S.NO SPECIFIC TIME CONTENT LEARNING A.

V EVALUATION
OBJECTIVE AND AIDS
TEACHING
ACTIVITY
1. Describe about 5 mins Lecture cum PPT
health assessment ? The ability to assess the patient is one of the most important skills discussion
of the nurse, regardless of the practice setting. In all settings where
nurses interact with patients and provide care, eliciting a
Complete health history and using appropriate assessment skills Care
critical to identifying physical and psychological problems and
concerns experienced by the patient. As the first step in the nursing
process, patient assessment is necessary to obtain data that will
enable the nurse to make a nursing diagnosis, identify and implement
nursing interventions, and assess their effectiveness.
THE ROLE OF A NURSE IN HEALTH ASSESSMENT:

The role of the nurse in health assessment includes obtaining the

patient’s health history and performing a physical assessment.

A growing list of nursing diagnoses is used by nurses to identify

and categorize patient problems that nurses have the knowledge,
skills, and responsibility to treat independently.
All members of the health care team (physicians, nurses, nutritionists,
social workers, and others), use their unique skills and knowledge to
contribute to the resolution of patient problems by first obtaining a
health history and physical examination.
S.NO SPECIFIC TIME CONTENT LEARNING AND A.V AIDS EVALUATION
OBJECTYIVE TEACHING
ACTIVITY
2. Explain about the 10 Lecture cum PPT
basic guidelines to mins BASIC GUIDELINES TO CONDUCT A HEALTH discussion
conduct
SPECIFIC health TIME ASSESSMENT:
CONTENT LEARNING AND A.V AIDS EVALUATION
assessment
OBJECTIVE TEACHING
 Before starting with the health assessment the
ACTIVITY
nurse attempts to establish rapport, put the
person at ease, encourage honest
communication (Fuller & Schaller-Ayers, 2000),
make eye contact, and listen carefully to the
person’s responses to questions about health
issues, this will help to reduce anxiety level in
clients.

 When obtaining the health history or

performing the physical examination, the nurse
must be aware of his or her own nonverbal
communication as well as that of the patient.

 The nurse takes into consideration the

educational and cultural background as well as
language proficiency of the patient.

S.NO SPECIFIC TIME CONTENT LEARNING AND A.V AIDS EVALUATION

OBJECTYIVE TEACHING
ACTIVITY
5 Lecture cum PPT
mins discussion
 Questions and instructions to the patient are
phrased in a way that is easily understandable.
Technical terms and medical jargon are avoided.
S.N
O
Types of Information Needed Lecture cum PPT
discussion
 General health and lifestyle patterns sleeping
pattern, diet, stability of weight, usual exercise
and activities, use of tobacco, alcohol, illicit
drugs.

 Acute infectious diseases measles, mumps,

whooping cough, chickenpox, pneumonia,
pleurisy, tuberculosis, scarlet fever, acute
rheumatic fever, rheumatic heart disease,
tonsillitis, hepatitis, polio, sexually transmitted
disease (STD), tropical or parasitic diseases, any
other acute infectious problem the patient
describes.

Immunization of polio, diphtheria, pertussis, tetanus,

measles, mumps, rubella, haemophilus influenza type b,
hepatitis B, hepatitis A, pneumococcal influenza,
varicella, Lyme, and last purified protein derivative or
other skin test, abnormal or unusual reaction
 Explains how to A. Family history:
collect family The age and health status, or the age and cause of death,
historyu
of first-order relatives (parents, siblings, spouse, children)
and second-order relatives (grandparents, cousins) are Lecture PPT
cum
elicited to identify diseases that may be genetic in origin, discussion
communicable, or possibly environmental in cause.

Purposes

 To present a picture of the patient's family health,

including that of grandparents, parents, brothers,
sisters, aunts, and uncles. It also involves the
health of close relatives because some diseases
show a familial tendency or are hereditary.
 To describe the health of the patient's spouse and
children because this may give clues about
possible communicable disease problems. It also
will be important in determining what sort of
condition a family is in and how this affects the
patient.

Method of Collecting Data

 Begin by explaining the purpose and type of

 questions you will be asking; for example, I am
now going to ask you some questions about your
past health.
 Explain that these questions are important to
obtain an accurate picture of all the events that
affected or that did not affect the patient's health
in the past.
 Use direct questions; for example, How would you
describe your general health? and then proceed
with more specific queries, such as Has your
weight been stable over the past 5 years?

Types of Information Needed

 Age and health status (or age at and cause of

death) of maternal and paternal grandparents,
parents, siblings
 History, in immediate and close relatives, of heart
disease, hypertension, stroke, diabetes, gout,
kidney disease or stones, thyroid disease,
pulmonary disease, blood problems, cancer
(types), epilepsy, mental illness, arthritis,
alcoholism, obesity

A. Family history:
The age and health status, or the age and cause
of death, of first-order relatives (parents, siblings,
spouse, children) and second-order relatives
(grandparents, cousins) are elicited to identify
diseases that may be genetic in origin,
communicable, or possibly environmental in
cause.

Purposes

 To present a picture of the patient's

family health, including that of
grandparents, parents, brothers, sisters,
aunts, and uncles. It also involves the
health of close relatives because some
diseases show a familial tendency or are
hereditary.
 To describe the health of the patient's
spouse and children because this may
 give clues about possible communicable
diseases.

Types of Information Needed

 Age and health status (or age at and

cause of death) of maternal and
paternal grandparents, parents, siblings
 History, in immediate and close
relatives, of heart disease,
hypertension, stroke, diabetes, gout,
kidney disease or stones, thyroid
disease, pulmonary disease, blood
problems, cancer (types), epilepsy,
mental illness, arthritis, alcoholism,
obesity
 Genetic disorders, such as hemophilia
or sickle cell disease
 Age and health status of spouse and
 children

Method of Collecting Data

 Begin with an explanation of what you are asking and why

because the patient may not understand the purpose of
your questions. For example: I am going to ask about the
health of your immediate family and relatives. It is
important to know if there are any conditions that tend to
or could occur in your family, or in you as a member of the
family.
 Ask direct questions.
o Begin with the patient's siblings. Do you have any
brothers and sisters?
o How old are they and what is the state of their
health?
o List each sibling separately, giving age and state of
health.

A. Review of systems:
The systems review includes an overview of general health as well
as symptoms related to each body system. Questions are asked
about each of the major body systems in terms of past or present
symptoms. Reviewing each body system helps reveal any relevant
data. Negative as well as positive answers are recorded.

Types of Information Needed

Subjective information about what the patient feels or
sees with regard to the major systems of the body. A
review of systems can be organized in a formal
checklist,

 Which becomes a part of the health history,

one advantage of a checklist is that it can be
easily audited and is less subject to error than a
system that relies heavily on the interviewer’s

memory. Skin: rash, itching, change in

pigmentation or texture, sweating, hair growth
and distribution, condition of nails, skin care
habits, protection from sun

 Skeletal: stiffness of joints, pain, deformity,

restriction of motion, swelling, redness, heat (If
 there are problems, asks the patient to specify
any activities of daily life that are difficult or
impossible to perform.)

Head: headaches, dizziness, syncope, head injuries

 Ears: hearing acuity, earache, discharge,

tinnitus, vertigo, history of tubes or infection

 Nose: sense of smell, frequency of colds,

obstruction, epistaxis, postnasal discharge, sinus
pain or therapy, use of nose drops or sprays (type
and frequency)

 Teeth: pain; bleeding, swollen or receding

gums; recent abscesses, extractions; dentures;
dental hygiene practices, last dental examination

 Mouth and tongue: soreness of tongue or

buccal mucosa, ulcers, swelling

 Throat: sore throat, tonsillitis, hoarseness,

dysphagia

 Neck: pain, stiffness, swelling, enlarged glands

 or lymph nodes

 Endocrine: goiter, thyroid tenderness,

tremors, weakness, tolerance to heat and cold,
changes in hat or glove size, changes in skin
pigmentation, libido, easy bruising, muscle
cramps, polyuria, polydipsia, polyphagia,

Respiratory:
o Pain in the chest and relationship to
respirations
o Dyspnea, wheezing, cough, sputum
(character, quantity), hemoptysis
o Last tuberculin test or chest X-ray and
result (indicate where obtained)
o Exposure to tuberculosis.

 Cardiovascular:
o Presence of pain or distress and location
(have patient point to location); radiation
of pain; precipitating or aggravating
causes; alleviating measures; timing and
duration
 o Palpitations, dyspnea, orthopnea (note
number of pillows required for sleeping),
history of heart murmur, edema,
cyanosis, claudication, varicose veins
o Exercise tolerance (determine in relation
to patient's regular activities how much
can he do before stopping to rest?)
o Blood pressure (if known): last
electrocardiogram (ECG) and results
(indicate where obtained)

 Hematological: anemia (if so, treatment

received), tendency to bruise or bleed,
thromboses, thrombophlebitis, any known
abnormalities of blood cells,

 Lymph nodes: enlargement, tenderness,

suppuration, duration and progress of
abnormality

 hormone therapy, unexplained weight change

Gastrointestinal:
o Appetite and digestion, intolerance to
certain classes of foods
o Pain associated with hunger or eating,
 eructation, regurgitation, heartburn,
nausea, vomiting, hematemesis
o Regularity of bowel movement (describe
normal bowel habits and whether they
have changed recently); diarrhea,
flatulence, stools (color brown, black,
clay; tarry, fresh blood, mucus)
o Hemorrhoids, jaundice, dark urine, use of
laxatives type, frequency
o History of ulcer, gallstones, polyps,
tumors
o Previous diagnostic tests where, when,
results

 Genitourinary: dysuria, pain, urgency,

frequency, hematuria, nocturia, polydipsia,
polyuria, oliguria, edema of the face, hesitancy,
dribbling, loss in size or force of stream, passage
of stones, stress incontinence, hernias, human
immunodeficiency virus status, history of STD
o Males: puberty onset, sexual activity, use
of condoms, libido, sexual dysfunction
o Females
 Menses onset, regularity,
 duration of flow, dysmenorrhea,
last period, intermenstrual
bleeding or discharge,
dyspareunia
 Libido, sexual activity,
satisfaction with sexual relations
 Pregnancies (G, P, O, L)
 Methods of contraception, STD
protection
 Breasts pain, tenderness,
discharge, lumps, mammograms,
breast self-examination
(techniques and timing with
regard to menstrual cycle)

 Neurological:
o Mental status history of loss of
consciousness; orientation to time, place,
person
o Memory distant and recent
o Cognition, or ability of patient to
conceptualize (very useful information in
determining a health education plan for
the patient)
 o In coordination, weakness, numbness,
paresthesia, tremors, muscle cramps

 Psychiatric:
o Patient's description of personality how
patient views self
o Mood changes, difficulty concentrating,
sadness, nervousness, tension, irritability,
change in social interaction
o Obsessive thoughts, compulsions, manic
episodes, suicidal or homicidal thoughts

 General constitutional symptoms: fever,

chills, night sweats, malaise, fatigability, recent
loss or gain of weight
A. Personal and social history
Purposes

 To describe the patient's life situation may have a bearing on the

present condition, overall health, or ability to cope
 To develop a plan of care that the patient. Here the interviewer
finds out the many personal and family resources an individual has
to aid in coping with the situation both long-term and short-term
 To identify an opportunity for health promotion activities
 To determine if the patient's occupation is directly or indirectly
related to his condition

Types of Information Needed

 Personal status birth place, education, armed service affiliation,

position in the family, education level, satisfaction with life
situations (home and job), personal concerns
 Habits and lifestyle patterns
o Sleeping pattern, number of hours of sleep, difficulty
 sleeping
o Exercise, activities, recreation, hobbies
o Nutrition and eating habits (diet recall for a typical day)
o Alcohol frequency, amount, type; CAGE questionnaire

Method of Collecting Data

 Begin by explaining that you are going to ask questions about the
patient's life situation to gain a clearer perspective of the patient's
condition and of how you might help.
 Your manner should be matter-of-fact, yet concerned. If you are
uncomfortable asking the questions, most likely the patient will
sense that and be uneasy answering them.
 A sensitive interviewer can ask most of the questions listed above
in an initial interview without alienating the patient. For instance,
ask What has been your education? Instead of How far have you
gone in school?

A. End of history taking

When you have completed the history, it is often helpful to say: Is there
anything else you would like to tell me? Or What additional concerns do
you have? This allows the patient to end the history by saying what is on
his or her mind and what concerns the patient most.

1. PHYSICAL ASSESSMENT

Physical assessment, or the physical examination, is an integral

part of nursing assessment. The physical examination is usually
performed after the health history is obtained. It is carried out in a
well-lighted, warm area. The patient is asked to undress and draped
appropriately so that only the area to be examined is exposed. The
person’s physical and psychological comfort is considered at all
times.
An organized and systematic examination is the key to obtaining
appropriate data in the shortest time. Such an approach encourages
cooperation and trust on the part of the patient. The individual’s
health history provides the examiner with a health profile that
guides all aspects of the physical examination. Although the
sequence of physical examination depends on the circumstances
and on the patient’s reason for seeking health care, the complete
examination usually proceeds as follows:
  Skin
 Head and neck
 Thorax and lungs
 Breasts
 Cardiovascular system
 Abdomen
 Rectum
 Genitalia
 Neurological system
 Musculoskeletal system.
GENERAL PRINCIPLES

 A complete or partial physical examination is conducted

following a careful comprehensive or problem-related
history.
 It is conducted in a quiet, well-lit room with consideration
for patient privacy and comfort.