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. Show "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. Whether the setting is a hospital or other healthcare facility, it is important to gather information regarding the child’s history and current status.
Collecting Subjective DataInformation spoken by the child or family is called subjective data. Conducting the Client InterviewMost subjective data are collected through interviewing the family caregiver and the child.
Interviewing Family CaregiversThe family caregiver provides most of the information needed in caring for the child, especially the infant or toddler.
Interviewing the ChildIt is important that the preschool child and the older child be included in the interview.
Interviewing the AdolescentAdolescents can provide information about themselves.
Obtaining a Client HistoryWhen a child is brought to any health care setting, it is important to gather information regarding the child’s current condition, as well as medical history.
Collecting Objective DataObjective data in nursing is part of the health assessment that involves the collection of information through observations. The collection of objective data includes the nurse doing a baseline measurement of the child’s height, weight, blood pressure, temperature, pulse, and respiration. General StatusThe nurse uses knowledge of normal growth and development to note if the child appears to fit the characteristics of the stated age.
Measuring Height and WeightThe child’s height and weight are helpful indicators of growth and development.
Measuring Head CircumferenceThe head circumference us measured routinely in children to the age 2 or 3 years or in any child with a neurologic concern.
Vital SignsVital signs, including temperature, pulse, respirations, and blood pressure, are taken at each visit and compared with the normal values for children at the same age. Temperature
Pulse
Respirations
Blood pressure
Physical ExaminationData are also collected by examining the body systems of the child. Head and NeckSymmetry or a balance is noted in the features of the face and in the head.
Chest and LungsChest measurements are done on infants and children to determine normal growth rate.
HeartIn some infants and children, a pulsation can be seen in the chest that indicates the heart beat, which is called the point of maximum impulse.
AbdomenThe abdomen may protrude slightly in infants and small children.
Genitalia and RectumWhen inspecting the genitalia and rectum, it is important to respect the child’s privacy and take into account the child’s age and stage of growth and development.
Back and ExtremitiesThe back and extremities should also be assessed for abnormalities.
NeurologicAssessing the neurologic status of the infant and child is the most complex aspect of the physical exam.
What type of data is collected during a physical examination?Objective data is obtained during the physical examination component of the assessment process. Examples of objective data are vital signs, physical examination findings, and laboratory results. An example of objective data is recording a blood pressure reading of 140/86.
Which type of patient data will the nurse obtain through physical examination?Objective data is anything that you can observe through your sense of hearing, sight, smell, and touch while assessing the patient. Objective data is reproducible, meaning another person can easily obtain the same data. Examples of objective data are vital signs, physical examination findings, and laboratory results.
What data should be collected in nursing assessment?Nursing Process. Assessment (gather subjective and objective data, family history, surgical history, medical history, medication history, psychosocial history). Analysis or diagnosis (formulate a nursing diagnosis by using clinical judgment; what is wrong with the patient). What are the 4 components of a physical assessment?WHEN YOU PERFORM a physical assessment, you'll use four techniques: inspection, palpation, percussion, and auscultation.
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