{"id":174,"date":"2021-08-19T13:24:42","date_gmt":"2021-08-19T17:24:42","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/69\/"},"modified":"2024-06-05T15:02:17","modified_gmt":"2024-06-05T19:02:17","slug":"69","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/69\/","title":{"raw":"Introduction to Health Assessment","rendered":"Introduction to Health Assessment"},"content":{"raw":"<p style=\"text-align: left\"><span style=\"color: #000000\">Health <strong>assessment<\/strong> is the first phase of the nursing process and involves the <strong>collection<\/strong> and <strong>analysis of client data<\/strong>. Although it is the first phase, it is an ongoing process. Data collected as part of the health assessment process can be categorized as subjective and objective data. See <strong>Table 1<\/strong>\u00a0for an overview and examples of <strong>[pb_glossary id=\"330\"]subjective[\/pb_glossary] <\/strong>and <strong>[pb_glossary id=\"332\"]objective[\/pb_glossary]<\/strong>\u00a0data.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Table 1:<\/strong> Overview and examples of subjective and objective data - adapted from Lapum et al.,<\/span> <a href=\"https:\/\/ecampusontario.pressbooks.pub\/healthassessment\/\" target=\"_blank\" rel=\"noopener\">https:\/\/ecampusontario.pressbooks.pub\/healthassessment\/<\/a><\/p>\r\n&nbsp;\r\n<table class=\"lines alignleft\" style=\"border-collapse: collapse;width: 100%;height: 45px\" border=\"0\">\r\n<tbody>\r\n<tr class=\"shaded\" style=\"height: 15px\">\r\n<th style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\r\n<p class=\"no-indent\"><strong>Data<\/strong><\/p>\r\n<\/th>\r\n<th style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\r\n<p class=\"no-indent\"><strong>Example<\/strong><\/p>\r\n<\/th>\r\n<\/tr>\r\n<tr style=\"height: 15px\">\r\n<td style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Subjective <\/strong><\/span><\/p>\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Information that a client or another person (i.e., family, caregiver) shares with the nurse spontaneously or in response to questions.<\/span><\/p>\r\n<\/td>\r\n<td style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\r\n<ul>\r\n \t<li><span style=\"color: #000000\">A client says, \u201cI have had a rash on my ankle and leg for the last two weeks.\u201d<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">A parent says, \u201cMy eight-month-old son is having trouble breathing.\u201d<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">A client\u2019s reason for seeking care is \u201cdiarrhea for 10 days.\u201d<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">A client types, \u201cI feel sick to my stomach.\u201d<\/span><\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 15px\">\r\n<td style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Objective <\/strong><\/span><\/p>\r\n<p class=\"no-indent\"><span style=\"color: #000000\">Information that the nurse observes when conducting a physical examination, and collecting lab and diagnostic results.<\/span><\/p>\r\n<\/td>\r\n<td style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\r\n<ul>\r\n \t<li><span style=\"color: #000000\">The nurse observes that a client has a bright red rash on the dorsal side of the foot, the lateral malleolus, and anterior and lateral side of the lower leg.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">The nurse observes the client sitting upright, leaning forward, breathing fast with eyes wide open.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">The nurse measures the client\u2019s blood pressure and records it as 112\/84 mm Hg and pulse of 84 beats per minute.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Lab test results: potassium (K+) 4.0 mmol\/L, fasting glucose 4.8 mmol\/L.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Chest X-ray report: lungs well inflated and clear. No evidence of pneumonia or pulmonary edema.<\/span><\/li>\r\n<\/ul>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Subjective data can include information about both symptoms and signs. <strong>Symptoms<\/strong> are something that the client feels (e.g., nausea, pain, fatigue). The nurse will not know about a symptom unless the client shares this information. <strong>Signs<\/strong> are observable, such as a rash, bruising, or skin perspiration. Signs can be categorized as subjective or objective because the client may tell you about their rash, and you as the nurse may also observe the rash. As reflected in <strong>Figure 1<\/strong>, a symptom is noted in the image on the left as \u201cI\u2019m having pain\u201d while a sign can be observed in the image on the right, which is the bruising on the left arm.<\/span><\/p>\r\n<img src=\"http:\/\/pressbooks.library.ryerson.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2021\/08\/symptom-vs-sign_bruising-1024x748-1.png\" alt=\"Shows a person saying I'm having pain and another person with a bruise on arm.\" width=\"1024\" height=\"748\" class=\"alignnone size-full wp-image-67\" \/>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Figure 1:<\/strong> Symptoms and signs<\/span>\r\n<span style=\"color: #000000\">(Attribution: Taken from<\/span> <a href=\"https:\/\/ecampusontario.pressbooks.pub\/healthassessment\/\" target=\"_blank\" rel=\"noopener\">https:\/\/ecampusontario.pressbooks.pub\/healthassessment\/<\/a>)<\/p>\r\n&nbsp;\r\n\r\nAge ranges are important to consider when determining normal and abnormal findings during health assessment. Depending on the source, these ranges can vary. Unless specified, we use the following terms and estimates in this resource:\r\n<ul>\r\n \t<li>Newborns and neonates: newborns are birth to a few hours old and neonate is up to 28 days.<\/li>\r\n \t<li>Young children: clients who are 5 years and younger, including infants (28 days to 1 year), toddlers (1\u20132 years), and preschoolers (3\u20135 years).<\/li>\r\n \t<li>Older children and adolescents: clients who are 6\u201317 years, including older children\/school-age children (6\u201312 years) and adolescents (13\u201317 years).<\/li>\r\n \t<li>Adults and older adults: clients who are 18 years and older, including adults (18 years and older) and older adults (65 years and older).<\/li>\r\n<\/ul>","rendered":"<p style=\"text-align: left\"><span style=\"color: #000000\">Health <strong>assessment<\/strong> is the first phase of the nursing process and involves the <strong>collection<\/strong> and <strong>analysis of client data<\/strong>. Although it is the first phase, it is an ongoing process. Data collected as part of the health assessment process can be categorized as subjective and objective data. See <strong>Table 1<\/strong>\u00a0for an overview and examples of <strong><button class=\"glossary-term\" aria-describedby=\"174-330\">subjective<\/button> <\/strong>and <strong><button class=\"glossary-term\" aria-describedby=\"174-332\">objective<\/button><\/strong>\u00a0data.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Table 1:<\/strong> Overview and examples of subjective and objective data &#8211; adapted from Lapum et al.,<\/span> <a href=\"https:\/\/ecampusontario.pressbooks.pub\/healthassessment\/\" target=\"_blank\" rel=\"noopener\">https:\/\/ecampusontario.pressbooks.pub\/healthassessment\/<\/a><\/p>\n<p>&nbsp;<\/p>\n<table class=\"lines alignleft\" style=\"border-collapse: collapse;width: 100%;height: 45px\">\n<tbody>\n<tr class=\"shaded\" style=\"height: 15px\">\n<th style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\n<p class=\"no-indent\"><strong>Data<\/strong><\/p>\n<\/th>\n<th style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\n<p class=\"no-indent\"><strong>Example<\/strong><\/p>\n<\/th>\n<\/tr>\n<tr style=\"height: 15px\">\n<td style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Subjective <\/strong><\/span><\/p>\n<p class=\"no-indent\"><span style=\"color: #000000\">Information that a client or another person (i.e., family, caregiver) shares with the nurse spontaneously or in response to questions.<\/span><\/p>\n<\/td>\n<td style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\n<ul>\n<li><span style=\"color: #000000\">A client says, \u201cI have had a rash on my ankle and leg for the last two weeks.\u201d<\/span><\/li>\n<li><span style=\"color: #000000\">A parent says, \u201cMy eight-month-old son is having trouble breathing.\u201d<\/span><\/li>\n<li><span style=\"color: #000000\">A client\u2019s reason for seeking care is \u201cdiarrhea for 10 days.\u201d<\/span><\/li>\n<li><span style=\"color: #000000\">A client types, \u201cI feel sick to my stomach.\u201d<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<tr style=\"height: 15px\">\n<td style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Objective <\/strong><\/span><\/p>\n<p class=\"no-indent\"><span style=\"color: #000000\">Information that the nurse observes when conducting a physical examination, and collecting lab and diagnostic results.<\/span><\/p>\n<\/td>\n<td style=\"width: 50%;height: 15px;vertical-align: top;text-align: left\">\n<ul>\n<li><span style=\"color: #000000\">The nurse observes that a client has a bright red rash on the dorsal side of the foot, the lateral malleolus, and anterior and lateral side of the lower leg.<\/span><\/li>\n<li><span style=\"color: #000000\">The nurse observes the client sitting upright, leaning forward, breathing fast with eyes wide open.<\/span><\/li>\n<li><span style=\"color: #000000\">The nurse measures the client\u2019s blood pressure and records it as 112\/84 mm Hg and pulse of 84 beats per minute.<\/span><\/li>\n<li><span style=\"color: #000000\">Lab test results: potassium (K+) 4.0 mmol\/L, fasting glucose 4.8 mmol\/L.<\/span><\/li>\n<li><span style=\"color: #000000\">Chest X-ray report: lungs well inflated and clear. No evidence of pneumonia or pulmonary edema.<\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Subjective data can include information about both symptoms and signs. <strong>Symptoms<\/strong> are something that the client feels (e.g., nausea, pain, fatigue). The nurse will not know about a symptom unless the client shares this information. <strong>Signs<\/strong> are observable, such as a rash, bruising, or skin perspiration. Signs can be categorized as subjective or objective because the client may tell you about their rash, and you as the nurse may also observe the rash. As reflected in <strong>Figure 1<\/strong>, a symptom is noted in the image on the left as \u201cI\u2019m having pain\u201d while a sign can be observed in the image on the right, which is the bruising on the left arm.<\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/pressbooks.library.ryerson.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2021\/08\/symptom-vs-sign_bruising-1024x748-1.png\" alt=\"Shows a person saying I'm having pain and another person with a bruise on arm.\" width=\"1024\" height=\"748\" class=\"alignnone size-full wp-image-67\" \/><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Figure 1:<\/strong> Symptoms and signs<\/span><br \/>\n<span style=\"color: #000000\">(Attribution: Taken from<\/span> <a href=\"https:\/\/ecampusontario.pressbooks.pub\/healthassessment\/\" target=\"_blank\" rel=\"noopener\">https:\/\/ecampusontario.pressbooks.pub\/healthassessment\/<\/a>)<\/p>\n<p>&nbsp;<\/p>\n<p>Age ranges are important to consider when determining normal and abnormal findings during health assessment. Depending on the source, these ranges can vary. Unless specified, we use the following terms and estimates in this resource:<\/p>\n<ul>\n<li>Newborns and neonates: newborns are birth to a few hours old and neonate is up to 28 days.<\/li>\n<li>Young children: clients who are 5 years and younger, including infants (28 days to 1 year), toddlers (1\u20132 years), and preschoolers (3\u20135 years).<\/li>\n<li>Older children and adolescents: clients who are 6\u201317 years, including older children\/school-age children (6\u201312 years) and adolescents (13\u201317 years).<\/li>\n<li>Adults and older adults: clients who are 18 years and older, including adults (18 years and older) and older adults (65 years and older).<\/li>\n<\/ul>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"174-330\" hidden><p>are information that the client shares spontaneously or in response to a question.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"174-332\" hidden><p>are information that is collected when performing a physical exam.<\/p>\n<\/div><\/div>","protected":false},"author":34,"menu_order":2,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by-nc"},"chapter-type":[],"contributor":[61],"license":[56],"class_list":["post-174","chapter","type-chapter","status-publish","hentry","contributor-61","license-cc-by-nc"],"part":170,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/174","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":4,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/174\/revisions"}],"predecessor-version":[{"id":2555,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/174\/revisions\/2555"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/parts\/170"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/174\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/media?parent=174"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapter-type?post=174"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/contributor?post=174"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/license?post=174"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}