump in breast or
elsewhere
I -Indigestion or dysphagia
O -Obvious change in wart or mole
N -Nagging cough or hoarseness
U -Unexplained anemia
S -Sudden & unexplained weight loss
EMERGENCY TRAUMA ASSESSMENT
"ABCDEFGHI"
A -Airway
B -Breathing
C -Circulation
D -Disability
E -Expose & examine
F -Full set of vital signs
G -Give comfort measures
H -History and head-to-toe assessment
I -Inspect posterior surface
NORMAL VITAL SIGNS
PULSE 60-100 bpm
BLOOD PRESSURE 120/80 mmHg
RESPIRATION 12-20 breaths per min

02 SATURATION 95-100%

TEMPERATURE 36.5-37.7 °C (96.0-

99.9 °F)
HEAD-TO-TOE
ASSESSMENT
Before the exam, Orientation
Knock What is your name?
Introduce yourself Do you know where you
Wash hands are?
Ensure privacy Do you know what month it
Keep the room is?
comfortable What are you doing here?
Sit/stand at eye level, and A&O X4= Oriented to
make good eye contact Person, Place, Time and
Verify patient ID and DOB Situation
Explain what you are
doing using non-medical
language
Use open-ended
questions to gather
unbiased information
 LEVEL OF CONCIOUSNESS "AVPU"
ASSESSMENT
A -Alert Eyes open spontaneously.
Appears aware of and responsive
Child is active and
responds appropriately to
to the environment. SO and other external
Follows commands eyes tract stimuli.
peoples and objects.

V -Voice Eye do not open spontaneously

but open to verbal stimuli.
Respond only when his or
her name is called
Able to respond in some
meaningful way when spoken to.

P -Pain Does not respond to questions but

moves or cries out in response to
Respond only when
painful stimuli is received
painful stimuli such as pinching such as pinching the nail
the skin or earlobe. bed.

U -Unresponsive Patient does not

respond to any
No response at all.

stimuli.
PHYSICAL ASSESSMENT TECHNIQUES "IPPA"
Inspection visual examination of the patient
done when the person doing the assessment
Palpation places their fingers on the body to determine
things like swelling, masses, and areas of pain
light palpation
more superficial and therefore it permits
identification of the superficial organs or
masses, and sometimes it can detect abdominal
wall crepitus.
deep palpation
allows examination of organs including the liver,
caecum

Percussion tapping the patient's bodily surfaces and hearing

the resulting sounds to determine the presence
of things like air and solid masses affecting
internal organs
Auscultation listening to an area of the body using a
stethoscope
Integumentary
Inspect the skin Neck, Chest, & Heart
1. color
2. moisture Neck
3. texture Inspect and palpate Heart
4. turgor Palpate carotid pulse Auscultate
5. lesions Check skin turgor under heart
the clavicle sounds
Posterior Chest (A,P,E,T,M)
Head & Face Inspect w/
Auscultate lung sounds diaphragm
Head in posterior and lateral and bell
Inspect head/scalp/hair Eyes chest (Noe any crackles -Note any
Palpate head/scalp/hair Inspects external eye or diminished breath murmurs,
Face structures sounds) whooshing,
Inspect Inspect color of bruits, or
conjunctiva and sclera
Anterior Chest
Check for symmetry Inspect
muffled
Test CN VII PERRLA -Use of accessory muscles heart
-raise eyebrows (Pupils Equal, Round, -AP to transverse diameter sounds
-smile Reactive to Light, & -Sternum configuration
-frown Accomodation) Palpate: symmetric expansion
Auscultate lung sounds
-show teeth
(anterior and lateral)
-puff out cheeks
-Note any murmurs,
-tightly close eyes whooshing, bruits or muffled
heart sounds
Peripherals Spine
Have the patient stand up (if
Peripherals able)
Ankles
Upper extremities Inspect the skin on the back Inspect and palpate
Inspect and palpate Inspect: spinal curvature Post tibial pulse (+1, +2, +3, +4)
Note any texture, lesions, Dorsal pedis pulse bilaterally
(cervical/thoracic/lumbar)
temperature, moisture, (+1, +2, +3, +4)
Palpate spine
tenderness & swelling – Check strength bilaterally
Note any lesions, lumps, or
Palpate radial pulses -Dorsiflexion flexion against
abnormalities
bilaterally ( +1, +2, +3, +4) resistance
+1 Diminished Lower
+2 Normal
+3 Full Extremities Abdomen
+4 Bounding, strong •Inspect:
Inspect:
Shoulder – Overall skin coloration – Skin color
Inspect , palpate, assess – Lesions – Contour
– Hair distribution – Scars
Elbows – Varicosities – Aortic pulsations
Inspect , palpate, assess – Edema Auscultate bowel sounds:
Palpate: Check for edema all 4 quadrants (start in RLQ and go
Hands and Fingers (pitting or non-pitting) clockwise)
Inspect hands, fingers, nails Check capillary refill Light palpation: all 4 quadrants
Palpate hands and finger bilarerally ABSENT: Must listen for at least 5 minutes to
joints
Check muscle strength of
Hips chart absent bowel sounds
HYPOACTIVE: One bowel sound every 3-5 mins
Inspect & palpate NORMOACTIVE: Gurgles 5-30 time per minute
hands bilaterally (If both HYPERACTIVE: Can sometimes be heard
hands can grip evenly) Knees without a stethoscope constant bowel sounds,
> 30 sounds per minute
Inspect & palpate
Musculoskeletal
Assess ROM and muscle
strength
Check for + grade and any
edema
Inspect posture and gait
Test deep tendon reflexes

Overall
Positions and drapes patient
appropriately
during exam (gave patient
privacy)
Gave patient
feedback/instructions
Exhibits professional manner
during exam,
treated patient with respect
and dignity
Organized: exam followed a
logical sequence
(order of exam “made sense”)
I can do all things through Christ
who strengthens me.
PHILIPPIANS 4:13

Good luck future RN!

References
Chelsea (2020). Complete Nursing School Bundle. CeceStudyGuides.

May, B. (2017). Verbal Numerical Rating Scale: A Reliable Pediatric Pain Assessment Tool. Clinical
Pain Advisor. Retrieved from https://www.clinicalpainadvisor.com/home/topics/pediatric-pain-
management/verbal-numerical-rating-scale-a-reliable-pediatric-pain-assessment-tool/

Tuttle, K. (2020). The Complete Nursing School Bundle. NurseInTheMaking LLC.

Vera, M. (2018). Nursing Health Assessment Mnemonics & Tips. Nurses Labs. Retrieved from
https://nurseslabs.com/nursing-health-assessment-mnemonics-tips/

Weber, J. & Kelley, J. (2014). Health Assessment in Nursing. Fifth Edition. Lippincott Williams &
Wilkins.

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