HEALTH ASSESSMENT

DEFINITION

Health assessment is an important basic or the first step in identifying the patient’s medical needs & problems. It includes the plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. It is the process of  evaluating the health status of the patients from obtaining a comprehensive health history & performing a Physical Examination.

PURPOSES OF HEALTH ASSESSSMENT

• Health History:
  • To provide subjective database of client’s health
  • To Identify patient’s Strengths
  • To determine the client’s Actual & Potential Health Problems
  • To plan care for client from Admission to Successful Discharge
  • To provide Holistic care.
• Physical Examination:
  • To Obtain Objective Database of client’s health
  • To validate the Health History
  • To precisely to identify client’s problems
  • Combined with Health history & physical Examination are essential in formulating Nursing Diagnosis & developing Plan of care for clients.

Purposes of Health History

• Providing Subjective Database: As the word “subjective” suggests, that this type of data refers to information that is spontaneously shared by the client in response to questions asked while collecting the health history. This data provides a clue or Information about the health condition.
• Identifying Client's Strengths: It focusses on assessing and diagnosing the client's dysfunction & pathologic condition then looking for the level of functioning & ability to contribute to the success of treatment.
• Determining Actual & Potential Problems:
  • Actual problem determines the defining characteristics which is the major and minor clinical cues that determine the presence of a disease or pathology.
  • Potential Problems are determining the risk factors which is identifiable intrinsic and extrinsic characteristics of the client. E.g. risk for infection.
• Planning care from Admission to discharge: While Obtaining Health history the plan of care is not only planned while patient is admitted in the hospital but a successful discharge plan begins on admission with the health history and the care will be complete only if the client follows the plan of care even after Discharge.
• Providing Holistic Care: Holistic care refers to the provision of care to patients that are based on a mutual understanding of their physical, psychological, emotional, and spiritual dimensions. In addition, holistic care emphasizes the partnership between nurse and patient which is done by obtaining a complete health History.

Purposes of Physical Examination

• Obtaining Objective Database: Objective Data is the physical data i.e. observed using the 5 senses. Objective findings come in either a measurement or a direct observation. Objective data is measured and observed through vitals, tests, and physical examinations that helps in obtaining the basic & critical Information about the client’s Health Condition.
• Validating Health History: Validating is assessing the clues obtained from health history by checking or proving the accuracy of the complaints that led the patient to seek health care which is done by performing the Physical Examination.
• Precise Identification of client's Health Problems: Physical Examination is performed by clear observation of the senses that helps in screening the client’s General wellbeing, the current health problems & the findings will serve as a baseline Information for future Assessments.
• Formulation of Diagnosis & Developing Plan of care: The Information gathered in the health history & the physical Examination will serve as basis for clinical Decision making which includes formulating the diagnosis. While formulating diagnosis it is important to refine the possible diseases by checking specific tests & the diagnosis is justified then moving forward to the treatment .

Process of Health Assessment

The process of Health Assessment involves collecting detailed information from the client that evaluates the risks and the nature of problems to be identified.

While Assessing integrate all the relevant issues which explores the medical, physiological, social and psychological function of the person.

The assessment process provides encouragement to be curious and to consider the best possible interventions that can be provided to minimize risks and maximize  patient’s quality of life.

The two main process of Health Assessment are

Two process of Heath Assessment

1. Health History
2. Physical Examination

• Health History: 
  • The health history is subjective data obtained by direct face to face Interview with the client . It consists of
  • what the patient tells , what the patient perceives, and
  • what the patient thinks about the health Status
  • It provides a holistic, qualitative picture of the client & the Clues that are obtained from the health history are validated by the physical assessment and are essential in developing a successful plan of care.
• Physical Examination: 
  • The physical examination is a process by which the 5 senses are used to collect objective data. The skills of assessment required in physical Examination are—cognitive, psychomotor, interpersonal, affective, and ethical/legal—to perform an accurate, thorough physical assessment. We must know normal findings before beginning the assessment to distinguish abnormal ones.
  • The best way to improve the physical assessment skills is through practice. Effective communication skills are essential to establishing the trust needed to proceed with the examination.
  • Also remember to follow the ethical and professional responsibility to the patient in respecting their right to privacy and confidentiality

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