A comprehensive health assessment gives nurses insight into a patient’s physical status through observation, the measurement of vital signs and self-reported symptoms. It includes a medical history, a general survey and a complete physical examination. Show
The general survey consists of a patient’s age, weight, height, build, posture, gait and hygiene. Nurses use health assessments to obtain baseline data about patients and to build a rapport with them that can ease anxiety and lead to a trusting relationship. A comprehensive health assessment is generally conducted at the time of admission into an acute care facility or during the first visit to an outpatient clinic. When nurses perform an assessment, they may use techniques such as: Inspection This is the most frequently used method for assessment. Nurses look for indications of a health problem by using their eyes, ears and nose. They may inspect skin color, lesions, bruises or rashes as well as pay attention to abnormal sounds and odors. Auscultation Nurses listen to the sounds of the abdomen by placing the diaphragm or bell of a stethoscope on the bare skin of a patient. Palpation Nurses apply varying degrees of pressure on the patient with different parts of their hands. Palpation allows nurses to assess for texture, tenderness, temperature, moisture, pulsations and the presence of masses. Percussion Nurses firmly press on sections of a patient’s body with the distal part the middle finger on their non-dominant hand. The technique is used directly over suspected areas of tenderness to check a patient’s level of discomfort. Expand your nursing knowledge with an RN to BSN online. Expand your nursing knowledge with an RN to BSN online. What Steps Are Involved in a Comprehensive Health Assessment?Typically, a comprehensive assessment begins with documenting a patient’s health history before starting a physical exam. According to AMN Healthcare Education Services, the health history includes: the patient’s medical complaint, present state of health, past health record, current lifestyle, psychosocial status and family history. The health history provides nurses with in-depth information about symptoms, childhood illnesses, related medical experiences and risks for developing certain diseases. After the health history data is recorded, a physical is conducted which covers a review of the patient’s body systems. A head to toe examination includes assessments of the following:
A thorough and accurate assessment is important because it helps differentiate the normal condition of the patient from the abnormal. And, a comprehensive health assessment establishes if a patient needs diagnostic testing or additional medical care. How Can Earning a BSN Improve a Nurse’s Assessment Skills?Nurses learn assessment skills in nursing school. An online RN to BSN program like the one offered by Eastern Illinois University (EIU) includes the course Advanced Nursing Health Assessment that prepares students to perform precise examination. The curriculum builds on a nurse’s basic nursing assessment proficiencies. Once nurses earn the BSN, they are prepared to give a comprehensive health assessment and apply the knowledge to make sound clinical judgements. A comprehensive health assessment is a crucial component in the nursing practice. Without it, nurses can have a difficult time pinpointing a patient’s medical requirements. It is not enough for patients to tell nurses what is wrong. Instead, nurses need to rely on the observations they record from physical examinations to decide on a course of action. By completing a systematic and efficient assessment, nurses are able to communicate with patients and help them take measures to maintain or manage their health. Learn more about Eastern Illinois University’s online RN to BSN program. Sources: RN.com: Overview of Nursing Health Assessment Nurse.org: How to Conduct a Head-to-Toe Assessment RegisteredNursing.org: Techniques of Physical Assessment: NCLEX-RN Health Science Journal: Health Assessment The Nerdy Nurse: Subjective Data Vs. Objective Data in Nursing If you are a nurse, you know that a comprehensive patient health assessment is an important first step in developing a plan to deliver the best patient care. Health assessments are a key part of a nurse's role and responsibility. The assessment is a tool to learn about your patient's concerns, symptoms and overall health. "It is a critical step because this is where comprehensive data including physiological, psychological, socioeconomic, social determinants of health, spiritual and lifestyle information is gathered to help determine nursing diagnoses, which are used to develop nursing care plans that aim to improve health outcomes," says U.S. Public Health Service Commander Derrick Wyatt, MSN, RN-BC, a health scientist administrator for the Agency for Healthcare Research and Quality (AHRQ). During the assessment, nurses may notice signs of potential or underlying health issues that need to be addressed, as well. "I am reminded of how law enforcement officers gather detailed information using interviews, physical evidence and observations to help solve cases. Nurses use the information gathered during the comprehensive health assessment to achieve similar goals for solving complex problems with the interdisciplinary team," says Wyatt. There are many components to a comprehensive health assessment. Before beginning the assessment, nurses should try to develop a rapport with their patients, introducing themselves, explaining what they will be doing during the assessment, and why. Depending on the setting or reason for the visit, the patient may be anxious, and establishing a rapport can help put the person at ease. Social, cultural and behavioral factors influencing the patient's health are also important to keep in mind. A comprehensive health assessment usually begins with a health history, which includes information about the patient's past illnesses or injuries (including childhood illnesses and immunizations), hospitalizations, surgeries, allergies and chronic illnesses. It also includes finding out about diseases that run in the patient's family. During the health history component of an assessment, the patient is asked to describe his or her symptoms, when they started, and how they developed before moving on to the physical exam. The physical exam begins with a complete set of vital signs (blood pressure, heart rate, respiratory rate and temperature). With the increase in chronic conditions and the growing elderly population, learning how to be in tune with unique patient characteristics is an important component of an RN to BSN program. Wyatt says the approach to conducting a comprehensive health assessment will remain the same no matter the age or health status of a patient; however, "It is essential for students to understand and address nuances when conducting assessments on different populations, such as pediatric and geriatric patients or with patients with specific disease processes and family dynamics." Once the comprehensive health assessment has been performed, the next step is to put all of the information together, analyzing the objective and subjective data and developing a care plan. Those critical thinking skills are part of the training for a BSN degree, and they will be needed more than ever in the future. "I think complex medical conditions, the shift to value-based care, and the industry changing to a proactive care model, will place an emphasis on health assessments to identify opportunities to screen for preventative care and promote healthier lifestyles in the elderly population." says Wyatt. The online program that Texas A&M International University (TAMIU) offers is affordable, flexible, and designed to deepen your knowledge and skills to conduct comprehensive health assessments through the life span for patients of different ages and with specific health conditions. The ACEN-accredited program at TAMIU also covers nursing research, cultural determinants of health behavior, nursing history, global health nursing, community nursing and more. The RN to BSN curriculum also helps nurses advance to leadership roles and sharpen their skills in critical thinking, effective communication, ethical and legal handling of issues, conflict resolution, quality improvement, and change initiation. Learn more about TAMIU's online RN to BSN program. Sources: Nurse.org: How to Conduct a Head-to-Toe Assessment University of New England Center for Excellence: Center for Excellence in Health Innovation Agency for Healthcare Research and Quality (AHRQ) Derrick Wyatt, MSN, RN-BC, health science administrator for AHRQ (email interview Nov. 30, 2018) Have a question or concern about this article? Please contact us. What data should the nurse collect during the interview portion of a health assessment?During an interview obtain information about a patient's physical, developmental, emotional, intellectual, social and spiritual dimensions.
Which of the following questions would be most important for the nurse to ask first when obtaining the health history?Which of the following questions should the nurse ask first when obtaining the health history? "What is your major health concern at this time?" A nurse collects data about a client's family health history.
Which factor may influence how well a patient with diabetes adheres to a self care and drug regimen?Adherence to these self-care practices is influenced by a variety of factors such as socio-economic status, diabetes education, health beliefs, education level, family history of diabetes and patient demographic characteristics [16,17,18,19].
Which positive health habit may prevent the development of chronic illness later in life?Quit Smoking
Stopping smoking (or never starting) lowers the risk of serious health problems, such as heart disease, cancer, type 2 diabetes, and lung disease, as well as premature death—even for longtime smokers.
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