WEEK 1 - OVERVIEW OF THE HEALTH ASSESSMENT

Health Assessment

It 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 facility. It is the orderly collection of objective
information about the client’s health status (objective data are observable, measurable, and verifiable
by more than one person). It is the foundation of all health care (physical assessment is part of every
holistic health evaluation).

ASSESSMENT

     First and most critical phase of health process.

     The health provider is responsible for assessing the patient for any problems or needs;
determining when those findings require the attention of a nurse, physician, or other
professional; notifying the appropriate persons of the assessment findings; and ensuring
follow up for the patient.
     Assessment involves the collection of data about the system (individual, family, or
community). Data is collected by way of interview, physical examination, research, and
review of records. The complete body of information about the patient is called the
patient data base.
     At times, it may be necessary to perform a focus assessment instead of a complete
assessment. For example, you may be ambulating a patient and he may complain about
being constipated. You won't want to collect a complete history and physical at this time
because that has already been done. However, you would want to focus on the problem
of constipation and find out how long it has been going on, the last bowel movement, the
characteristics of the bowel movement, any pain the patient may be having, what factors
contributed to the constipation, the client's diet and fluid intake, and his usual
treatment for constipation.

Why Health Assessment is important?

    Collects health data from the patient and compares these to the ideal state of health,
taking into account the patient’s age, gender, culture, ethnicity, and physical,
psychological, and socioeconomic status.
      Prioritize client problems based from the
     Provide privacy and confidentiality.

This series will describe the different approaches to assessing health needs, how to identify
topics for health needs assessments, which practical approaches can be taken, and how the results can
be used effectively to improve the health of local populations. It will give examples of needs
assessment from primary care but will also cover the specific problems of needs assessment for hard
to reach groups.

What is the Purposes of Health Assessment? 

     Collect holistic subjective & objective data to determine a client’s overall level of
functioning in order to make a professional clinical judgment.

     The health provider collects physiologic, psychological, sociocultural, developmental and

 spiritual data about the client.

     The mind, body and spirit are considered to be interdependent factors that affect a person’s
level of health.

     Health provider focus on how the client’s health status affects activities of daily living
(ADL) and how those ADL affects the client’s health.

     Health provider assesses how clients interact within their family and community and how the
client’s health status affects the family.
     The health provider also assesses how family and community affect the individual client’s
health status.

Framework for Health Assessment in your future career:

     Health provider framework helps to organize information and promotes the collection
of holistic data.
      This provides clues that helps to determine human responses.
     A professional health provider should constantly observe situations and collect
information to make judgements. It can occur no matter what the setting:
hospital, clinic, home, community or  long-term care.

Types of Health Assessment

1.Initial Comprehensive Assessment

Involves collection of subjective data about the client’s perception of his/her health of all body
parts or system, past health history, family history, and lifestyle and health practices. Objective
data, gathered during a step by step physical examination.

An Initial Comprehensive Assessment describes in detail the client's medical, physical and

psychosocial condition and needs.  It identifies service needs being addressed and by whom; services
that have not been provided; barriers to service access; and services not adequately coordinated.
Involves collection of subjective data about the client’s perception of his/her health of all body parts
or system, past health history, family history, and lifestyle and health practices.

A comprehensive health assessment gives health provider insight into a

patient's physical status through observation, the measurement of vital signs and self-reported
symptoms. It includes a medical history, a general survey and a complete physical examination.
Regardless of who collects the data, a total health assessment is needed, (subjective and objective data
regarding functional health and body system). When client enter a health care facility, an establish
baseline data is needed for future health status changes can be measured and compared. Frequency of
comprehensive assessments depends on the client’s age, risk factors, health status, health promotion
practices and lifestyle.

2.Ongoing or Partial Assessment

Consist of data collection that occurs after the comprehensive database is established. This
consists of a mini overview of the client’s body system and holistic health patterns as a follow-up on
health status. Any problems that were initially detected in the client’s body system or holistic health
patterns are reassessed to determine any changes (deterioration or improvement) from the baseline
data. This type of assessment is usually performed whenever and wherever the practitioner or
another healthcare professional has an encounter with the client, whether in the hospital, community,
or home setting.
 Ongoing assessments alert the health provider to:

      changes in the patient's responses to health and illness

     suggest necessary changes in the plan of or care offered by other healthcare
professionals

3. Focused or Problem-Oriented Assessment

 Does not replace the comprehensive health assessment. It is performed when a comprehensive
database exists for a client who comes to the health care agency with a specific health concern. A
focused assessment consists of a thorough assessment of a particular client problem and
does not address areas not related to the problem. A problem focus assessment collects data
about a problem that has already been identified.  Problem Oriented Assessment of patient complaint
area only. Patient complains of chest pain, you perform vital signs, and assess the patient's. This type
of assessment has a narrower scope and a shorter time frame than the initial assessment.

4.Emergency Assessment

An emergency assessment is a very rapid assessment performed in life-threatening situations. In

such situations, (choking, cardiac arrest, drowning), an immediate assessment is needed to provide
prompt treatment. This guides the health provider to assess potential or actual threats to Airway,
Breathing, Circulation and Disability. Interventions may need to be undertaken if a threat to these
elements are discovered (when cardiac arrest is suspected). The rapid triage assessment in the
emergency care environment is a quick assessment that helps the triage health provider identify those
patients requiring immediate care from those who can safely wait.
AIRWAY
BREATHING
CIRCULATION
DISABILITY
EXAMINE
FARENHEIT
GET VITALS
HEAD-TO-TOE ASSESSMENT
INTERVENTION

       Triage System

      Triage is the prioritization of patient care (or victims during a disaster) based on
illness/injury, severity, prognosis, and resource availability.
     The purpose of triage is to identify patients needing immediate resuscitation; to assign
patients to a predesignated patient care area, thereby prioritizing their care; and to
initiate diagnostic/therapeutic measures as appropriate.

     The rapid triage assessment in the emergency health provider environment is a quick
assessment that helps the triage health provider identify those patients requiring
immediate care from those who can  safely wait.
     The intention behind triage is to improve the emergency care and to prioritize cases in
terms of clinical urgency.

What is the health provider’s role in health assessment?

The role can be divided into two subjects: holistic and physical medical. The holistic role of
health providers in health assessment is to collect holistic subjective and objective data to determine a
client’s overall level of functioning in order to make a professional clinical judgment.  The physical
medical assessment focuses primarily on the client’s physiologic development status.

GENERALIZATION:

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 care 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. Ongoing or Partial 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.

“Good health is not something we can buy. However, it can be an

extremely valuable savings account.”

Anne Wilson Schaef