HEALTH ASSESSMENT&IT'S

IMPORTANCE INCLINICAL
FIELD

Submitted to Submitted by
Madam S Poddar Jayita gayen
Professor, M.Sc. Nursing Student
Govt College Of Nursing 1st Year
ID &BG Hospital Campus Govt College Of Nursing
ID &BG Hospital Campus
 HEALTH ASSESSMENT
Introduction:
Health assessment are a key part of nurse’s role and responsibility. The assessment is a
tool to learn about our patient’s concern, symptoms and overall health. During the
assessment, nurses may
notice signs of potential or underlying health issues that need to be addressed, as well.
Health is a state of wellbeing.
ASSESSMENT is defined as a systematic, dynamic process by which the nurse
through interaction with client, significant others and health care providers, collects and
analyze data about the client.
Definition:
Health assessment is a process involving systematic collection and analysis of health-
related information on patients for use by patients, clinicians, and health care terms to
identify and support beneficial health behaviors and mutually work to direct changes in
potentially harmful health behaviors.
COMPONENTS OF HEALTH ASSESSMENT:
1.Health history
2.Physical examination
Purposes of health assessment:
 The purpose of health assessment is to get a general understanding of the state of our
health across mental, physical, psychological and sexual wellbeing. Health
assessments enable to take a proactive stance towards health and screen for certain
diseases. At Sirius Health, we believe that knowledge is power and we know that
health assessment enable our patients to make informed decisions about their health
and wellbeing.
 A health assessment is a collection of requested by an employer to evaluate a person’s
fitness to do a job, or they are ordered at a specific age group to give an indication of a
person’s state of health, and highlight any necessary interventions that need to be
made.
 To establish a data base of client’s normal abilities, risk factors that can contribute to
dysfunction and any current alteration in functions.
 To get a clear picture of a client’s health status and health related problems.
 To identify cause and extent of disease.
 To identify the problem at early stage.
 To determine the nature of treatment required for the client.
 To get holistic view of the client.
 To contribute in medical research.
 To identify client’s strength, weakness, knowledge, attitude, motivation, support
systems and coping skills.
 To compare client’s health status with an ideal status.
TERMINOLOGY:
 Diagnosis- It is the determination of the nature and extent of a disease.
 Prognosis- It is the forecast of the course and duration of a disease.
 Etiology-It is the science of the cause of a disease.
 Signs-The presence of a disease that can been seen or elicited e.g., fever.
 Symptoms-Any evidence as to the nature and location of a diseases noted by the
client.
 Subjective Symptoms- When the symptoms are not by the client himself e.g., pain.
 Objective Symptoms-When the symptoms are noted by the observer as well as by
the client e.g, Jaundice.
HEALTH HISTORY:
 It is a collection of subjective data in detail regarding client’s health in a
chronological order.
FACTORS AFFECTING THE COLLECTION OF SUBJECTIVE DATA:
 Physical setting
 Client’s personality and behavior
 Nurses personality and behavior
 Communication skill
 Patient’s problem
FORMAT OF HEALTH HISTORY:
 Biographic data
 Chief complaints
 History of present illness
 Past health history
 Family history
 Occupational and environmental history
 Psychosocial history
  Review of systems
BIOGRAPHIC DATA:
 Name, address, gender, age, marital status, occupation, religion, family income
(monthly), educational qualification etc.
CHIEF COMPLAINTS:
 It is a brief assessment of client’s problem for which clients seeks medical care
 It should be written in client’s statement.
HISTORY OF PRESENT ILLNESS:
 Onset
 Signs and symptoms S & S
 Duration
 Treatment taken (if any)
 Other complaints such as loss of appetite, insomnia, disorders of stomach etc.
 Client’s health habits- eating, sleeping etc.
PAST MEDICAL HISTORY:
 Childhood illness- mumps, measles and so on.
 Allergies
 Medical disease- HT, DM, anemia, etc.
 Surgery – any history of surgery
 Hospitalization- any hospitalization in the past
 Obstetric history- number of live births, abortions , mode of delivery
FAMILY HISTORY:
 Family tree (pedigree chart)
 Information about family members
 Family history of any illness (diabetic Mellitus, hypertension, etc.
OCCUPATIONAL HISTORY:
 Collecting data regarding client’s job, nature of job, environment in job, exposure to any
hazardous substance if any?
PSYCHO SOCIAL HISTORY:
 Smoking- alcoholism
 Food habits and food fads
 Likes and dislikes
 Pattern of sleep
 Exercises
REVIEW OF SYSTEMS:
 Information is gathered systemwide.
IMPORTANCE OF REGULAR HEALTH ASSESSMENT:
It has been reported that 40% of deaths from cancer and 80% of death from type 2
diabetes, heart disease and stroke could be prevented by regular exercise, following a
healthy diet and quitting smoking.
Not only do preventable diseases claim the lives of thousands of people every year, they
are responsible for lost time and resources, both in terms of time off and in terms of the
medical expenses incurred in treating them.
Health care provider will be able to guide with a management strategy that may include
 Input on a healthy diet and regular exercise
 Medication aimed at preventing the onset of chronic disease
 Chronic disease medication to manage health should present with a chronic disease

Specific screening tests will apply depending on age group. In addition to age – specific
testing, we can expect.
PART OF HEALTH ASSESSMENT:
 Medical history update
Medical practitioner will update our medical history and enquire about any new health
issues that be experiencing.

 Measurement
Patient will be weighed and measured , and patient’s file will be updated with this
information, Patient’s blood pressure and heart rate will also be documented for his/her
file and compared to previous measurement.

 Medications
Health care practitioner will ask patients about any medication
they are taking, and find out if they have been taking it as prescribed.

 Health education
Assessment will also include some health education, whereby practitioner will give them
feedback bout their diet, weight and activity levels, highlighting areas for improvement.
 Children’s health assessments
Children over the age of 3 and under the age of 5 who are receiving childhood
vaccinations as part of the National Immunization Program are eligible for the Health
Kids Check.
 Adults aged 40-49
Type 2 diabetes assessments
Adults between the ages of 40 and 49 should have a diabetes type 2 risk assessment
every three years. The purpose of this assessment is to evaluate risk of developing type 2
diabetes .The assessment indicate that they are at heightened risk of diabetes .Healthcare
practitioner will give them life style advice to improve diet and exercise level. For
diabetes, they can check out their post about the best treadmills for home to help them
stay shape indoors.

 Chronic disease assessment

Adults aged 40 to 49 should also have a chronic disease assessment to evaluate risk of
developing chronic disease such as heart disease, diabetes and hypertension.

 Persons with intellectual disabilities

Persons with intellectual disabilities should be evaluated for health risk on an annual
basis.

 People over the age of 75

People who are over the age of 75 receive an annual health assessment. This assessment is
conducted to establish whether there are any underlying health conditions that could be
prevented or managed, to improve quality of life and overall health.
DIFFERENT TYPE OF HEALTH ASSESSMENT:
Practitioner will conduct an assessment, based on patient’s particular needs. He or she
may perform:
Brief health assessment
This is a simple health assessment that is usually conducted in half an hour or less.

Standard health assessment

The standard assessment is a 45 minutes session, and it is employed when need more
than a brief assessment, but do not have any complex health issues that warrant a longer
assessment.
 Long health assessment
If present with complex health issues, healthcare practitioner will order a long health
assessment. This assessment is usually completed in an hour.

Prolong health assessment

This is a complex assessment that is completed when need a preventive healthcare plan.
It usually exceeds 60 minutes in duration, Healthcare provider will advise how long to
set aside for this consultation, based on the tests they need.
IMPORTANCE OF ASSESSMENT IN NURSING:
“Assessment is the first stage of the nursing process, in which data about the patients’
health status is collected and from which a nursing care plan can be devised “.
The gathering of information for the assessment can pose problem if the patient is
suffering from an injury or illness which can affect their speech. Thus meaning that the
process is delayed and any time constrictions which are laid down during the assessment
process are affected. To resolve this problem nurses use past medical history to complete
the assessment. Although this may mean that this information is not up to date as the last
time they used medical services.

IMPORTANCE OF HEALTH ASSESSMENT IN CLINICAL FIELD:

Health assessment is important for everyone. It is an assessment in which we judge the
mental and physical quality of the person. In this we plan of care that identifies the
specific need of the person and how healthcare system will fulfill those needs. It is an
evaluation in which we detect a disease in the person who look and feel well by taking a
physical exam. Hence, it is differed from the diagnostic test in which symptoms are
already known. The technique of assessment involves inspection, palpation, percussion
and auscultation.
By this assessment we detect disease early followed by the treatment and lower the risk
of serious complications. This test most often performs on elderly people. This
assessment mostly performs by the insurance company or employers for looking a
review on employee’s overall health performance. The methods of self-assessment are as
follows:
1. Nutrition assessment
2. Physical assessment
3. Mental assessment
4. Self-care assessment
5. Result.
CONCLUSION:
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
care approaches range from preventive, 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.
References:

1. Kundu Arup; Bedside Clinics in Medicine; 5th Edition; Bangalore; KSP Publishers;2020; Page No:
134-138.
2. The Trained Nurse Association of India; Fundamental of Nursing A Procedure Manual; 1 st Edition;
New Delhi; Published by Secretary General; 2011; Page No: 574-582.
3. Tylor Carol, Lillie Carol, Lynn Pamela; Fundamental of Nursing: The Art and Science of Person-
Centred Nursing Care; 8th Edition; New Delhi; Published by Wolters Kluwer Pvt Ltd; Page No:
324-337.
4. West Bengal Nursing Council; Nursing Theories and Practices; 4th Edition; Kolkata; Nursing
Publication; 2019; Page No: 241-245.