Chapter 2. Patient Assessment

2.8 Summary

This chapter has outlined the different components of health assessment. Different assessments are done in different contexts and are dependent on the type of patient, health care professional, and environment.

The health assessment is an opportunity to develop a therapeutic relationship with the patient, optimize communication, promote health, and provide patient education as necessary. Throughout the assessment, be aware of ensuring patient safety, privacy, and dignity.

The assessment must always be documented according to the agency policy, and any unusual findings must be reported comprehensively, in conjunction with other pertinent findings, to appropriate members of the health care team.

Key Takeaways

  • Health assessment refers to a systematic method of collecting and analyzing data for the purpose of planning patient-centred care.
  • A pain assessment should be measured at the beginning of the physical assessment, and comfort measures taken as necessary.
  • Safety considerations should be followed throughout any physical assessment.
  • Components of health assessment include conducting a health history, performing a physical examination, and communicating and documenting the findings according to agency policy.
  • The amount of information gained during a health assessment depends on several factors, including the context of care, patient needs, and the health care professional.
  • The types of health assessments are head-to-toe, focused, initial, and emergency assessment.
  • The data collected during the health assessment is organized and interpreted to initiate or continue a plan of care.

Suggested Online Resources

1. Auscultation Assistant, The. This website provides audio clips of heart murmurs and lung sounds.

2. BC Patient Safety & Quality Council: 48/6 Model of care. This resource offers a model of care for hospitalized seniors (aged 70 and older) in British Columbia. It is an integrated care initiative that addresses six care areas of functioning through patient screening and assessment (assessments are completed only where screening shows areas of concern) within the first 48 hours of hospital admission.

3. Canadian Patient Safety Institute (CPSI): The Canadian framework for teamwork and communication. This framework provides health care providers with techniques to improve teamwork and collaboration.

4. Canadian Patient Safety Institute (CPSI): The safety competencies. Developed by the Safety Competencies Steering Committee of CPSI, this interprofessional patient safety framework identifies the knowledge, skills, and attitudes required by all health care professionals to practise safely.

References

Anderson, B., Nix, N., Norman, B., & McPike, H. D. (2014). An evidence based approach to undergraduate physical assessment practicum course development. Nurse Education in Practice, 14(3), 242-246.

Assessment Skill Checklists. (2014). Checklists from Nursing 1019: Clinical Techniques (BCIT BSN program course).

Jarvis, C., Browne, A. J., MacDonald-Jenkins, J., & Luctkar-Flude, M. (2014). Physical examination and health assessment. Toronto, ON: Elsevier-Saunders.

Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical skills and nursing techniques (8th ed.). St Louis, MO: Elsevier-Mosby.

Rosdahl, C. B., & Kowalski, M. T. (2007). Textbook of basic nursing. Philadelphia, PA: Lippincott Williams & Wilkins.

Stephen, T. C., Skillen, D. L., Day, R. A., & Jensen, S. (2012). Canadian Jensen’s nursing health assessment: A best practice approach. Philadelphia, PA: Wolters Kluwer-Lippincott.

Wilson, S. F., & Giddens, J. F. (2013) Health assessment for nursing practice (5th ed.) St Louis, MO: Mosby.

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2.8 Summary by British Columbia Institute of Technology (BCIT) is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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