Physical assessment is taking an educated, systematic look at all aspects of an individual’s health status utilizing knowledge, skills and tools of health history and physical exam.
To collect data- information about the client’s health, including physiological, psychological, sociocultural and spiritual aspects
To establish actual and potential problems
To establish the nurse-client relationship
Method: The history is done first, then the physical examination focuses on finding data associated with the history.
Health History- obtained through interview and record review.
Physical exam- accomplished by tools and techniques
** A complete assessment is not necessarily carried out each time. A comprehensive assessment is part of a health screening examination. On admission, you will do an admission assessment (not necessarily including everything presented here) and document it on the admission form. You will do a daily shift assessment (patient systems review). And, if client has a specific problem, you may assess only that part of the body (focused).
Information is organized into objective and subjective data:
Subjective: Apparent only to person affected; includes client’s perceptions, feelings, thoughts, and expectations. It cannot be directly observed and can be discovered only asking questions.
Objective: Detectable by an observer or can be tested against an acceptable standard; tangible, observable facts; includes observation of client behavior, medical records, lab and diagnostic tests, data collected by physical exam.
** To obtain data for the nursing health history, you must utilize good interview techniques and communications skills. Record accurately. DO NOT ASSUME.
D. Frameworks for Health Assessment
There are two main frameworks utilized in health assessment:
Head to Toe- systematic collection of data starting with the head and working downward.
Functional Health Assessment- Gordon’s 11 functional health patterns that address the behaviors a person uses to maintain health.
PERSON is the ACC-ADN framework for assessment. It is similar to Gordon's functional health patterns.