1810NRS: Role of Health Assessment in Holistic Care Planning

This essay provides a comprehensive overview of health assessment within the context of nursing practice. It defines health assessment, emphasizing its importance in planning and delivering holistic, patient-centered care. The essay outlines the major components of a health assessment, includi...Read More

Running head: HEALTH ASSESSMENT
HEALTH ASSESSMENT
Name of the Student
Name of the university
Author’s note

1HEALTH ASSESSMENT
Written assignment
Introduction
Health assessment can be considered as the key component of the nursing practice and is
essential for the planning and for the provision of a patient and a family centred care (Forbes &
Watt, 2015).
This essay would focus upon the importance of the health assessment in the planning and
the delivery of a safe care, the different components of the health assessment and how they are
important. It would further focus on the objective or the purpose of the health assessment with
reference to the framework of clinical reasoning cycle. Finally the paper would provide health
assessments in two clinical settings- With a child in a community situation and with an ageing
person in an elderly care facility.
Health assessment
A health assessment can be defined as a plan of care for a person that determines the
specific requirements of a person. It is a deliberative and a systematic process by which the
nurses utilise their critical thinking process for the collection, validation and analysis and
synthesis of the collected information for making judgement about the health status of the
patients, families or the communities (Forbes & Watt, 2015). A health assessment includes the
physical examination of a patient or the use of various tools and the techniques for the diagnosis
of diseases. It is the health assessment based on which the health care professionals make
decisions about the interventions that has to be taken for the care of the patient.

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Major components of a health assessment
The major components of a health assessment includes-
Patient history, Physical, mental, social and spiritual assessment and Consideration of the
laboratory results. While assessing the health of the patient, it is essential to obtain the health
history (Estes, 2013). The main objective is to gather subjective data from the patient or the
family such that a treatment plan can be constructed fir the promotion of health or treating acute
health care problems or minimisation of the chronic health care conditions. Health assessment
involves the overall assessment of the patient's physical, emotional and the behavioural state of
the patient. The general appearance of the patient should be seen at first. Consideration of all
kinds of patients should include body symmetry, facial features, mood and affect, gross and the
motor skills and personal hygiene (Estes, 2013).
A primary assessment consists of Airway, breathing, Circulation and disability. Nurses
should asses for a clear and open airway, obstruction, respiratory distress or for any edema or
bleeding. After the airway, the ventilation is observed by auscultating the lungs, observing the
chest movement and by counting the respiratory rate. Adequate circulation is required for the
maintenance of the tissue perfusion and cellular oxygenation (Estes, 2013). A neurological
assessment should be done for assessing any sort of motor or sensory deficit in the patient. It is
necessary to assess the level of consciousness, the time and orientation of the person and the
place, assessing the response to pain stimulation and more. Secondary assessment refers to the
assessment of the vital signs like blood pressure, temperature, oxygen saturation, pain, blood
glucose levels, cardiac enzymes and diagnostic reports.

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Purpose of a health assessment in nursing
In nursing, health assessment is a plan of care that identifies specific mental and physical
needs of a person. Depending on these needs, the therapy planning is framed. One of the
important approaches of performing health assessment highlights the use of the clinical
reasoning framework. Clinical reasoning framework helps to generate positive health outcome
(Weber & Kelley, 2013). The Levette Jones Clinical Reasoning Cycle is composed of eight
different steps. The first aspect highlights the consideration of the patient’s situation in the
domain of his age and current unrest within the body (Hoffman et al., 2011). According to
Fayers and Machin (2013) patient situation is the first step towards drafting the care plan. The
second step of the clinical reasoning cycle includes collection of cues of the information. This
mainly deals with review of the current information, gathering of new information based on the
current situation of the patient and recall of knowledge in order to link the available resources
with the past information (Weber & Kelley, 2013). Weber and Kelley (2013) highlighted that
collection of the information in the domain of patient’s health must be done in reference to the
past and the present medical history. This helps in the avoidance to encountering error in therapy
planning. The third step in the clinical reasoning is processing of the information. Information
processing is important in health assessment as prediction of the current health status from
available data will help to draft the care plan (Weber & Kelley, 2013). Suppose a patient is
having high blood pressure and high respiratory rate along with high level of cholesterol then it
can inferred that the his current health condition is due to certain level of cardiac complications
(Byrd et al., 2013). The fourth step of the clinical reasoning cycle includes identification of the
problem (Weber & Kelley, 2013). Identification of the problem helps in drafting person-centred
care plan. The fifth step of the clinical reasoning cycle, for performing health assessment

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includes establishments of goals. These goals must be framed in such a manner that specifically
captured the health needs of concerned patients (Weber & Kelley, 2013). This further highlights
the importance of the proper health assessment. The sixth and the seventh step include taking
proper actions in fulfilling the goals and evaluation approaches in order to ascertain the whether
the goals have been successfully achieved (Weber & Kelley, 2013). The last step of the clinical
reasoning cycle includes reflection on the overall process stating the main learning outcomes
(Weber & Kelley, 2013). According to the Code of Professional Conduct for Nurses in Australia
(2018), it is the duty of the nursing professional to practice via reflection and this helps in
improve the overall professional approach of nursing.
Health assessment
 Health assessment of a child in a GP practice
Situation- A 6 years old boy has been brought to the primary care setting with high respiratory
distress and wheezing.
Age- 6 years old boy
Primary Assessment (ABCDE Assessment)
Airway- The boy should be assessed for any wheezing noise from the airways. If the child is
unable to answer, it is necessary to assess for an airway obstruction (Pijnenburg et al., 2016).
Breathing and ventilation- The oxygen saturation of the child should be checked. Auscultation
with the help of a stethoscope can be helpful in determining wheeze. A high flow oxygen should
be given for breathing difficulties (Pijnenburg et al., 2016).

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Circulation- Cardiovascular assessment is necessary as trauma due to trauma can add up
complications.
Disability- It is necessary to check that the motor and the sensory skills of the boy is functioning.
Nebulisers like salbutamol can be given and oxygen therapy should be given in case of low
oxygen saturation.
 Health assessment of an elderly patient in the aged care setting
Situation- 65 years old James who have had a history of cardiovascular disease and was found to
be having chest tightness and mild pain over 2 days.
Age - 65 years.
Past health history- It is essential to know about the past health history such as hypertension,
cholesterol, elevated blood pressure.
Physical examination
Thorax- It is necessary to check the skin colour of the thoracic region.
Eyes- Identification of yellowish plaques
Palpation- It is necessary to palpate the radial pulse.
Percussion- Percussion can be helpful in locating the cardiac borders. It is necessary to percuss
across the anterior axillary line and continue towards the sternum (Kristensen & Knuuti, 2014).
Auscultation- Auscultation of the heart sounds can be helpful in determining cardiovascular
diseases. Heart murmurs can be used to detect complications.

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Furthermore it is also necessary to find out the quality of the pain and the exact location
of the pain and other symptoms like dyspnoea, fatigue, light-headedness and the current
medications. Vital signs like the blood pressure, temperature, heart rate and respiratory rate
should be measured.
Conclusion
In conclusion it can be said that a proper health assessment is the basic step in the nursing
procedure that helps in the development of an ideal treatment regimen for the patients. A proper
health assessment enables a health care professionals to identify the predisposing factor of the
clinical condition and avoid them during the planning of the interventions. Health assessment are
person centred and varies with age and clinical complications. In this assignment it could be seen
that the cardiovascular assessment for the elderly patient is totally different from that of the child
suffering from asthma. However, a health assessment has to be done properly by adhering to the
clinical guidelines to avoid any clinical errors.

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References
Byrd, J. B., Vigen, R., Plomondon, M. E., Rumsfeld, J. S., Box, T. L., Fihn, S. D., & Maddox, T.
M. (2013). Data quality of an electronic health record tool to support VA cardiac
catheterization laboratory quality improvement: the VA Clinical Assessment, Reporting,
and Tracking System for Cath Labs (CART) program. American heart journal, 165(3),
434-440. https://doi.org/10.1016/j.ahj.2012.12.009
Estes, M. E. Z. (2013). Health assessment and physical examination. Cengage Learning.
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Hoffman, K., Dempsey, J., Levett-Jones, T., Noble, D., Hickey, N., Jeong, S., ... & Norton, C.
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