A health assessment involves the use of screening and assessment tools to determine the status of a patient with a view to providing the most appropriate care possible. The assessment can be conducted by nurses in various clinical settings and usually follows a structured approach that is dependent on the patient’s needs.
The initial assessment of a patient should include historical medical information, a thorough validation of their current medical status, possible psychosocial factors, and any other observations that the nurse may make. These findings should ideally be captured on the patient’s profile in a clinical database for future reference.
First, the medical facility will have a standard questionnaire that covers the patient’s medical history, including operations, chronic illnesses, and any other medical conditions that may exist. It is also important for nurses to discover the family medical history, as many conditions can be the result of a physical characteristic that has been passed down through family genes.
The nurse will record details of current medications as well as establish whether the patient smokes, their average alcohol intake in a week, and any substance use other than medication.
Allergies are an underlying cause of many ailments, and it is important to establish whether the patient is allergic to certain medications, foods, animals, pollen, or other substances. If the nurse suspects a possible allergy, an allergy test can be recommended.
A physical examination follows once all questions have been satisfactorily answered. The nurse takes the patient’s temperature, monitors heart rate and blood pressure, checks their breathing, and assesses pain levels if applicable. A more in-depth examination will explore any present symptoms and the reasons for the visit.
Pain assessment is crucial in the diagnosis and treatment of patients. Living with acute pain can be debilitating and will eventually affect normal functioning in other areas of the body. Pain can be sharp or dull, throbbing, intermittent, stabbing, or excruciating. The nurse must pay attention to the type of pain and be aware of potential causes.
Nurses are trained to observe and ask questions. If there is a strong smell of alcohol on the patient’s breath, for example, or bruises that are not consistent with falling, other signs of abuse, or possible malnourishment, the nurse needs to delve a little deeper into the psychological and social factors present. They can then decide what measures to take, such as enlisting the help of a social worker.
Adult-gerontology primary care nurse practitioners are often using their nursing expertise to make a difference in the lives of adult and elderly patients. These patients are often dealing with multiple ailments at a time and are often in stressful end-of-life circumstances. With an online Master of Science in adult-gerontology primary care nursing, individuals will gain in-depth knowledge about patient assessments and learn to recognize the signs that are not immediately obvious to the untrained observer. The Online MSN program at the University of Indianapolis empowers nurse practitioner students with the clinical skills needed for a future in the rewarding field of specialist nursing.
Effective patient assessment involves a range of strategies aimed at making the patient feel comfortable and willing to share information.
First, if the patient is unable to communicate due to language restraints, the nurse should enlist the assistance of an interpreter. Most hospitals and clinics make a point of having a contingent of staff who speak various languages, particularly in multilingual communities.
Patients are more likely to disclose their health issues if they feel welcome and comfortable. The nurse achieves this by being attentive and listening to what the patient has to say. Indicating an understanding of their condition or circumstances and being gentle when conducting physical examinations enables the nurse to put the patient at ease.
Once the assessment is completed, nurses should repeat their understanding of the information and ask the patient to clarify any ambiguous statements. The nurse should provide as much detail as possible about the patient’s condition and finally, provide the patient with a summary.
A career worth pursuing
Nurse practitioners have the training and skills to work in a variety of settings, from hospitals and clinics to homes for the elderly or mentally infirm. They can open their own practice or start a clinic in a disadvantaged community. The shortage of medical personnel has encouraged nurse practitioners to take on more responsibility where needed, with leadership and innovation becoming an integral part of their daily lives as they ease the workload of primary care practitioners. Nursing today is a dynamic, rewarding, and well-respected profession.