health assesment

Health Assessment

The nursing process of collecting data about a patient’s health status

Nursing Process

Assessment, Diagnosis, Planning, Implementation, and Evaluation

Assessment

Collection of patient data

Subjective Data

Information the patient tells the nurse

Objective Data

Information the nurse observes, measures, hears, feels, or smells

Initial/Baseline Assessment

The first or admission assessment used to establish baseline data

Focused Assessment

Assessment focused on a specific complaint, problem, or body system

Ongoing Assessment

Periodic or repeated assessment used to monitor the patient’s condition

General Survey

Overall observation of physical appearance, body structure, mobility, behavior, and vital signs

Physical Appearance

Age, sex, race/ethnicity, level of consciousness, skin color, and facial features

Body Structure

Body build, stature, height, weight, nutritional status, symmetry, posture, usual position, and gross abnormalities

Mobility

Gait, movements, tremors, range of motion, and motor activity

Behavior

Facial expressions, mannerisms, mood, affect, speech, dress, hygiene, grooming, and odors

Vital Signs

Temperature, pulse, respirations, blood pressure, oxygen saturation, and pain

Unconscious Bias

Unintentional assumptions or judgments that may affect patient assessment or care

Health History

Subjective information about the patient’s health status

Demographic Information

Contact information, birth date, age, gender, sex, pronouns, race, ethnicity, religion, occupation, employment status, relationship status, living situation, and advance directives

Chief Concern

The reason the patient is seeking healthcare

History of Presenting Illness

Detailed information about the patient’s current health concern

COLDSPA

Character, Onset, Location, Duration, Severity, Pattern, and Associated factors

Character

What the symptom feels like

Onset

When the symptom began

Location

Where the symptom is located

Duration

How long the symptom lasts or how often it occurs

Severity

How severe the symptom is

Pattern

What makes the symptom better or worse and how it behaves over time

Associated Factors

Other symptoms occurring with the main symptom

Medical History

Previous childhood illnesses, medical conditions, surgeries, psychiatric history, immunizations, health screenings, allergies, and medications

Family Medical History

Health information about grandparents, parents, siblings, children, and grandchildren, including acute and chronic disorders and age at death

Psychosocial History

Information about support systems, occupation, hobbies, substance use, and social activities

Health Promotion Behaviors

Diet, exercise, safety equipment, stress management, sleep patterns, and sun exposure prevention

Therapeutic Communication

Communication techniques used to obtain information and establish a therapeutic relationship

Active Listening

Consciously listening and demonstrating attention to the patient

Open-Ended Questions

Questions that allow the patient to provide a detailed response

Clarifying

Seeking additional information when something is unclear

Focusing

Directing attention toward an important topic or concern

Summarizing

Reviewing the main information discussed

Nonverbal Communication

Communication through appearance, posture, gait, facial expressions, eye contact, gestures, and personal space

Assessment Tools

Inspection, palpation, percussion, and auscultation

Inspection

Using sight, smell, and hearing to assess the patient

Palpation

Using touch to assess size, consistency, texture, temperature, location, and tenderness

Light Palpation

Palpation less than 1 cm deep

Deep Palpation

Palpation approximately 4 cm deep, used for deeper structures and the abdomen

Tender Areas

Areas of tenderness should be palpated last

Dorsal Surface of Hand

Back of the hand used to assess temperature

Palm

Part of the hand used to detect vibrations

Fingertips

Used to detect pulsations, position, texture, turgor, size, and consistency

Percussion

Tapping body parts to assess size, location, tenderness, abnormalities, and the presence or absence of air or fluid

Direct Percussion

Tapping directly on the body

Indirect Percussion

Tapping a finger or hand placed against the body

Fist Percussion

Tapping with a fist to identify tenderness over areas such as the kidneys, liver, and gallbladder

Auscultation

Listening to body sounds using a stethoscope or Doppler

Diaphragm

Stethoscope side used for high-pitched sounds; pressed firmly against the body

Bell

Stethoscope side used for low-pitched sounds; pressed lightly against the body

Amplitude

Intensity of a sound

Pitch

Frequency of a sound

Duration

Length of time a sound lasts

Quality

What a sound sounds like

Normal Assessment Order

Inspection, Palpation, Percussion, Auscultation

Abdominal Assessment Order

Inspection, Auscultation, Palpation, Percussion

EHR

Electronic Health Record

Medical Record Purposes

Communication, legal documentation, financial billing, education, research, and auditing

Documentation

Recording patient assessments, interventions, evaluations, education, communications, and other relevant care information

Purpose of Documentation

Provide continuity of care, enhance communication among healthcare team members, and promote patient safety

When to Document

After every assessment, intervention, patient education, and communication with a healthcare team member

Pre-Charting

Documenting care before it occurs; it should never be done

What to Document

Assessments, interventions, evaluations, education, communications, and other relevant patient-care information

How to Document

Accurately, timely, objectively, and confidentially

Factual Documentation

Documentation based on observable or reported facts rather than opinions or assumptions

Subjective Documentation

Information obtained from the patient’s perspective

Direct Quotes

The patient’s exact words documented when appropriate

Objective Documentation

Information obtained by the nurse through assessment

Objective Data Sources

What the nurse sees, hears, feels, and smells

Nonjudgmental Documentation

Documentation that avoids criticism, labels, assumptions, and personal judgments

Accurate Documentation

Documentation that correctly represents what was observed, measured, reported, or performed

Concise Documentation

Documentation that is clear, specific, relevant, and not unnecessarily lengthy

Exact Measurements

Specific measurements used instead of vague descriptions

Comprehensive Documentation

Documentation that includes all relevant information needed to understand the patient’s care

Timely Documentation

Documentation completed promptly after the care or event occurs

Organized Documentation

Documentation arranged clearly so the patient’s care can be easily understood

Interpretation in Documentation

The nurse’s personal conclusion or assumption about a situation; it should not replace factual observations

Documentation Standards

Factual, specific, nonjudgmental, accurate, concise, comprehensive, timely, and organized

Subjective Documentation Rule

Document information from the patient’s perspective and use direct quotes when appropriate

Objective Documentation Rule

Document what the nurse actually sees, hears, feels, smells, or measures

Documentation Safety Rule

Never pre-chart and never document assumptions or personal interpretations