Health Assessment in Nursing: Components, Purpose, and Examples

This study explores the meaning of term health assessment providing its major components, and its purpose from a nursing point of view and with examples. Lastly, it will briefly discuss the plan of care for a child in a school setting and an elderly lady with dementia in a family setting.

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The Student’s Name: Radhika Chand
Essay Title: Health Assessment in Nursing
Word Count: 1200 words
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When a person is ill and goes to a health acre facility, there need to be a care plan on
how his or her specific needs will be attended to. The evaluation ranges from physical
examination to the health history of the patient (Weber & Kelley, 2013). This study will
explore the meaning of term health assessment providing its major components, and its
purpose from a nursing point of view and with examples. Lastly, it will briefly discuss the
plan of care for a child in a school setting and an elderly lady with dementia in a family
setting.
A health assessment is a care plan that outlines the particular needs of a patient and
how to go about the specific needs by the skilled nursing or healthcare facility or system
(Toney-Butler & Whitten, 2018). Gimenes, Reis, da Silva, de Camargo Silva, and Atila
(2016) explain that a health assessment is subdivided into three categories which are general
survey, health interview and physical examination. When nurses do the health assessments,
they aim at collecting subjective and objective data. Gimenes et al. (2016) state that,
subjective data is basically information analyzed from a patient’s perspective while objective
data is information identified, measured and observed comparing it with a specific and
accepted standard. The first component of a health assessment is the general survey whereby
the nurse’s initial impression is marked regarding the health status of a patient. This step
determines the health status of a patient; ill or in good health, by observing briefly the general
body appearance like the facial outlook, skin texture and condition, the sexual development
age-wise, body structure (deformities, weight or height), behavior (speech and facial
expression) and even mobility. The patient is not aware of these observations (Gimenes et al.,
2016). The next phase is conducting a health interview that collects the patient’s health
history. The examiner looks at the history of the patient with certain disorders, injury, and
discomfort and their reoccurrence (Wu, & Orlando, 2015). Sometimes a family member or a
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parent is involved. The last component is the physical examination that involves these sub
components Inspection involves the nurse looking at specific areas of the patient’s body like
colour, shape and consistency (Weber & Kelley, 2013). Palpation is the next phase whereby
the nurse or the health provider uses his or her hands (finger pads, palmar surface and the
dorsal surface of the hands) to feel aberrations during health assessment. (Weber & Kelley,
2013). Percussion follows and involves, tapping body parts to produce sound waves. From
the waves or vibrations the examiner can assess underlying structures like chest walls,
abdomen or back amongst others. The examiner is able to determine fluid in the chest cavity
or mass within the stomach to inform further diagnosis (Weber & Kelley, 2013). The last
component is auscultation and involves the use of a stethoscope. In this component, the
examiner listens to the patient’s heart, lungs, neck or abdomen to identify problems through
sound amplification (Petersen, 2016).
The Purpose of a Health Assessment in nursing is primarily systematic data
collection. From the data collected, the treatment plan is informed. Heath assessment despite
being identified as a data collection method is more than just collecting information about the
health status of a patient. Assessments serve the purpose of also analyzing and synthesizing
the gathered information continuously from one component to the other (Weber & Kelley,
2013). One observation from an inspection may inform a palpation practice or an auscultation
practice. When synthesizing the data, the nurse is able to make judgments about how
effective a nursing intervention will be and evaluate the possible outcomes. A patient health
history and physical examination are important factor to inform nursing intervention.
According to Weber & Kelley (2013), the purpose of nursing health history assessment is
different from medical examinations like physical therapy or dietary assessments. The
nursing health assessment is used to collect all-inclusive idiosyncratic and impartial
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information to determine the clinical judgment of a client that directs how a clinical judgment
will look like. A range of data is also collected from this examinations. For example, for a
mental health patient under assessment, the nurse will collect psychological, sociocultural,
spiritual, developmental or physiologic information about him. Mind, spirit and body are
termed as independent factors that affect a person’s level of health (Eedes, 2016). The nurse
particularly focuses on how the presenting morbidity alters with the client’s activities of daily
living and also how the activities affect the client’s health in general. A good example is an
elderly man (78 years) with a broken femoral neck from a fall while playing golf. In this
case, the client will be forced to stay away from golf activities as his Golfing is again a
predisposing factor to another fall. The same case with a client of asthma. She will be unable
to enjoy recreational activities like camping and cannot also walk in smoggy environments or
in conditions of extreme temperature. Moreover, the nurse also asses how clients interact
with their families and the community in general plus how the present status of health for the
client affects the community and family (Weber & Kelley, 2013). A patient of diabetes
mellitus type two cannot eat the same food as the rest of the family and cannot be of any
significant input towards community projects.
A sample case health assessment is of a 10-year-old Girl in School. The girl is in
adolescence. Adolescence is a critical time for children especially girls. The stage comes with
rapid physical, sexual, social and cognitive and psychological growth (World Health
Organization, 2018). These factors extricates the adolescent girl from her assessment and
health care needs and expectations from those of an adult. Adolescent girls are naturally shy
to talk about the changes to teachers and parents they experience in their bodies. They
therefore will not be in a position of explaining themselves with confidence and in complete
details and thus necessitates a thorough assessment by the healthcare provider. The clinician
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should have a working knowledge on the onset, order, interrelationships and physiognomies
of pubertal growth and how it affects the child’s health. This necessitates using the right
etiquette and posture (bending to the child’s height) to encourage the girl to explain her
condition without fear or shyness. The clinician should then perform physical examinations
like inspection, palpation, percussion and auscultations to look for other characteristics of
illness. Another sample case health assessment in nursing involves an elderly woman with
dementia in a family setting. Health assessments for the aged are very difficult. With
dementia, the woman has a weak memory and therefore the most reliable assessment is not
verbal but physical. The assessment of the patient medical history should not be reliant on
what the patient says, but from the records kept. The purpose of the assessment is planning a
person-centered care in order to support the family and the client to living the best quality
life. The approach to assessment for her should be a combination of nomothetic and
idiographic perspectives considering the three key elements of personhood: relationship,
individuality and embodiment (Molony, Kolanowski, Van Haitsma & Rooney, 2018). The
healthcare provider should observe good etiquette and ensure that she does not violate the
social-cultural beliefs of the woman.
In conclusion, health assessments are indeed very crucial determinants of the
outcomes of care. A well carried out assessment, depending on the patient’s particular
charteristics is fundamental in recovery. Health history, inspection, palpation, percussion and
auscultation are important components of the accurate examination and they interrelate
indirectly or directly to determine the best treatment model. In nursing, a health assessment
serves as s mode of systemic data collection, analysis and synthesis. Finally, assessment is
approached differently depending on the client as seen with the 10-year-old adolescent school
girl and the old woman with dementia in a family setting.
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References
Eedes, D. (2016). Being mortal-Illness, medicine, and what matters in the end.
Gimenes, F. R. E., Reis, R. K., da Silva, P. C. D. S., de Camargo Silva, A. E. B., & Atila, E.
(2016). Nursing Assessment Tool for People With Liver Cirrhosis. Gastroenterology
Nursing, 39(4), 264. doi:10.1097/SGA.0000000000000153
Molony, S. L., Kolanowski, A., Van Haitsma, K., & Rooney, K. E. (2018). Person-centered
assessment and care planning. The Gerontologist, 58(suppl_1), S32-S47.
doi.org/10.1093/geront/gnx173
Petersen, S. W. (2016). Advanced health assessment and diagnostic reasoning. Jones &
Bartlett Learning.
Toney-Butler, T. J., & Whitten, R. A. (2018). Nursing, Admission Assessment. StatPearls
Publishing
Weber, J. R., & Kelley, J. H. (2013). Health assessment in nursing. Lippincott Williams &
Wilkins.
World Health Organization (2018). Adolescent development. Retrieved 4 October 2018, from
http://www.who.int/maternal_child_adolescent/topics/adolescence/development/en/
Wu, R. R., & Orlando, L. A. (2015). Implementation of health risk assessments with family
health history: barriers and benefits. Postgraduate medical journal, 91(1079), 508-
513. doi: 10.1136/postgradmedj-2014-133195
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