Health Assessment Components - Essay Example

A health assessment exercise can primarily be defined as a care plan undertaken by healthcare professionals to figure out the specific wants and needs of an individual. As such, a health assessment consists of an evaluation of an individual’s health by analyzing her/his health history and then performing a physical exam. This paper will focus on health assessment. Consequently, the paper will highlight the components of a health assessment, the necessary and relevant equipment needed, the various techniques applied by nurses to retrieve patient information, how to carry out a head to toe assessment correctly. According to Taylor, Lillis, and LeMone (1990) a health assessment is not a treatment but rather an evaluation and analysis of an individual’s health status in relation to the health continuum. A health assessment is done majorly for various purposes. First, a health assessment is done to establish a good relationship between a nurse and his or her patient. Secondly, the assessment aids the health care professionals to establish a patient’s potential and actual problems in addition to his/her strengths and weaknesses. On a broader spectrum, a health assessment lays the foundation for the nursing process. Subsequently, the data gathered from this process is used by nurses to diagnose problems that need nursing care. Taylor, Lillis and LeMone (1990) separate health assessment into physical assessment and history assessment. History as a concept is significant since health tends to occur on a continuum. It is commonly understood in the nursing/ healthcare industry that focusing on the history of the patient provides critical data to the nurses. The level of healthcare assessment is dependent on the healthcare practitioner. However, majorly the focus is mainly bio psychosocial in general. For example, if a patient is in the emergency room, the main focus will be on the chief complaint and how to aid the patient recover. If the patient suffers from a heart attack, then initially the focus will be directed on the physical/biological problem. Types of healthcare assessment In the healthcare field, there are four types of health assessment: comprehensive health assessment, ongoing partial, focused and emergency health assessment. Comprehensive health assessment forms the basis of clinical practice. This assessment is carried out the instant a patient is admitted to a healthcare institution or facility. On the other hand, health assessments which are done periodically represent the ongoing partial assessment. In order to focus on a specific problem, a focused health assessment is carried out on the patient. Also, Taylor, Lillis, and LeMone (1990) implied that an emergency health assessment is only carried on a patient to figure out fatal conditions. These types of assessments each help the professional to identify potential and actual health risks, patient care needs. Also, the process helps nurses in treatment and care options, and decision making. The quality of data used in undertaking health assessments is directly proportional to the quality of life, health outcomes and safety of the patients. During a health history assessment, the health professional or nurse should focus on the patient’s lifestyle, family history, the present illness’ s history, his/her previous medical history, biographical data and the patient’s reason for looking for help in the facility. This implies that the patient himself/herself is the primary sourc4e of information. Therefore, the nurse should try as much as possible to put emphasis on the patient to give out all the information correctly. Moreover, a history assessment enables the nurse to establish rapport with the patient’s family. This is quite significant for healthcare professionals. In a social and psychological examination, emotional health and intellectual health are the main areas for assessment. Cognitive function assessment, checking for delusions, hallucinations, measuring/ finding out the patient’s concentration levels, his/her interests and hobbies make up an intellectual assessment. Additionally, an emotional assessment is necessary. Under this concept, a patient is asked how he feels and how he reacts to the feelings. On the psychological level, a patient’s perceptions are assessed: why do they think they’re being examined. Other vital areas for a nurse to consider during an assessment are the patient’s beliefs and religion. In any assessment, a physical examination must be included to find out or rule out anomalies and structural damage. Physical examination Apart from a history assessment, a nursing assessment is made up of a physical examination. This includes the measurement and observation of signs or asking the patients how he /she feel. Symptoms like vertigo and nausea are often felt by the client. When preparing for the physical assessment, the nurse should take into consideration the psychological and physiologic wants of the client. Secondly, the patient should comprehend the entire process. Thirdly, the nurse should take the initiative to lower the fear and anxiety of the patient by insisting that the examination (physical) would be painless. Also, the nurse has to inform the patient to empty his bladder and wear a gown. To make the patient feel at ease, his/her questions should be honestly and plainly answered. The answers should be simple and easily understood. Fifth, a consensus should be reached on the correct time for the assessment. This time frame is recommended not to interfere with the client’s visiting hours, meals and routines. Sixth, an examination table has to be prepared (Taylor, Lillis & LeMone, 1990). In the process, the nurse should ensure that the patient is not experiencing any pains, or the pains experienced are at the lowest level possible. Next the nurse should give the client a gown to wear. Also, the nurse should ensure the necessary and relevant instruments and supplies needed are available. Lastly, if the assessment is being done in an open area, a screen or curtain should be raised to ensure patient privacy. Instrumentation While carrying out a physical assessment, clinical instruments have to be used. Various instruments have been developed to aid nurses in their assessments. For example, a stethoscope to listen to the patient’s internal body, a tuning fork for hearing, an ophalmoscope to examine the client’s eyes, a nasal speculum to visualize or examine the nose’s turbinates, and an otoscope may be needed In order to examine the nostrils, mouth and ears. A snellen chart may be used to assess the patient’s vision. The chart is made up of 11 lines of letters sized differently. A patient will be required to point out the letters from a distance and then the results recorded. Postures adopted during an assessment To assess the patient’s positioning, sitting, supine, dorsal recumbent, sims, prone, knee to chest and lithotomy postures are adapted by the patient. The siting posture allows the nurse to examine the neck, head, anterior and posterior lungs and thorax, heart, and breast. This position lets the nurse to view the patient’s upper body. A supine positioning lets the patient to relax his abdominal muscles. The nurse uses this position to examine the anterior thorax, head, neck, lungs, heart, abdomen, breasts, peripheral pulses and extremities. In this position, a patient is made to lie flat on his back. A patient adopts the dorsal recumbent by bending his knees while on his back. This position enables the nurse to assess the head, neck, anterior thorax, lungs, heart, breast, peripheral pulses and extremities. On the other hand, a sims position enable the healthcare professional to assess the vagina and rectum (Taylor, Lillis & LeMone, 1990). A prone position is adopted by the patient lying on the abdomen. Whereas a knee to chest positioning lets the nurse examine the rectal area, a lithotomy position enables the nurse to assess female genitalia and rectum. Lastly, a nurse requires the patient to tale a standing position to assess the balance, gait and posture. Examination techniques In order to acquire the correct information, nurses use various techniques: inspection, palpation, percussion and auscultation techniques. While inspecting, a nurse employs the physical senses such as hearing, smelling and seeing. This is often a purposeful examination of the patient. According to Taylor, Lillis, and LeMone (1990) palpation is the art of using hands and fingers to examine a patient. While using fingers and the hands, a nurse should look for abnormal temperature, turgor, texture, moisture, shape and vibrations. In order to examine the density, size and location of tissue, a nurse uses the percussion technique. This technique employs different tones such as tympany and dull. As earlier implied in the text, a stethoscope is normally used to figure out sounds within the human body. This technique is termed as auscultation. A general survey should then be carried by the nurse to ascertain his/her findings. Conclusion Health assessment is the first step/stage into the nursing process. A healthcare professional does a holistic and complete examination of the patient’s wants and needs. A health care professional should find the appropriate instruments, favorable position, drape the assessment area, prepare the environment, prepare the patient and lastly apply the relevant physical assessment techniques. The major reason for this exercise is to single out and identify problems ailing the patient. Most of these problems express themselves as either potential or actual. References Taylor, C., Lillis, C., & LeMone, P. (1990). Fundamental of nursing: The art and science of nursing care. Dimensions of Critical Care Nursing, 9(1), 28. Read More