Patient Health Assessment

2988 Words12 Pages
On admission to a healthcare facility, a health assessment is a mandatory tool in assessing the patient’s health status. In general an assessment is broken down in a two types of reviews, by conducting a health history which includes the collection of subjective data (information elicited by the patient or patients family members) and a physical examination of the patient which includes the gathering of evidence based data (Wilson & Giddens, 2009). Collecting and documenting accurate information is imperative in providing the allied health team this information to facilitate an efficient and well-formed care plan, as well establishing a baseline for subsequent assessments (Springhouse, 2004; Wilson & Giddens, 2009). PATIENT INTERVIEW A health assessment should consist of establishing a patient profile and incorporate a full medical history (Harvey, 2004). The traditional approach includes collecting subject matter on “biographical data, present health concerns (or present illness) and the chief complaint, past history, family history, review of system and patient data” (Farrell & Dempsey, 2010, p. 74). The assessment interview builds the foundation of the nurse and patient relationship, building good rapport with the patient will alleviate any stress, anxiety or discomfort the patient may be feeling. The patient will be asked personal questions and times may not understand or may not want to divulge information about their personal life/situation. As a nurse being open and honest, explaining why this type of information is necessary and asking open-ended questions will help prompt the patient to disclose the facts required, expedite the process and be fundamental in performing a successful assessment (Springhouse, 2004). The... ... middle of paper ... Physiotherapist: A career in health fact sheets (2010). Retrieved at Springhouse. (2005) Assessment: A 2-in-1 Reference for Nurses USA: Lippincott Williams & Wilkins Springhouse. (2007) Health Assessment Made Incredibly Visual! USA: Lippincott Williams & Wilkins Tough, J., (2004, May 26) Nursing Standard : Assessment and treatment of chest pain. Vol. 18, Iss. 37; pg. 45, 9 pgs. Retrieved at Wilson, S. F., & Giddens, J. F. (2009) Health Assessment for Nursing Practice (4th Edition). USA: Mosby Elsevier. Weber, J. R, & Kelley, J. (2007) Health Assessment in Nursing (3rd Edition). USA: Lippincott Williams & Wilkins
Open Document