Six out of every 10 adults in the U.S. have a chronic disease, and four out of 10 have two or more, according to the Centers for Disease Control and Prevention. A health assessment is a key tool for detecting, treating, and managing chronic diseases.
For that reason, the process of health assessment in nursing is an essential part of an advanced nursing education. Understanding how to conduct one, its basic components, and its different varieties are all fundamental skills for patient care.
What Is a Health Assessment?
Health assessments are known by a variety of names, such as a physical assessment or a head-to-toe assessment. Regardless of the label, the goal is the same: the systematic collection of information on a patient’s health status and health risks. Health assessments have several key characteristics.
Data is what a health assessment is all about: collecting it, organizing it, analyzing it, documenting it, and communicating it. This data covers a patient’s physiological condition, but may relate to their psychological, social, and spiritual condition and needs as well.
A health assessment gathers data in a systematic fashion.
- It follows defined protocols.
- It looks at a comprehensive set of aspects of a patient’s condition.
- It examines them in a standard order.
A health assessment provides a snapshot of a patient’s overall condition, designed to evaluate all significant aspects of a patient’s health in a relatively short period of time.
It is not an in-depth diagnostic tool. Rather, it tries to identify areas of concern, for which a nurse or physician can later seek to conduct tests and make diagnoses.
A health assessment in nursing is typically the first step in evaluating a patient. A nurse generally performs one when a patient is being admitted to a hospital or a clinic.
But it’s not necessarily a one-time event. Health assessments may be repeated periodically as part of an annual checkup or during a course of treatment to measure the treatment’s effectiveness and determine whether it should be modified.
Why Perform a Health Assessment?
Like a Swiss Army knife for health care, a health assessment is a single tool that can be used for a wide variety of purposes.
Performing a health assessment at the beginning of a patient’s care can allow practitioners to build a patient’s trust in sharing personal information and confidence that the institution can provide effective treatment.
Through looking at all aspects of a patient’s condition, a health assessment highlights areas of concern and issues that may call for testing, diagnosis, and development of a care plan.
By documenting vital signs and symptoms, a nurse establishes baselines for a patient. Those measurements can be compared against future health assessments, allowing nurses to identify potential areas of concern.
A health assessment can identify issues or potential risks in a patient’s condition, providing nurses with an opportunity to educate patients. The nurse can recommend actions and lifestyle changes that can improve their health.
Potential Ethical Dilemmas
A patient’s medical history and psychosocial needs can help nurses anticipate possible ethical dilemmas, such as conflicts with a patient’s religious beliefs or dealing with a patient’s advance directives.
What Are the Key Components of a Health Assessment?
The most basic type of health assessment in nursing is a head-to-toe assessment. It physically examines a patient’s body systems from head to toe.
It also covers a comprehensive range of other topics related to a patient’s health, from their health history to their social situation. Key components can include:
- The patient’s health history and chief complaint
- Medications the patient is currently taking
- Vital signs, such as temperature, pulse, respiratory rate, and blood pressure
- Examination of the head, neck, eyes, ears, nose, and throat
- Evaluation of body systems, including respiratory, cardiac, gastrointestinal, genitourinary, and skin
- Neuromuscular signs, such as reflexes and balance
- Pain assessment: location, intensity, and duration
- Mental health, such as signs of depression, substance misuse, or delusions
- Psychosocial needs, such as feeling safe in the health care environment or having religious beliefs that should be honored
What Are Other Types of Health Assessments?
Although head-to-toe is the most common type of health assessment in nursing, an advanced practice nurse may be called on to perform more specialized types.
These assessments focus on the particular system where a complaint is occurring such as respiratory, cardiovascular, or gastrointestinal. Most often performed in an emergency department or urgent care clinic, they aim to identify and address a specific issue, rather than a patient’s overall condition.
An emergency assessment may be conducted continuously during a medical emergency until the patient reaches a stable condition.
The protocol for emergency assessments is known as ABCCS. These assessments include:
- Making sure the Airway is not blocked
- Ascertaining that the patient is Breathing and breathing normally
- Monitoring Circulation, such as pulse and heart rhythm
- Observing the level of Consciousness and noting any sudden changes
- Ensuring the patient’s Safety from any potential harms
In a medical-surgical unit, patients are being prepared for surgery or recovering from it. For such patients, nurses conduct a med-surg assessment once every shift or after a sudden change in condition.
The assessment is a condensed version of a head-to-toe assessment. In addition to the patient’s physical condition, it checks devices hooked up to the patient, such as lines, drains, oxygen, and infusion of medications through IVs.
An ICU assessment is a more thorough version of a head-to-toe, for patients in intensive care units. At a minimum, it checks:
- Body systems: nervous, respiratory, circulatory, and renal systems, as well as skin and abdomen
- Parameters: blood pressure, respiratory and heart rates, and oxygen saturation
- Care interventions: tubes, catheters, and dressings
But an ICU assessment can also focus on particular body systems if a patient suddenly experiences symptoms like irregular heartbeat, low blood pressure, respiratory distress, or chest pain.
Learn More About an Advanced Nursing Career
With so many Americans suffering from chronic diseases, high-quality health assessments have never been more important. That’s one reason there’s high demand for nurses to expand their skills and become nurse practitioners. A degree program like the online Master of Science in Nursing at Regis College can help nurses take the next career step into a specialization like adult gerontology, family practice, pediatrics, psychiatric health, or women’s health.
With online coursework, the program can help working nurses make the transition to nurse practitioner while staying in their current job and fitting classes into their schedule. Learn more about how the program can help you pursue your professional goals in an advanced nursing career.