NURS 3020 Health Assessment Paper
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history. It is done to detect diseases early in people that may look and feel well.
Holistic medicine, frequently referred to as integrative health and medicine, has been steadily gaining traction among patients. And as more patients realize the benefits of this model, the need for nursing staff capable of providing such specialized care increases. Specifically, nurses would be well-served to develop a deeper understanding of the role of holistic health assessments as well as the overall benefits of holistic care.NURS 3020 Health Assessment Paper
lamar_holistic_assessment_and_care-300×300.jpgHolistic health assessments are an important part of nursing care
What Is a Holistic Health Assessment?
According to the Academy of Integrative Health and Medicine (AIHM), holistic medicine is the “art and science of healing that addresses the whole person — body, mind, and spirit.” It utilizes a combination of traditional and alternative treatments and ultimately seeks to promote disease prevention through maintaining ideal health and wellness in all areas of life.
Holistic health assessments are integral components of patient care under this model. Composed of physical examinations and a series of well-designed questions, these assessments are used by nurses to evaluate how each area — body, mind and spirit — is affecting the patient’s overall health.
Nurses play a vital role in obtaining this information from patients and recording it in the medical chart. For example, the nurse may:
Conduct a thorough physical examination (body).
Encourage the patient to share their concerns about their condition (mind).NURS 3020 Health Assessment Paper
Ask the patient about their spiritual or religious beliefs and how their disease has affected their faith (spirit).
By asking these types of questions and taking on the role of an active, empathetic listener, the nurse is able to establish a deeper relationship with the patient and better evaluate the entirety of their situation. This can lead to several positive outcomes. If the patient is able to discuss stressors that are affecting their health, for example, the nurse can help them identify appropriate coping mechanisms or direct them to other valuable resources like counseling.
Likewise, if the patient would benefit from spiritual encouragement or guidance, the nurse is able to swiftly recognize that need — one that might have otherwise gone unnoticed without a holistic health assessment.
The Origins of Holistic Nursing
The concept of holistic nursing is often attributed to the work of Florence Nightingale, a 19th century nurse who provided patient care at a British hospital during the Crimean War. She held a strong belief that a patient’s relationships and surroundings heavily influenced their overall health and wellness. She became one of the earliest healthcare advocates, and many consider her among the first holistic nurses.
In 2006, holistic nursing earned official recognition as a nursing specialty by the American Nurses Association (ANA). The specialty status meant that a scope and standards of practice specific to holistic nursing was also established.
Today, the American Holistic Nurses Association (AHNA) defines holistic nursing as “all nursing practice that has healing the whole person as its goal. This practice recognizes the totality of the human being — the interconnectedness of body, mind, emotion, spirit, social/cultural, relationship, context, and environment.”
Nursing and Holistic Care
As mentioned previously, holistic nurses strive to form a deeper bond and partnership with their patients. They listen carefully to the patient’s feelings and experiences and honor their values and beliefs. They seek to learn all aspects of a patient’s situation rather than simply focusing on their disease or illness.NURS 3020 Health Assessment Paper
In doing so, nurses in this specialty are more likely to incorporate the principles of CAM — complementary and alternative modalities — with mainstream, traditional treatments. The modalities are frequently classified into four domains, including:
Manipulative and body-based practices such as acupuncture, dance therapy, massage, qi gong and aromatherapy.
Mind-body medicine such as art therapy, guided imagery, meditation and neuro-linguistic programming.
Biologically-based practices such as biofeedback, hydrotherapy, and nutritional counseling.
Energy medicine such as prayer, reiki and therapeutic touch.
A fifth category — whole medical systems — applies to all four domains and includes homeopathy and osteopathic medicine.
By combining traditional and CAM philosophies, holistic nurses hope to achieve the highest level of healing for their patients’ physical, psychological and spiritual ailments. Nurses provide this type of care in a number of healthcare settings as well. A 2011 AHNA study showed that 48 percent of holistic nurses work in hospitals or clinics, 14 percent in private practice, 13 percent in an academic setting, and 7 percent in home care or hospice.
Furthermore, AIHM estimates that more than 40 percent of hospitals now offer inpatient integrative services, along with a significant rise in the number of services offered on an outpatient basis. Commonly used to treat cancer, depression and chronic pain, more than one-third of U.S. adults use some form of integrative health and medicine.
Learning More About Holistic Care
Given the growing popularity of holistic medicine and treatments among patients and healthcare organizations, current and prospective nurses are encouraged to learn more about this specialty. Lamar University’s online RN to BSN program offers coursework that covers comprehensive holistic health assessments. Students learn the skills necessary to properly conduct the assessment in today’s healthcare settings.
Nursing health assessment is an important role for a patient being diagnosis and give appropriate treatment (Bellack, 1992, p.12). In my past clinical practice, only some simple assessments were conducted as it is able to reduce the affect of the problem but not solve it. After studied nursing health assessment, some more extensive and specific assessments should be done to identify patient’s health status. The actual problem, strengths deviations and the risk of the health problem are explored at a detail and in-depth way. This article is going to discuss about the specific nursing health assessment for a patient suffered from abdominal pain, who was met in my past practicum placement.NURS 3020 Health Assessment Paper
Ms. Ma, Age 54, housewife, admitted via A&E and complained she was having abdominal pain for 5 days. Sharp pain starts at mid-abdomen and then at right lower quadrant. Level of pain increased when coughing. She had had Panadol 500mg an hour ago but pain can not relief. Nausea and vomited small amount of undigested food twice in the past few days. No diarrhea. She feels tired but can not sleep because of the sharp pain. Her vital signs are: pulse 98, blood pressure 148/85 mmHg, temperature 39.2oC. Her skin is warm and dry. Rebound pain occurred at the right lower quadrant of abdomen. She has hypertension and need to take medicine 2 times per day.
Ms. Ma was diagnosed with acute appendicitis. Keep NPO and IV 500ml normal saline is established. Blood test, abdominal X-ray and ultrasound abdomen are planned.
Assessment of abdomen
In the past clinical practice, I only give analgesics by doctor’s order and the patient may sometimes relief pain after medication. However, abdominal assessment skills are necessary to identify Ms. Ma‘s condition for getting at the root and having a better outcome.
There are five important steps for evaluating abdomen: take health history, inspection, auscultation, percussion and palpation. These assessment skills will be discussed one by one in the following paragraphs.
Health history and lifestyle health practices
First, find out the patient’s chief complaint, record the details and observe Ms. Ma‘s general appearance.
Then, assess the abdomen pain by COLDSPA— character, onset, location, duration, severity, pattern and associated factors. It is the most accurate measurement to identify whether it is parietal peritoneal pain, visceral pain or referred pain (Judy, 2008).
After that, collect individual and family past and current health status. Ask if there was any injuries or trauma may cause the pain, any eating disorder, any abdominal surgery was done before, any food allergy, history of suffering inflammatory bowel disease, family history of cancer and chronic disease, etc. Also, collect Ms. Ma‘s lifestyle and health practices. Ask her if smoke, drink or not, her eating habit, bowel pattern and movement, the amount, colour and texture of stool, any change in appetite, weight and abdominal girth recently and her stress level (Medical Education, 1998).NURS 3020 Health Assessment Paper
Past history and current lifestyle health practices are the useful information to identify the risk factors of the problem.
After collecting all background information, the physical examination should be proceed. Physical examination is using senses to collect objective data. It is used to identify the actual and potential health problems, discover patient’s abnormalities and diagnosis the problem (Nursing 2010 Magazine, 2010).
For physical examination of abdomen, Ms. Ma needs to empty her bladder first in order to avoid the bladder irritation then, place Ms. Ma in a supine position. The hands should be at aside and knees slightly bent. Tell her keep relax of the abdominal muscles. The assessment should be started in the right lower quadrant of abdomen and then proceeding in a clockwise direction. Also, the examination should go forward in the order of inspection, auscultation, palpation and finally percussion for avoid affecting the quality of bowel sound and increase peristalsis (Bellack, 1992).
Physical examination of abdomen
Inspection is systemic visual examination. For abdominal examination, it should be started at the mouth, which is the beginning of gastrointestinal tract, and finally the rectum and anus (Bellack, 1992).
First, ask Ms. Ma opens her mouth and says “Ar” or use tongue depressor to inspect the structure of mouth cavity to see whether any inflection, ulcer or not. Then, give a swelling test to Ms. Ma for examine the swelling ability. Place a spoon with some water on the middle part of her tongue and ask her to swell the water slowly to observe any choking or water leaks out. After that, inspect the texture of abdomen, the condition and colour of skin, any bruises or scars presence on abdomen. Normally, abdomen is homogenous in colour. If redness or yellow orange appear, it may indicate inflammation or liver disease respectively. Normal abdomen should also be symmetry from side to toe, flat and have normal movement when smooth respiration. If the abdomen is asymmetric, obesity, abnormal enlargement of organs, fluid distention or even intestinal obstruction may be suffered. Also, aortic pulsation should be present as Ms. Ma is having hypertension. Finally, ask Ms. Ma to take a deep breathe and hold it, it is used to inspect the presence of hernias or not (Bellack, 1992).
Auscultation of abdomen is used to define the bowel sound, which are caused by the movement of air or fluid at small intestine, by stethoscope.NURS 3020 Health Assessment Paper
The examination is started at the right lower quadrant, where the clearest bowel sound can be heard. Normal bowel sounds are at high-pitched, bubbling sound and occur five to thirty times per minute. If hyperactive bowel sounds occur, it indicates diarrhea or early stage of gastroenteritis. If hypoactive or even absent of bowel sounds for five minutes, it indicates intestinal obstruction, peritonitis or pneumonia.
Besides bowel sounds, vascular sounds of aortic, renal, iliac, and femoral arteries can also be auscultated. It is an important examination to assess hypertension patient such like Ms. Ma whether she suffers from portal hypertensive and liver cirrhosis or not. If the vessels constricted or dilated, a bruit can be heard when blood flows (National Institute for Health and Clinical Excellence, 2008).
Palpation is using sense of touch to collect data. For abdominal examination, finding out the location of pain is a great help of diagnosis abdominal pain. Light palpation and deep palpation are used to assess the abdominal organs, to define the tenderness and presence of mass. It is essential to assess the liver and spleen in abdominal examination.
Light palpation which is not more than 1 am deep on each quadrant. Normal abdomen should be smooth and consistent. If broad-like hardness appears, it states peritoneal irritation is suffered.
Deep palpation, which is press deeply from5cmto8cm, is used to indicate the abdominal organs and detect some obscure masses. Palpate the liver to test Murphy’s sign of cholecystitis. Palpate on the right upper quadrant at midclavicular line and parallel to the midline. If Ms. Ma feels pain and has inspiratory arrest, it states positive Murphy’s sign and indicate cholecystitis. Then, palpate the spleen at costal margin on left upper quadrant to feel if the spleen is enlarged and Ms. Ma will feel pain when the peritoneum is inflamed.NURS 3020 Health Assessment Paper
Finally, as the rebound tenderness was being tested to Ms. Ma, that is pushing 90o angle at the right lower quadrant deeply and then release quickly. It is the reliable test of peritoneal inflammation if the patient feels sharp pain when the force released (Watkins, 2010).
Besides, obturator test and iliopsoas test can also be done for diagnosing appendicitis. For obturator test, Ms. MA need to hold her right leg above the knee at 90o angle, grasp the ankle and rotate her leg laterally and medically. If she feels pain, it states obturator muscle is irritated. For iliopsoas test, straight up Ms. Ma’s right leg and press deeply on her upper thigh and ask her to oppose the pressing force. If she feels pain, it states that she is suffering from appendicitis (Beltran, 2009).
Percussion collects data by vibrations and sounds. For abdominal examination, percussion is used to assess the amount of fluid or gas, the location of mass, the size of liver and spleen. Normally, tympanic sound is found at hollow organs such as stomach and intestine; dullness sound is found at liver, spleen or masses.
To estimate the liver is enlarged or not, the normal distance of liver is 6 to12cm, which depends on the body size and gender, at the midclaricular line.
To estimate the spleen by percussing behind the left midaxillary line. If the distance is greater than7cm, it states that the spleen is enlarged due to infection, mononucleosis or trauma.NURS 3020 Health Assessment Paper
Moreover, test of shifting dullness and fluid wave to assess ascites. If the ascites of abdomen is more than 500ml, shifting dullness will be found. Normally, tympany is produced at abdominal midline (Bellack, 1992). However, for the abnormal case, dull sound is produced because of the cumulated fluid. Ask Ms. Ma rolls to right side and percuss from top to bottom. If the fluid is present, sound will change from tympanis to dullness and fluid wave will be generate when percuss on a side of the abdomen. It also has great variate in the abdominal girth.
After the physical examination, documentation is necessary for the findings and development of care plan.
Current of illness
Ms. Ma states that her abdominal pain started five days ago. On the pain scale from 0 to 10, as 10 being the worst, she rates her pain is 7. Sharp pain occurs at mid-abdomen and then at right lower quadrant continuously. Level of pain increases when coughing. She has no known drug allergy and food allergy. She had Panadol 500mg an hour ago but pain can not relief. Nausea and vomited small amount of undigested food twice in the past few days. She has loss of appetite and lost about 3 pounds of body weight. No change in her abdominal girth. She has no diarrhea. She feels tired but can not sleep because of the sharp pain. She is having fever as her vital signs are: pulse 98, blood pressure 148/85 mmHg, temperature 39.2oC.
Past health history and lifestyle practice
Ms. Ma is a non-smoker and non-drinker. She has hypertension and need to take medicine 2 times per day. No abdominal surgery was dome before. She denies any injury or trauma occurs recently on her abdomen. She does not have history of suffering inflammatory bowel disease or family history of cancer and chronic disease.
She states that her eating habit is health and the amount, colour, texture of stool are normal, but constipation sometimes. She does not feel stress or depression.NURS 3020 Health Assessment Paper
Ms. Ma has normal structure of mouth cavity and good swelling ability. There is no bruise or scar presence on abdomen. Her abdomen is symmetric and homogenous in colour. Her skin is warm but dry. By using the stethoscope, her bowel sounds are normal and no bruits are heard. Ms. Ma has rebound tenderness at the right lower quadrant of abdomen, pain occurs at obturator test and iliopsoas test when palpation. Normal tympanic sound is produced at abdominal midline when percussion.
Action and responses
Ms. Ma is hospitalized. IMI 50mg Tramadol is given and her pain is temporary relief. Blood test was done and the result shows the level of white blood cell is high. The abdominal X-ray and ultrasound abdomen show her appendix is enlarged
Ms. Ma is booked for an urgent operation for appendectomy.
In conclusion, some early symptoms of disease are not obvious, which will be easily misdiagnosed. Therefore, collecting health history and physical examination are very important as the data collected are in-depth and specific. It helps to have fast and accurate diagnosis in order to provide appropriate treatments to solve the patient’s problem and the symptoms at the same time.
As stated by Weilitz & Potter (2007), “Health assessment is the process of gathering, verifying, analyzing, and communicating data about a patient.” (p. 5). This sentence shows that health assessment is essential for fully understanding the situation of a patient.
In the following passage, there is a case study to discuss which kind of health assessment can be used in order to provide a better nursing care for a patient.
Mr Wong, aged 58, arrived at my ward with his wife. He was sweating and coughing. He had a difficulty of breathing and a wheezing sound was heard. After 15 minutes of rest, he felt better. He explained that while he was chasing a bus with his wife, he felt breathlessness and dizzy. He did not recovered after resting for awhile on the street so his wife brought him to the hospital.
Mr Wong was a retiree for a year and he was a constructive worker before. He explained that retirement was because of not enough energy for daily work. He had smoked for over 30 years, one and half pack of cigarette per day, and had 5 cans of beer every week. He was obese and had medical history of hypertension for 5 years with own medicine. He was married and lived with his wife in an old building. He was fatigued when climbing up the stairs as well as walking for awhile. Due to the fatigue, he reduced the social activities and stayed most of his time at home.NURS 3020 Health Assessment Paper
He complaint of not having a good sleep because of night cough (on-and-off for a year) and kept coughing with production of sputum for a year. Besides, he had respiratory track infection more frequently in this year. In recent 2 months, he had poor appetite and lost 8 pounds.
During the conversation, Mr Wong usually needed a rest for answering every 3 questions. He looked tired and had deep circles under his eyes. His lip was dry. He was upset about the fatigue and felt useless of himself. He said that his quality of life was affected and lost interest of his previous hobbies. He did not have any social activities in this year nearly.
Mr Wong had a low grade fever and blood pressure was around 145/90. His pulse was around 110. He had taken a chest X-ray after admission and the result was pending. He took the test of spirometry and FEV1 was between 40-50%. His 12-lead ECG was normal. 2-liters of oxygen was given through nasal cannula. He always sat up and seldom leaving the bed. Mr Wong was diagnosed with chronic obstructive pulmonary disease (COPD).
When Mr Wong arrived, I took vital signs of him as a baseline. His weight as well as height were recorded.
Then I took the health history by an interview. The interview was started with the main complaint of Mr Wong. After that I took the past health status. They were medical history, done surgery, medication history, food and drug allergy.NURS 3020 Health Assessment Paper
The lifestyle and health practice of Mr Wong were also asked. It included different areas. Smoking and drinking must be included as both were the risk factors of COPD. From his diet, hobbies and activity level, I needed those information for discovering the reasons of weight loss and obesity of Mr Wong. I also asked Mr Wong if he had constipation while if he felt breathless during passing stool and bathing.
After the interview, I held a physical examination for Mr Wong. There were 2 parts, inspection and auscultation. I measured the respiratory rate and rhythm and observed the shape of his chest and any central or peripheral cyanosis. Auscultation was followed. I recorded the abnormal sounds like wheezing.
Advanced nursing health assessment
In the case of Mr Wong, a very simple and brief health assessment was done. It was unsatisfied because the health assessment was not completed and informative. The following passage is going to provide more health assessment and methods which can improve the case of Mr Wong.
The interview of Mr Wong was too brief. More questions should be asked.
First of all, Mr Wong’s family history should be reviewed as COPD can be inherited (CMP Medica, 2007). More information of his blood relatives such as patients, grandparents and children has to be obtained. Nurse can find out any rare illness among the families which may relate to respiratory disease (Barnett, 2006).
Secondly, Mr Wong work history should be also assessed. Since he was a constructive worker, he usually exposed to the chemical irritant. The nature and the environment of his work directly regard to COPD. Nurse needs to identify any personal protective equipment he used as well (Weilitz & Potter, 2007, p.157).
Thirdly, information regarding home conditions is important to establish how Mr Wong coped at home. As he was living in an old building, the building may be without a lift or with many stairs. It is possible for Mr Wong having difficulty to go out or it may be the reason of reducing social activities (Barnett, 2006).NURS 3020 Health Assessment Paper
Fourthly, nurse has to question Mr Wong’s sleeping pattern as he did not sleep well because of night cough. Nurse should document how many hours he slept and why he could not sleep well. Sleeplessness or limited sleep may lead to tiredness and inability to cope with daily activities. By knowing the cause, doctor and nurse can treat the night cough of Mr Wong to deal with the insomnia. And they can prevent giving treatment with night sedative due to the side effects, which may depress the respiratorycentre(Barnett, 2006).
The physical examination includes different parts which can give a complete picture of Mr Wong’s condition. They will be introduced one by one, from simple to complicated.
Body mass index
From the article of Shepherd (2010), it states that “Nutritional depletion in patients with COPD is common and has negative impact on respiratory and peripheral muscle function.”(p.559). As Mr Wong had poor appetite and lost 8 pound in 2 months, the body mass index (BMI) should be recorded for follow-up. Nurse has to find out causes of weight loss and deals with those problems efficiently.
COPD assessment test
COPD assessment test is a simple questionnaire. It is used to measure the impact of COPD on the life of patient, and how this changes overtime. By this test, nurse takes it as a reference to improve the treatment. The test contains 8 questions. They are the frequency of coughing, if he feels any mucus in his chest, if his chest feels tight, if he feels breathless when climbing up hills or stairs, if he is limited doing any activities at home, if he is confident leaving his home despite his lung problem, if he sleeps soundly, if he has lots energy(GlaxoSmithKline, 2009).
Medical Research Council( MRC) Dyspnoea Scale
Measurement of breathlessness is essential for a COPD patient. The Dyspnoea Scale of MRC allows patients to grade their breathlessness on a scale of 1-5 according to activity carried out. The degree of breathlessness related to activities is from grade1-5 which means from mild to severe. It acts as a baseline and is useful for monitoring purposes for nurses and doctors (Barnett, 2009).NURS 3020 Health Assessment Paper
Physical examination of Chest
Through the process mentioned in above passages, nurse can receive higher proportion of basic information about Mr Wong’ condition. In the coming passages, several techniques which focus on chest are going to introduce. There are 4 physical respiratory examination, inspection, palpation, percussion and auscultation. Although inspection and auscultation were applied in the case of Mr Wong, they were imperfect.
Inspection consists of several parts. For the case of Mr Wong, nurse mainly focus on the inspection of breathing pattern, use of accessory muscles and positioning (Weber & Kelley, 2010).
Nurse needs to observe the rate, depth and rhythm of respiration. If these factors are abnormal, they represent the increasing workload of breathing. The pattern of respiration should be recorded if there is any special such as tachypnoea, hyperventilation, Cheyne-Strokes respiration, Biot’s respiration…etc. It allows the doctor giving particular treatment (Massey & Meredith, 2010).
Abnormal posture shows the patient may have difficulty in breathing. Mr Wong always sat up or leaned forward because he can better tense the respiratory muscle and contractility (Massey & Meredith, 2010). In addition, using of respiratory muscles (trapezius, or shoulder) helps inspiration especially chronic airway obstruction (Weber & Kelley, 2010). Nurse should pay more attention and provide suitable nursing care (such as oxygen supply, suction, removing tight clothes…etc) when above symptoms occur.
Palpation for tenderness and sensation can determine whether there is inflammation, muscle sore or infection. It can be performed by one or both hands following the sequences. It should be started towards the midline at the level of the left scapula then the nurse moves her hand from left to right. The moving is systematically downward and out to cover the lateral portions of the lungs at the bases. The nurse should compare the finding bilaterally. The nurse can also check if there is mass or tumor (Weber & Kelley, 2010).
During the palpation, a crackle sensation may be sensed which means crepitus. This sensation is because of air passing through fluid and exudates in the lungs. Fremitus should be assessed. It is a vibration of air movement through the chest wall. It can be increased, decreased or absent which represent different lung problem like consolidation or bronchial obstruction, pulmonary edema, pneumothorax…etc (Weber &Kelley, 2010).NURS 3020 Health Assessment Paper
Percussion has 2 main functions, determining the tone as well as the diaphragmatic excursion.
When nurse percusses the chest wall, the sound produced can show whether lung tissue is filled with air, liquid or solid. Same as palpation, a sequence of percussion should be followed. The process is started at the apices of the scapulae then across the top of both shoulders. Next, nurse percusses the intercostals spaces across and down. Finally, she moves from the lateral aspects at the bases of the lung (Weber & Kelley, 2010). By comparing the sound of percussed areas, nurse may discover the lung mass or other respiratory problems (Weilitz & Potter, 2007). Measuring the diaphragmatic excursion is also important. Emphysema may be a cause of limited diaphragmatic descent.
For auscultation, breathing sound is not the only element to assess. The voice sound can also be assessed. It is easy that nurse auscultates the chest wall while she asks the patient to repeat pronouncing “ninety-nine”. This is the way to identify if there is consolidation from pneumonia, atelectasis, or tumor (Weber &Kelley, 2010).
For the patient with CODP, they usually reduce the daily activities like Mr Wong did. The patient may not use to the changes of the quality of life( 醫院管理局,2010). Closely observation and listening to the patient are the easiest and useful ways to assess the mental state of the patient. If there is any abnormal, the condition should be recorded and report to the senior nurse.NURS 3020 Health Assessment Paper
In this article, some health assessment tools and techniques are suggested for a CODP patient, Mr Wong. There is no traumatic procedure involved. However, the results of different examination can give large amount of information of the patient’s body condition. And this is essential for the clinical staff to improve the clinical decision making in order to provide better treatments for the patient.
Health assessment is important and often first step in identifying the patient’s problem. Health assessment helps to identify the medical need of patients. Patients health is assessed by conducting physical examination of patient.A health assessment is a judgment of physical, mental and quality standards of a person’s life. It is most often conducted by a medical office and it is often given to elderly people. A health assessment may also be done by insurance companies or employers, looking to review an employee’s overall health. Each medical institution uses its own scoring and scale of good health. You will want to judge both the appearance of health, the need of assistance and the person’s pain or feeling during the activity. You should decide upon the difficulty and pain scale before performing the health assessment. For example, some people use words to describe pain while other people use a scale of between 1 and 10, with 10 being the worst. This article will tell you how to do a health assessment.
Health assessments are utilized by nurses to evaluate patients’ medical status. During this process, nurses must make certain that patients understand how important health assessments are for their current and future wellbeing. The information collected via health assessments also assists caregiving organizations in improving community health conditions, identifying potential areas of concern within the public health sector and developing health policies which can improve patient outcomes across multiple settings.NURS 3020 Health Assessment Paper
Importance of Health Assessments
Health assessments are important for a number of reasons, but two key benefits are that health assessments help health leaders target high-risk conditions specific to their communities and identify early signs of disease when, at first glance, a patient may appear to be healthy. Early identification is beneficial for health care providers, because it helps nurse leaders develop a more accurate understanding of the community that they are serving as well as identify potential causes of a disease afflicting large numbers of the population. As of late, electronic health records have been used to improve health assessment analysis, allowing caregivers to discover hidden trends, share research, identify underserved conditions and evaluate performance. Once assessments are complete, caregivers can leverage collected data to develop key initiatives that will help improve the overall health of the community, such as educating on the dangers of smoking, the importance of wellness plans and effective methods for managing stress.
Role of the Nurse Leader in the Health Assessment Process
Although nurse leaders may occasionally give health assessments, their primary responsibility is to organize and manage the health assessment process as well as the caregivers administering assessments. They may also provide training to younger nurses that lack experience with assessments. Nurse leaders continue their training and leadership throughout the process as they assist their peers with analysis and identification techniques as they sift through data to determine current health concerns and those that may be developing amongst the community. To optimize their efficiency, nurse leaders should expand their comprehension and expertise in the collection and analysis of data and diagnostic formulation, as these skills are important for helping to identify potential health concerns and in managing the health assessment process as a whole.NURS 3020 Health Assessment Paper
Upon identifying potential risks, nurse leaders then pursue actions to alleviate the conditions or behaviors afflicting the patients and/or community population. Some of these actions may include following up with patients, developing community presentations on how to minimize health risks, and developing health policies or a community health improvement plan. As a whole, health assessments have an important role in maintaining and improving individual and community wellbeing. Through health assessments, nurse leaders and the medical community are able to identify potential areas of concern within a specific region. Once risks have been identified, nurse leaders help develop and implement initiatives to maintain and improve the current and future health of their respective communities
Regular assessments are performed by hospital staff during your hospital stay. These assessments are undertaken to explore your medical, physical, psychological and social needs. Assessments help to find the cause of your illness and check your ability to do day-to-day tasks. Assessments help to keep you safe by identifying areas of risk or deterioration in your health. They are particularly valuable for older people, who may decline more rapidly when they are admitted to hospital.
In hospital, assessments may include a list of questions or tasks that staff members will ask you to complete. These are used to work out whether there is a problem and to measure your progress once you have started treatment.
Definition of a health assessment in hospital
Assessment is a broad term that is used to describe a process of measuring your health and ability to perform everyday skills during a hospital stay.NURS 3020 Health Assessment Paper
Assessments can involve a set list of questions or tasks that staff members will ask you to perform. These are used to help work out whether or not there is a problem. Assessments are often repeated in order to help measure your progress and identify your ongoing needs. This helps make sure you get the best care in hospital and helps with planning for when you leave hospital.
For some assessments you need to answer questions, for others you need to perform certain tasks. Staff may also want to talk to your family, carers and your GP to understand more about your needs.
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Purpose of health assessments in hospital
Regular assessments of patients by hospital staff help to identify problems quickly. If health issues are not picked up early, they can get worse. This can mean a longer hospital stay or more severe health problems later.
It is important for you and your family to participate in the assessment process and to tell staff if you have concerns.
Your healthcare team in hospital are always checking your health and ability to do everyday skills. Part of their role is to identify and diagnose problems that will impact on your quality of life. Your healthcare workers look at your medical issues and they also investigate your social, physical, and psychological health.
Ongoing assessment by hospital staff means they can also recommend the best care plan for you when you are discharged from hospital, and put you in contact with services that can support you outside of hospital.
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Tips for participating in a health assessment in hospital
When answering assessment questions, remember your privacy will be respected. Hospitals and hospital staff are not allowed to share information about you and your health without your consent (except when medically or legally necessary).NURS 3020 Health Assessment Paper
Examples of the types of questions that a person may be asked during a hospital health assessment include:
Before the illness or injury that brought you to hospital, did you need someone to help you on a regular basis?
In general, do you see well?
Do you take more than three different medications every day?
Examples of tasks that a person may be asked to perform if they are able include:
standing or walking with or without assistance
drawing a clock
other memory and thinking tests.
It is important to:
Be open and honest when answering assessment questions.
Tell staff what matters to you and if you have any concerns.
Perform assessment tasks to the best of your ability.
Tell hospital staff straightaway if you:
feel very unwell
don’t understand why you are being asked questions or are performing tasks
are in pain during an assessment.
You may be asked the same types of questions many times during your stay, such as when your health changes or you are moved to a different ward. Answer each time to the best of your ability.
You may need ongoing assessments for other problems while in hospital. Some assessments are done routinely and some are performed as a precaution.
During your hospital stay it’s important that you and your family and carers tell hospital staff if you have any concerns about your health or about your ability to do activities.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history. There are different from diagnostic tests which are done when someone is already showing signs and/or symptoms of a disease. The major health assessments are Initial Assessment in which determine the nature of the problem and prepares the way for the ensuing assessment stages. Focused Assessment, which expose and treats the problem. Time-Lapsed Assessment, which ensure that the patient is recovering from his malady and his condition has stabilized. Emergency Assessments focus on rapidly identifying the root causes of concern for the patient and assessing the airway, breathing and circulation (ABCs) of the patient.NURS 3020 Health Assessment Paper
Evidence does not support routine health assessments in otherwise healthy people.
Health assessment is the evaluation of the health status of an individual along the health continuum. The purpose of the assessment is to establish where on the health continuum the individual is because this guides how to approach and treat the individual. The health continuum approaches range from preventative, to treatment, to palliative care in relation to the individual’s status on the health continuum. It is not the treatment or treatment plan. The plan related to findings is a care plan which is preceded by the specialty such as medical, physical therapy, nursing, etc.
Health assessment has been separated by authors from physical assessment to include the focus on health occurring on a continuum as a fundamental teaching. In the healthcare industry it is understood health occurs on a continuum, so the term used is assessment but may be preference by the speciality’s focus such as nursing, physical therapy, etc. In healthcare, the assessment’s focus is biopsychosocial but the intensity of focus may vary by the type of healthcare practitioner. For example, in the emergency room the focus is chief complaint and how to help that person related to the perceived problem. If the problem is a heart attack then the intensity of focus is on the biological/physical problem initially.NURS 3020 Health Assessment Paper
Our biometric health screening services are a key component of our comprehensive corporate wellness programs and are designed to help improve health awareness among employees and provide data for employers to gauge the health of their employees and track improvement over time. Biometric health screenings help identify, but not diagnose, risk factors that could signal the presence of an existing disease or the potential for developing one.
A health assessment is a set of questions, answered by patients, that asks about personal behaviors, risks, life-changing events, health goals and priorities, and overall health.
Health assessments are usually structured screening and assessment tools used in primary care practices to help the health care team and patient develop a plan of care. Health assessment information can also help the health care team understand the needs of its overall population of patients. Health assessments can vary in length and scope. They can be completed during office visits or between office visits, either on paper or computers. Health assessment questions may be asked about patients of all ages, including children and adolescents.
Some common health assessment questions ask about:
Sedentary behaviors such as sitting and watching TV or playing computer games.
Addictive behaviors such as gambling or drug use.
Violence, bullying or physical abuse.
Depression or anxiety.
Emotional and social support.
Safety issues such as wearing a seat belt while driving.
Overall health or well being.NURS 3020 Health Assessment Paper
Based on the results of employees’ health screenings, US Wellness provides targeted intervention strategies, relevant health education and coaching, and other appropriate preventive measures to help manage and reduce these health risks and encourage employees to adopt healthy lifestyle changes and take a more proactive role in their health. Aggregate health information about their employee population allows organizations to structure their employee health management program and design wellness initiatives in an effort to reduce overall health costs and improve the health and productivity of their workforce.
Health Screening Components
Our health screenings are comprised of the following elements:
HEALTH RISK ASSESSMENT (HRA)
US Wellness offers an online questionnaire that collects self-reported data from employees on their lifestyle, health goals, motivation, and willingness to make necessary behavior changes.
Our standard onsite biometric screenings measure a variety of important health factors including height, weight, BMI, pulse, and blood pressure.
For onsite health screenings, US Wellness conducts basic blood testing using a finger stick or venous blood draw (venipuncture). Finger stick tests yield immediate results; venous blood draws are sent to a laboratory for testing. Blood tests include a full lipid panel (total cholesterol, LDL, HDL, triglycerides) and glucose levels.
Biometric Screening Program Features
US Wellness designs a unique, branded online appointment scheduler for all of our clients with a custom URL for employees to access it.
OFFSITE SCREENING OPTIONS
We recognize the importance of employee participation for the overall success of the corporate wellness program and therefore offer offsite biometric screening options for remote employees or those unable to attend the scheduled onsite screening. Offsite options include a laboratory voucher for Walgreens or LabCorp, a home test kit, and a physician form. We also offer a custom, secure link for employees to submit the results of their offsite biometric screening by an approved physician.
SECURE DATA CAPTURE
US Wellness was the first biometric screening provider to develop an electronic data capture (EDC) platform. Since 2005, US Wellness has maintained its HIPAA compliant EDC system and has provided the system for industry leading organizations, including Walgreens and GlaxoSmithKline.NURS 3020 Health Assessment Paper
HEALTH RESULTS AND EDUCATION
US Wellness is committed to protecting the privacy of employees’ individual screening results. We adhere to strict guidelines to ensure employees’ health data remains confidential. Our team of licensed healthcare professionals informs employees of any measurements that are outside of normal ranges and offer recommendations, education, and coaching to help lower their risk.
US Wellness provides aggregate, de-identified data on the overall health of their employee population. We also share employee participation and engagement statistics and incentive tracking to help evaluate the success of the corporate wellness program.
Experienced Industry Leader in Health Screenings
US Wellness has provided corporate biometric health screening services to more than 500 organizations, servicing 10% of the US Fortune 500 companies. Last year alone, US Wellness administered over one million biometric health screenings nationwide.
US Wellness is committed to advancing the development of best practices by ensuring:
Measures are clinically valid and evidence-based, relating to factors shown to be associated with chronic illness
Measures are consistent and will enable comparative analysis and benchmarking
Data collection occurs at consistent intervals to measure the impact of programmatic activities
Data are standardized, allowing for the analysis of whole populations as well as subgroups
Data is actionable, leading to well-integrated wellness programs of lasting benefit for both the individual and the organization
Professional, Licensed Biometric Health Screening Staff
Unlike others in the industry, US Wellness does not subcontract its services. US Wellness maintains a proprietary network of licensed health care professionals, who are screened and regularly trained and evaluated to ensure compliance with our quality standards. NURS 3020 Health Assessment Paper