HEALTH ASSESSMENT

• Health is a relative state in which a person is able to live to their potential and includes the “7 facets”: Physical health, Emotional health, Social well-being, Cultural influences, Spiritual influences, Environmental influences, and Developmental level.
• The nursing health assessment entails both a comprehensive health history and a complete physical examination, which are used to evaluate the health and status of a person.
• The nursing health assessment involves a systematic data collection that provides information to facilitate a plan to deliver the best care for the patient.
• The first part of health assessment is the health history, which also incorporates the “7 facets”.
• The nurse asks pertinent questions to gather data from the patient and/or family.
• Past medical records may also be used to collect additional information.
• When the patient is communicative with her friends with regard to his marital problems, environmental influences, cultural influences, and social well-being are being applied.
• Learning about the patient’s physical and psychological issues, social and cultural associations, environment, developmental level, and spiritual beliefs contribute to the history.
• The phase of the nursing process where the nurse determines whether the goals made for the patient have been attained is known as Evaluation.
• The nursing diagnosis is based on real or potential health problems and determines the medical diagnosis of the patient.
• The phase of the nursing process where the nurse establishes both the short-term and the long-term goals for the patient is known as Assessment.
• The assessment phase of the nursing process continues throughout the entire patient encounter.
• When the patient is identifying a solution to financial problems in order to be rid of her financial stresses, emotional health, developmental level, physical health, and social well-being are being demonstrated.
• Spiritual influences, physical health, cultural influences, and emotional health are facets of health that can be demonstrated if the patient feels very much optimistic about the results of her pregnancy.
• Follow-up history is focused on the patient’s emergent problem.
• Problem-oriented assessment allows the nurse to obtain a full picture of the patient’s health status and current problems.
• The ability of the nurse to extrapolate the findings, prioritize them, and finally formulate and implement the plan of care is the overall goal of the nursing process.
• The second component of the health assessment is the physical examination.
• The nurse uses a structured head-to-toe examination to identify changes in the patient’s body systems.
• Diagnosis has a nursing focus and is based on real or potential health problems or human responses to health problems.
• The NURSING PROCESS is the ability of the nurse to extrapolate the findings, prioritize them, and finally formulate and implement the plan of care is the overall goal.
• Implementation of the interventions can be completed by the patient, the family, or members of the health care team.
• An emergency history is the data collection which focused on the patient’s emergent problem with a systematic prioritization of need beginning with the ABCs of airway, breathing, and circulation.
• An unusual or abnormal finding may support the history data or trigger additional questions.
• A follow-up history is a form of a focused assessment.
• The admission of a new patient to a clinic, hospital, long-term care facility, or visiting nurse agency usually requires a comprehensive health assessment.
• Evaluation is a continuing process to determine if the goals have been attained.
• A focused or problem-oriented assessment is where the nurse focuses on gathering information about the patient’s problem.
• Planning is devising the best course of action to address the patient’s diagnoses.
• Assessment is the first step of the nursing process and is the subjective and objective data gathered during the initial health history and physical examination and collected on each patient encounter.
• The nurse uses the NURSING PROCESS (a problem-solving process) to identify patient problems; set a goal and develop an action plan; implement the plan; and evaluate the outcome.
• The nursing care plan is revised based on the patient’s condition and whether the goals are realistic or appropriate for the patient.
• The information obtained throughout the health assessment should be documented in a clear, concise manner.
• The purpose of the nursing health assessment is to determine the patient’s health status, risk factors, and need for education as a basis for developing a nursing plan of care.
• Interviewing and Communication Health History Interview is a conversation with a purpose within three folds using health history format.
• The phases of Interview include Pre-interview, Introduction, and Working.
• Self-reflection is a continual part of professional development in clinical work and brings a deepening personal awareness to our work with patients, which is one of the most rewarding aspects of patient care.
• Reviewing the patient record and setting interview goals are part of the Pre-interview phase.
• Establishing the agenda for the interview and putting the patient at ease are part of the Introduction phase.
• Obtaining patient information, identifying and responding to emotional clues, expanding and clarifying the patient’s story, and generating and testing diagnostic hypotheses are part of the Working phase.