University of Ottawa

Faculty of Health Sciences - School of Nursing

Health Assessment I
NSG 1225

COMPLETE HEALTH ASSESSMENT INTERVIEW GUIDE

BIOGRAPHICAL DATA
Name ___________________________ Phone: _________________
Address______________________________________________________

Birth date _________________________ Birthplace _______________

Age __________ Gender _________ Marital status _____________
Race/ethnic origin____________________ Occupation ______________
Level of education _______________
Living arrangements (alone, residence, etc) __________________________
Functional Health Pattern: Health Perception/Management
1. Health Perception
! How would you describe your health now and during the past year?
(i.e. were there any days where you were sick and couldn t do your usual activitit
es?)
! Relative to other people your age, how would you rate your overall health at t
he present time:
a) Excellent
b) Very good
c) Good
d) Fair
e) Poor
! Why would you rate it this way?
2. Influencing Factors: Health Management and Adherence Behaviour
!
What do you do on your own to stay healthy?
!
Is there anything that makes it difficult for you to follow health advice? (i.e.
time, past experience
with health professionals...)
3. Health Habits: The next set of questions asks about your health habits.
a)
When were your last immunizations completed and what were they? ( Note to the st
udent: Prior
to conducting the health assessment, you must look up the immunizations required
for the
particular age group being assessed.)
Have you had any childhood diseases such as chickenpox, german measles, red meas
les,
mumps, polio, tuberculosis?
b) Do you:
! operate vehicles under the influence of alcohol or other drugs?
! ride with vehicle operators who are under the influence of alcohol or other dr
ugs?
! wear helmets and/or safety gear when riding a bike or roller blading?
! use seatbelts or child restraints?
c) Are there any factors in the home or at work that could potentially threaten
your health or cause
injury? If yes, describe.
4. Health Promotion Health Screening Activities
The next few questions refer to your health promotion activities.
!
Do you regularly practice self-examination of your: breast (BSE)_____, testicles
(TSE) ______,?
How often? Do you have any problems in performing the self-examination?
!
When were your last medical and dental examinations? What was the reason for the
examination and
what were the results?
5. Family Data
The next few questions relate to your family.
Is there anyone that lives with you? Are you related?
Tell me about your grandparents, parents, and siblings. Do any of these family m
embers have health
problems? (Prompts may be necessary - heart or lung problems, high blood pressur
e, diabetes,
arthritis, cancer, kidney problem, problem with depression or nerves). If yes, d
escribe onset,
duration, intensity, frequency, treatment and outcome. Describe the family healt
h history on the
family genogram below. ( Include the family members age, health problems and whe
ther he or she is
alive or deceased).
Family Genogram
(Male alive ; Male deceased ; Female alive ; Female deceased )
Functional Health Pattern: Stress and Stress Responses :
1. What major changes or stressors have you experienced recently or in the past?
2. Describe how these situations have affected you physically and /or emotionall
y.
3. How do you deal with stress? Describe whether these strategies are helpful or
not in alleviating stress.
Functional Health Pattern: Values and Beliefs:
1. What culture or ethnic group do you identify with? (i.e. Canadian, British, E
ast Indian....)
2. What are your beliefs regarding health and the factors promoting health?
3. What are your beliefs regarding illness and causes of illness?
4. Is there a religion you adhere to? Explain your religious practices and belie
fs.
5.
Are there any cultural, spiritual, religious practices or beliefs that could aff
ect your health care?
6.
Are you comfortable with the following forms of communication? If no, please des
cribe.
C silence
C close proximity
C touch
C gestures
C eye contact
Functional Health Pattern: Self Concept:
A.
Personal Identity:
1. How do you describe yourself as a person (age, appearance, personality) ?
2. What do you believe are your strengths and weaknesses?
3. How do you feel about your personal accomplishments (education, career)?
Functional Health Pattern: Roles and Relationships:
1.
Identify and describe the various roles and responsibilities you have within the
following groups?
C family member:
C social group member / friends:
C student:
C co-worker:

2. How well do you feel you accomplish what is expected of you?

3.
Do you encounter problems with any of these roles and would you like to change a
ny of your roles
and responsibilities ?
4.
Are their concerns within your family in the following areas? If yes, please des
cribe.
C communication
C parenting
C relatives
C abuse
C finances
C discipline
5.
What people and resources are supportive/ unsupportive to your family? (e.g., in
dividuals,
organizations, hobbies, work relationships, etc.) These relationships with signi
ficant others and
resources in the community can be diagramatically represented through the use of
an ecomap.
Complete the ecomap on the following page using the guidelines below:
Indicate strong, positive relationships with a straight line.
Indicate weaker relationships with a dotted line. ........
Indicate strained relationships with a slashed line. - - - -

Functional Health Pattern: Sleep - Rest:

Describe usual sleep pattern: - how many hours of sleep?
-usual routine before retiring
-environment (i.e. pillows, fan, temperature, room...)
Are there any health problems or disturbances (i.e. snoring, muscle spasms ...)
which alter your sleep
pattern?
Does your altered sleep pattern affect your activities of daily living?
Do you take any medications that affect your sleep? If yes, please describe name
, dosage, schedule,
length of time taking medication and outcome.
Functional Health Pattern: Nutrition and Metabolism: Skin, Hair, Nails
1.
Do you have any skin problems now or in the past ( allergies, birthmarks, tattoo
s, colour changes,
pigmentation, warts, moles, dryness, bruising, rashes or lesions)? If yes, pleas
e describe location,
onset, duration, intensity, frequency, treatment, and outcome.
2. Have you experienced any changes with your hair ( appearance, growth or loss)
?
3. Have you experienced any changes with your nails ( shape, colour, brittleness
)?
Functional Health Pattern: Nutrition and Metabolism:
l.
Current weight: _______ Height: ________ Body Mass Index:
Recent weight change ?
2.
Describe your usual eating pattern in terms of:
Canada s Food Guide: Complete one day dietary recall form.
C
special diet (prescribed or fad )
C
cultural influences
3. Do you have any health problems which affect your eating pattern? If yes, ple
ase describe
onset, duration, intensity, frequency, treatment, and outcome.
allergies
ulcers
heartburn
anaemia
indigestion
sore mouth
diabetes
 heart disease
hypertension

4.
Are you taking any medication or dietary supplement which will influence your ea
ting pattern (antacids,
diet pills, diet suppressant or stimulants, vitamins etc.)? If yes, identify nam
e, dose, schedule, when
started taking medication, reason for taking medication and outcome.
Functional Health Pattern: Nutrition and Metabolism: Nose, Mouth and Throat:
Nose:
Do you experience any of the following? If yes, describe onset, duration, intens
ity, frequency,
aggravating factors, treatment and outcome.
frequent or severe colds
trauma to the nose
sinus pain or sinusitis
nosebleed
post nasal drip
hay fever
nasal discharge
change in sense of smell
allergies (If yes, please document how you control your environment to minimize
your exposure.)
Mouth and Throat:
Do you experience any of the following? If yes, describe onset, duration, intens
ity, frequency,
aggravating factors, treatment, and outcome.
sores
voice change
lesions
difficulty swallowing
sore throat
change in sense of taste
bleeding gums
toothache
hoarness
lumps in your throat

3.
Describe self-care behaviour related to brushing and flossing of teeth, dental v
isits, dental appliances
(i.e. braces, dentures).
Functional Health Pattern: Nutrition and Metabolism: Head and Neck:
1.
Do you experience any of the following? If yes, describe onset, duration, intens
ity, frequency,
aggravating factors, associated symptoms, treatment and outcome.
C head injury
C headache
C dizziness
C neck pain

Functional Health Pattern: Elimination:

1.
Describe your usual pattern of bowel elimination:
C frequency, colour, consistency
C recent changes
2.
Self-care Behaviours: What activities/practices help you to maintain a regular b
owel pattern (exercise,
prunes, bran, fluid intake, medications etc.)?
3.
Do you experience any of the following? If yes, describe onset, duration, intens
ity, frequency,
aggravating factors, treatment and outcome.
abdominal pain / cramping
constipation
nausea and vomiting
bloody or black stool
diarrhea
rectal pain
difficulty getting to the bathroom on time
straining
stool that floats in toilet
flatulence
incontinence
haemorrhoids
anal fissures or ulcers

Do you have any past or present history of gastrointestinal problems (i.e. colit
is, heartburn, gallbladder
disease, surgery, trauma...)? If yes, describe onset, duration, intensity, frequ
ency, treatment, and
outcome.
5. Describe your usual pattern of urinary elimination in relation to frequency o
f voiding, colour, odour, and
recent changes.
6.
Self-care Behaviours: What activities and practices help you maintain regular bl
adder elimination (i.e.
exercise, diet, fluid intake, drugs)?
7.
Do you experience any of the following? If yes, describe onset, duration, intens
ity, frequency,
aggravating factors, treatment, outcome.
pain
frequency
urgency
dribbling
burning on voiding
incontinence
bladder infections
nocturia
difficulty starting urine flow
difficulty getting to the bathroom on time

Functional Health Pattern: Activity and Exercise:

1.
Describe a typical days activities (including rest, exercise, leisure).
2.
Describe any recent changes in patterns of activity or tolerance level including
precipitating factors,
causes, health problems, medication or injuries.
Functional Health Pattern: Activity and Exercise: Cardio and Peripheral Vascular

1.
Do you experience any of the following? If yes, describe onset, duration, intens
ity, frequency,
aggravating factors, treatment, and outcome.
chest pain
edema
leg pain or cramps
skin changes on arms or legs
fatigue
cyanosis/ pallor
2.
Do you have a past or present history of any of the following? If yes, describe
onset, duration,
intensity, frequency, aggravating factors, treatment and outcome.
C heart disease (heart attacks, rheumatic heart disease, increased cholesterol l
evels, hypertension
etc.)
C circulation problems ( varicose veins, leg pain, stroke, cerebral aneurysm etc
.)
C surgery (bypass surgery, grafts, pacemaker, vein surgery...)
Functional Health Pattern: Activity and Exercise: Thorax and Lungs:
1.
Do you experience any of the following? If yes, describe onset, duration, intens
ity, frequency,
aggravating factors, treatment and outcome.
C cough
C shortness of breath
C chest pain with breathing
C respiratory infections
C lung disease ( asthma, bronchitis, TB etc..)
C injury
C surgery
C cigarette smoking: Do you smoke cigarettes or other tobacco products?
At what age did you start?
How many cigarettes/packs per day do you smoke?
For how many years have you smoked?
Have you ever tried to quit? If yes, how and what was the outcome?
2.
Describe self-care behaviours related to immunization, chest x-ray and environme
ntal exposure.
Functional Health Pattern: Activity and Exercise: Bones, Joints and Muscles:
1.
Do you experience any of the following? If yes, describe location, onset, durati
on, intensity,
frequency, aggravating factors, treatment and outcome.
Joint: pain, stiffness, swelling, limitation of movement
Muscle: pain, cramping, weakness
Bone: pain, deformity
2.
Do you have a history of trauma, surgery or health problems related to joints, m
uscles, or bones? If
yes, describe onset, duration, intensity, frequency, treatment, and outcome.
3.
Activities of daily living:
The next set of questions asks whether you need help with any of the following a
ctivities of daily
living. I would like to know whether you can do these activities without any hel
p at all, or if you
need assistance to do them. Do you need help to:
a) use the telephone:
b) get to places out of walking distance (e.g. using transportation):
c) shop for clothes and food:
d) do your house work:
e) feed yourself:
f) dress and undress yourself:
g) take care of your appearance:
h) get in and out of bed:
I) take a bath or shower:
j) prepare your meals:
k) get to the bathroom on time:
4.
Describe self-care behaviours in relation to occupational hazards (heavy lifting
, repetitive strain injury,
chronic stress on joints, use of medication etc.)
Functional Health Pattern: Cognition and Perception
EYES and VISION
1.
How well do you see? If you have a loss of vision, does it affect your job or da
ily activities?
2.
When was your last eye examination? (Date and result)
3.
Do you wear glasses/contact lenses? If yes, type, describe duration, effectivene
ss.
4.
Do you have any health problems, symptoms, surgeries or hospitalizations related
to your vision?
(I.e. eyestrain, discharge, infections, visual blurring, glaucoma). If yes, plea
se describe onset,
duration, intensity, frequency, aggravating factors, treatment and outcome.
EARS AND HEARING
1. How would you describe your hearing? If you have a loss of hearing, does it a
ffect your job or daily
activities?
2.
Have you ever had an audiogram (hearing test)? If yes, describe reason for test
and results.
3.
Do you wear a hearing aid(s)? If yes, describe type used, duration, effectivenes
s.
4.
Do you have any health problems, symptoms, surgeries or hospitalizations related
to your hearing?
( i.e. infection, ringing, pain)
If yes, please describe onset, duration, intensity, frequency,
aggravating factors, treatment and outcome.
OTHER SPECIAL SENSES
1.
Have you ever had problems with any of the following? If yes, please describe on
set, duration,
intensity, frequency, aggravating factors, treatment and outcome.
ability to feel pain sensations
ability to feel temperature changes
smell
taste
NEUROLOGIC DYSFUNCTIONS
Do you experience any of the following? If yes, describe location, onset, durati
on, frequency,
associated symptoms, factors which precipitate and/or aggravate the problem, tre
atment and
outcome.
headaches
loss of balance
weakness
difficulty walking
numbness and tingling
frequent falls
vertigo (sensation of rotary movements)
seizures
dizziness
history of tremors
loss of consciousness (faint, black out)
difficulty swallowing
loss of coordination
difficulty speaking

FACTORS AFFECTING COGNITION AND PERCEPTION

1.
Do you have any health problems, symptoms, surgeries or hospitalizations related
to your nervous
system or spine? ( head injury, Parkinson s disease). If yes, describe onset, dura
tion, intensity,
frequency, treatment and outcome.
MENTAL STATUS EXAMINATION
Complete the following Mini-Mental State Examination according to the instructio
ns provided.
STRESSORS AS PERCEIVED BY CLIENT AND /OR FAMILY:
1. What do you consider your major problem, stress area, or areas of concern? (I
dentify problem areas)
2. How do present circumstances differ from your usual pattern of living? (Ident
ify lifestyle patterns)
3. Have you ever experienced a similar problem? If so, what was the problem and
how did you handle
it? Were you successful? (Identify past coping patterns)
4.
What do you anticipate for yourself in the future as a consequence of your prese
nt situation? (Identify
perceptual factors, i.e., reality versus distortions-expectations, present and p
ossible future coping
patterns)
5.
What are you doing and what can you do to help yourself? Describe whether these
strategies are
helpful or not in alleviating stress. (Identify percepual factors, i.e., reality
versus distortions-
expectations, present and possible future coping patterns)
6.
What do you expect care givers, family, friends, or others to do for you? (Ident
ify percepual factors,
i.e., reality versus distortions-expectations, present and possible future copin
g patterns)
COMPLETE PHYSICAL EXAMINATION GUIDE
Measurement and Vital Signs (Functional Health Patterns: Nutrition & Metabolism;
Activity &
Exercise)

1.
Weight
2.
Height
3.
Radial Pulse (rate, rhythm, force)
4.
Respirations (rate, depth, ease)
5.
Blood pressure
6.
Temperature
Skin (Functional Health Pattern: Nutrition and Metabolism)
1.
Integrate assessment of the skin with the corresponding region throughout the ex
amination process.
Document:
Color and pigmentation
Temperature
Moisture
Texture
Turgor
Lesions
Edema
Cleanliness
Bruising
Nails
Scar
Head and Face (Functional Health Pattern: Nutrition and Metabolism)
1.
Scalp, hair, cranium
2.
Face (cranial nerve VII)
3.
Temporal artery, temporomandibular joint
(cranial nerve V)
4.
Maxillary sinuses, frontal sinuses
Eyes (Functional Health Pattern: Cognition and Perception)
1.
Visual acuity: Snellen Eye Chart
2.
Visual fields (cranial nerve II)
3.
Extraocular muscles:
Corneal light reflex
Cardinal positions of gaze
(cranial nerves III, IV, VI)

4.
External structures:
Eyelids, eyelashes, eyebrows
Sclera
Conjunctiva
Lacrimal gland
5.
Anterior structures:
Cornea
Iris
Pupil size (cranial nerves III, IV, VI)
Pupil direct & consensual light reflex
(cranial nerves III, IV, VI)
Accommodation (cranial nerves III, IV, VI)
Ears (Functional Health Pattern: Cognition and Perception)
1.
External structures:
Shape and size
Tenderness
Auditory meatus

2.
Internal structures: (using otoscope)
External canal
Tympanic membrane
3.
Hearing acuity (cranial nerve VIII):
Voice test
Weber
Rinne
Nose (Functional Health Pattern: Nutrition and Metabolism)
1.
External nose (symmetry, inflammation)
2.
Patency of nostrils
3.
Speculum: Nasal mucosa
Septum
Discharge
Mouth and Throat (Functional Health Pattern: Nutrition and Metabolism)
1.
Lips and buccal mucosa:
Teeth and gums
Tongue
Hard/soft palate
2.
Tonsils
3.
Uvula (cranial nerves IX, X)
4.
Tongue (cranial nerve XII)
Neck (Functional Health Pattern: Nutrition and Metabolism)
1.
Symmetry, lumps, pulsations
2.
Cervical lymph nodes
3.
Carotid pulse (bruits if indicated)
4.
ROM and muscle strength (cranial
nerve lX)
MOVE TO BACK OF CLIENT WHO IS SITTING
Chest and Lungs (Posterior & Lateral) (Functional Health Pattern: Activity and E
xercise)
1.
Thoracic cage configuration
2.
Skin characteristics
3.
Symmetry
4.
Tactile fremitus
5.
Lumps or tenderness
6.
Spinous processes
7.
Percussion over lung fields
8.
Breath sounds
9.
Adventitious sounds
10. Diaphragmatic excursion
MOVE TO FRONT OF CLIENT WHO IS SITTING
Chest and Lungs (Anterior) (Functional Health Pattern: Activity and Exercise)
1.
Respirations and skin characteristics
2.
Symmetry
3.
Tactile fremitus, lumps, tenderness
4.
Percuss lung fields
5.
Breath sounds
6.
Adventitious sounds
Upper Extremities (Functional Health Pattern: Activity and Exercise)
1.
Contour, swelling, masses, pair or deformity
2.
ROM and muscle strength
Capillary refill
Neck Vessels (Functional Health Pattern: Activity and Exercise)
1.
Jugular Venous Pulse
Heart (Functional Health Pattern: Activity and Exercise)
1. Precordium, pulsations, thrills
2. Apical impulse (location and size)
3. Apical rate, rhythm and force
4. Heart sounds
Abdomen (Functional Health Pattern: Nutrition and Metabolism)
1. Contour, symmetry
2. Skin characteristics
3. Umbilicus and pulsations
4. Bowel sounds
5. Vascular sounds
6. Percussion
7. Liver span
8. Light palpation
Lower Extremities (Functional Health Pattern: Activity and Exercise)
1. Symmetry
2. Skin characteristics, hair distribution
3. Capillary refill
4.
Pulses:
Femoral
Popliteal
Posterior tibial
Dorsalis pedis
5. Temperature
6. Pretibial edema
7. Venous pattern/varicosities
8.
ROM/muscle strength:
Hips
Knees
Ankles & feet
9. Homan s sign
Neurologic (Functional Health Pattern: Cognition and Perception)
1.
Sensation:
Face
Arms & hands
Legs & feet
2. Sterognosis
3. Kinesthesia
4.
Cerebellar Function:
Finger-to-nose
Heel-to-shin
5.
Deep tendon reflexes
Biceps
Triceps
Brachioradialis
Quadriceps
Achilles
6. Babinski reflex (plantar)
CLIENT IS STANDING
Musculoskeletal (Functional Health Pattern: Activity and Exercise)
1.
Walk:
Across room
Heel to toe
On tiptoes/on heels
2.
Romberg sign
3.
Shallow knee bend
4.
Touch toes
5.
ROM spine
N.B.
Female and male genital and rectal examination is not part of this exercise but
would be
included in a total physical assessment. Refer to: Jarvis, C. (1996). Physical e
xamination
and health assessment. London: W.B. Saunders Company, Chapters 23, 24.
HELP CLIENT SIT UP/THANK CLIENT FOR TIME/CLOSE HEALTH ASSESSMENT INTERACTION
STRESSORS AS PERCEIVED BY THE NURSE:
1.
What do you consider to be the major problem, stress area, or areas of concern?
(Identify problem
areas)
2. How do present circumstances seem to differ from the client s usual pattern of
living? (Identify lifestyle
patterns)
3.
Has the client ever experienced a similar problem? If so, how would you evaluate
what the client did?
How successful do you think it was? (Identify past coping patterns)
4.
What do you anticipate for the future as a consequence of your client s present si
tuation? (Identify
percepual factors, i.e., reality versus distortions-expectations, present and po
ssible future coping
patterns)
5.
What can the client do to help himself? (Identify percepual factors, i.e., reali
ty versus distortions-
expectations, present and possible future coping patterns)
6.
What do you think the client expects from care givers, family, friends, or other
resources? (Identify
percepual factors, i.e., reality versus distortions-expectations, present and po
ssible future coping
patterns)
ANALYSIS OF DATA USING NEUMANS MODEL:
Based on the information you presented in the Stressors as perceived by the nurse
and client sections,
analyze the data further using Neumans Model. This data should represent the Pri
ority Functional Health
Pattern (PFHP) for the client.
1. Reorganise the PFHP data according to Neuman. Begin by categorising the data
according to the
following variables: physiological, psychological, sociocultural, developmental
and spiritual . Identify the
strengths and/or stressors/risks with accompanying supportive theoretical data.
Classify the data as intra,
inter or extra personal factors. For example: physiological: sleeps 4 hours per
night (Risk, Intra) Adults
require 6-8 hours of sleep per night. Dugas 1999, p 809).
2.
Analyse the stressor effect on system stability (include both strengths and stre
ssors/risks):
How have the stressors expanded or contracted the flexible lines of defense (FLD
)?
How have the stressors impacted on the normal line of defense (NLD)?
Are the stressors penetrating the lines of resistance (LOR)?
Which stressors are threatening the core?
3. Develop a summary statement of the PFHPi.
4. Develop a nursing diagnosis statement.
December 1999
NSG 1225/09