NUR 511 Comprehensive Health Assessment

NUR 511 Comprehensive Health Assessment

NUR 511 Comprehensive Health Assessment

Chapter 22 Health Assessment

Health assessment

• A comprehensive assessment of the physical, mental, spiritual, socioeconomic, and cultural status of an individual, group, or community

Nursing physical assessment

• Focus on the client’s functional abilities and physical responses to illness and other stressors

Physical assessment

• Consists of the techniques used to gather objective data about the body

The Nursing Physical Examination

• Used as part of a general health assessment
• Used to gather data about the client
• Focuses on functional abilities and responses to illness/stressor
• Purposes:
  • The nurse performs a physical examination to
    • Establish baseline data
    • Identifying nursing diagnoses, collaborative problems, or wellness diagnoses
    • Monitor the status of an identified problem
    • Screen for health problems
      • Regular checkups can help to identify health problems at early stages
    • Types of physical examinations
      • Depends on the client’s health status, the nature of client encounter, and the setting
      • Comprehensive
        • Done for an annual physical, on a client’s admission to an inpatient setting, or at the initial home health visit
        • Includes a health history interview
        • Interview plus complete head-to-toe examination of body systems
      • Focused
        • In an emergency situation
        • “focused on presenting problem
        • Adds to the database created by the comprehensive assessment
      • Ongoing
        • Performed as needed, after the initial database is completed, and ideally at every interaction with patient to assess status
        • Evaluates client outcomes
      • Organizing the examination
        • Head to toe
          • Starts at the head
          • Progresses “down” the body
          • System-related data found throughout
            • Heart sounds – chest
            • Pulses – periphery
          • Body systems
            • Gathers system-related data all at once may be done in a predetermined order that mimics head-to-toe examination
              • Neurological
              • Cardiovascular
              • Respiratory
              • Gastrointestinal
            • Preparing yourself: what the nurse needs
              • Theoretical knowledge
                • Anatomy and physiology
                • Examination of equipment and techniques
                • Therapeutic communication
              • Self-knowledge
                • Skill and comfort level
                • Willingness to seek help
              • Knowledge about client situation
                • Purpose about client situation
                • Client diagnosis
                • …

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