Introduction to Health Assessment:
Systematic health assessments are performed regularly in nearly every health care setting. The nurse must be competent in performing health assessments for safe and quality patient care. The nursing health assessment is an incredibly valuable tool nurses have in their arsenal of skills. A thorough and skilled assessment allows you, the nurse, to obtain descriptions about your patient’s symptoms, how the symptoms developed, and a process to discover any associated physical findings that will aid in the development of differential diagnoses. Assessment uses both subjective and objective data.
Subjective Data:
Information that is reported by the patient or a reliable historian who is knowledgeable about the patient’s health related information is organized in a report called health history. The health history is taken and updated with each patient encounter as necessary; such information informs patient care. A more detailed discussion of health history is found in Chapter 2 of this guide.
Objective Data:
Objective assessment data includes that which is observable and measurable (Jarvis, 2012). Objective data observation and measurement is done through a systematic physical assessment procedure using various assessment techniques, measurement of vital signs and correlation of physical manifestations with laboratory and diagnostic findings.
Types of Health Assessment:
Health assessment is performed by nurses and other providers alike. The following are the types of health assessments performed by nurses in various situations. A health assessment is guided by the nurses knowledge of anatomy and physiology , therapeutic communication skills, pathophysiology, among others.
- Comprehensive head-to-toe assessments are done when a patient is admitted. A shorter comprehensive head to toe assessments are also performed at the beginning of each shift, and when it is determined to be necessary according to the patient’s hemodynamic status and context.
- Brief physical assessments are done as necessary and to identify changes in a patient’s status and for comparison with the previous assessment.
- Focused assessments are done in response to a specific problem recognized by the assessor as needing further assessment of a body system.
- Emergency assessments are done in emergency situations. Because of the emergent nature of many health conditions, the nurse may modify the assessment to obtain necessary information to provide emergent care.
- A routine physical assessment reveals information to supplement a patient’s database. The assessment is documented according to agency policy, and unusual findings are reported to appropriate members of the health care team. Ongoing, objective, and comprehensive assessments promote continuity in health care.
The ability to think critically and interpret patient behaviors and physiologic changes is essential. The skills of physical assessment are powerful tools for detecting both subtle and obvious changes in a patient’s health. The nurse must develop competency in patient assessment in order to provide safe patient care. A more detailed discussion of the most common types of assessment performed will be discussed in the next chapters of this guide.
References:
Source:. Introduction to Patient Assessment: https://opentextbc.ca/clinicalskills/chapter/introduction-2/