Health Assessment. Regardless of the practice context, the ability to assess the patient is one of the most crucial skills of the nurse. Eliciting a comprehensive health history and employing proper assessment skills are crucial in all contexts where nurses interact with patients and deliver treatment to uncover physical and psychological problems and concerns. Patient assessment is required as the first phase in the nursing process in order to acquire data that will allow the nurse to develop a nursing diagnosis, identify and implement nursing treatments, and evaluate their success.
The Role of the Nurse in Assessment
The nurse’s role in health assessment includes gathering the patient’s medical history and conducting a physical examination. This function can be performed in a variety of locations, including acute care, clinics or outpatient offices, schools, long-term care facilities, and private residences. Nurses employ a growing number of nursing diagnoses to identify and categorize patient problems that they have the knowledge, skills, and authority to treat on their own. By initially acquiring a health history and physical examination, all members of the health care team—physicians, nurses, nutritionists, social workers, and others—use their particular talents and knowledge to contribute to the treatment of patient problems. A number of health history and physical examination styles have been established since each member of the health care team has a different focus. The database obtained by the nurse, regardless of format, is supplementary to databases obtained by other members of the health care team and focuses on nursing’s specific concern for the patient.
Basic Guidelines in Conducting Health Assessment
People who seek medical help for a specific issue are frequently anxious. Fear about future diagnoses, possible lifestyle disruptions, and other worries may exacerbate their anxiety. With this in mind, the nurse tries to build rapport, put the client at ease, encourage open conversation (Fuller & SchallerAyers, 2000), maintain eye contact, and pay attention to the person’s responses to queries concerning health conditions (Fig. 5-1).
When taking a patient’s health history or completing a physical examination, the nurse must be conscious of both his or her own and the patient’s nonverbal communication. The nurse considers the patient’s educational and cultural background, as well as his or her language proficiency. Questions and instructions to the patient are written in a clear and understandable manner. Medical jargon and technical terminology are avoided. Furthermore, the examiner must be aware of the patient’s disabilities or impairments (hearing, vision, cognitive, and physical limitations) and account for them during the history and physical examination. A number of health history and physical examination styles have been established since each member of the health care team has a different focus. The database obtained by the nurse, regardless of format, is supplementary to databases obtained by other members of the health care team and focuses on nursing’s specific concern for the patient.
Ethical Use of History or Physical Examination Data
When obtaining information from a person through a health history or physical examination, it is especially crucial to remember that the person has the right to know why the information is being sought and how it will be used. As a result, it’s critical to describe the history and physical examination, as well as how the information will be acquired and used (Fuller & Schaller-Ayers, 2000). It is also critical that the individual understands that participation is entirely optional.
The history interview and physical examination take place in a confidential setting, which fosters trust and encourages open honest discussion. The nurse selects the data relevant to the patient’s health status after taking the patient’s history and doing the examination.
The Health History
The impact of psychosocial, ethnic, and cultural background on the person’s health, sickness, and health-promotion behaviors is emphasized throughout the examination, particularly when acquiring the history. The person’s interpersonal and physical environments, as well as their lifestyle and everyday activities, are all thoroughly investigated. A full history of the person’s present health problems, past medical history, family history, and an examination of the person’s functional state are all required of many nurses. This produces a whole health profile that considers both health and illness and is better referred to as a health history rather than a medical or nursing history.
Although formats based on nursing frameworks, such as functional health patterns, have become standard, the health history format traditionally combines the medical history and the nursing assessment. Individual and family relationships, lifestyle patterns, health practices, and coping strategies are all included in the systematic review and patient profile. These elements of the health history form the foundation of nursing assessment and are easily adaptable to the demands of each patient group in any environment, institution, or agency.
In the event of a developmentally delayed, mentally handicapped, disoriented, confused, unconscious, or comatose patient, the informant, or the person providing the health history, may not always be the patient. The interviewer evaluates the informant’s trustworthiness and the usefulness of the information provided. A disoriented patient, for example, is typically unable to provide a reliable database, and drug and alcohol abusers frequently deny using these substances. The interviewer must make a judgment on the information’s reliability (based on the context of the entire interview), and this judgment must be recorded.
When gathering health information, the interviewer considers the person’s cultural background (Weber & Kelley, 2003). Each person’s experiences shape their cultural attitudes and ideas regarding health, disease, health care, hospitalization, drug use, and complementary therapies. They differ depending on an individual’s ethnic and cultural background. A person from a different culture may have a different perspective on personal health care than a health care provider.
Content of the Health History
When a patient is seen for the first time by a member of the health care team, the first necessity is a database, unless in emergency situations. The order and technique of obtaining information on a patient vary, but the material, regardless of format, usually addresses the same broad problems. An example of a standard approach is as follows:
The patient’s health history is contextualized with biographical information. Name, address, age, gender, marital status, occupation, and ethnic origins are all included in this data. Some interviewers prefer to ask more personal questions at this point in the interview, while others prefer to wait until the patient’s immediate or urgent needs have been handled before asking more personal inquiries. An interviewer who is more worried about marital or occupational status than promptly addressing the problem at hand is unlikely to have much patience with a patient in severe pain or with another urgent condition.
The issue that brings the person to the attention of the health care professional is the major complaint. The major complaint is generally elicited by questions like “Why have you come to the health facility today?” or “Why were you admitted to the hospital?” “What is bothering you the most today?” can be the first question in a family environment. The person’s precise statements are frequently documented in quote marks when an issue is found (Orient, 2000). A statement like “My doctor sent me” should, however, be followed up with an inquiry that identifies the most likely reason for the person seeking medical attention; this reason is then characterized as the major complaint.
Present Health Concerns or Illness
The single most significant aspect in assisting the health care team in arriving at a diagnosis or determining the person’s requirements is the history of the current health condition or sickness. The physical examination is beneficial, but it frequently serves just to confirm the information gleaned from the history. A thorough medical history aids in the selection of the most appropriate diagnostic tests. While diagnostic test findings might be beneficial, they frequently serve to confirm rather than to confirm the diagnosis.
The whole sequence of events is recorded if the current disease is only one episode in a series of episodes. History from a patient with an incident of insulin shock, for example, provides the complete course of diabetes to place the current episode in context. From the moment of commencement until contact with the health care team, the details of the health problem or current sickness are documented. These details are listed in chronological sequence, starting with “The patient was in good health until…” or “The patient first had stomach pain 2 months before seeking care.”
The date and manner (sudden or gradual) in which the problem occurred, the setting in which the problem occurred (at home, at work, after an argument, after exercise), manifestations of the problem, and the course of the illness or problem are all part of the history of the current illness or problem. Self-treatment (including alternative therapies), medical interventions, therapy progress and effects, and the patient’s beliefs of the problem’s cause or meaning are all included.
Past Health Histoy
The database includes a full summary of the person’s previous health. The interviewer may question about immunization status and any known allergies to drugs or other substances after evaluating the general health state. The dates of immunization, as well as the type of allergy and adverse responses, are all noted. If known, the person is asked to provide details about his or her most recent physical examination, chest x-ray, electrocardiogram, eye exam, hearing tests, dental checkup, Papanicolaou (Pap) smear and mammogram (if female), digital rectal examination of the prostate gland (if male), and any other relevant tests. Following that, previous ailments are discussed. Responses to a list of specific diseases, both positive and negative, are recorded.
To discover disorders that may be hereditary in origin, communicable, or maybe environmental in causation, first-order relatives (parents, siblings, spouses, children) and second-order relatives (grandparents, cousins) are asked about their age and health status, or their age and reason of death. Cancer, hypertension, heart disease, diabetes, epilepsy, mental illness, TB, renal disease, arthritis, allergies, asthma, alcoholism, and obesity are all common disorders. Using a family tree or genogram is one of the simplest ways to keep track of such information (Fig. 5-2). If known, the findings of genetic testing or screening are noted. A full examination of genetics can be found in Chapter 9.
Review of System
The system evaluation covers a general health overview as well as symptoms associated with each body system. In terms of previous or present symptoms, questions are asked regarding each of the major body systems. Examining each body system might assist you to find any pertinent information. Both negative and positive responses are recorded. The information is carefully reviewed if the patient reacts positively to questions about a certain system. It is not required to repeat any ailments that were previously stated or noted in this section of the history. Instead, the appropriate area in history where the information can be located is referenced.
More biographical information is obtained in the patient profile. The capacity to analyze the principal complaint and the person’s aptitude to deal with the problem requires a complete composite, or profile, of the patient. At this point in the interview, the information elicited is very personal and subjective. The person is encouraged to express their sentiments openly and talk about their personal experiences throughout this stage. When precise facts are required, it is advisable to start with generic, open-ended queries and then move on to direct questioning. When the interview moves from less personal information (birthplace, occupation, education) to more personal information (sexuality, body image, coping abilities), the patient often feels less nervous.
The following content sections make to a general patient profile:
- Past life events related to health
- Education and occupation
- Environment (physical, spiritual, cultural, interpersonal)
- Lifestyle (patterns and habits)
- Presence of a physical or mental disability
- Risk for abuse
- Stress and coping response