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.
First Steps
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).
Knowing What to Look For
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.”
Critical Thinking Skills
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)
