Health assesment

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Contents

History.........................................................................................................................................................2

Family history..........................................................................................................................................3

Current lifestyle and psychological issues...................................................................................................3

Nutrition..................................................................................................................................................3

Smoking...................................................................................................................................................3

Alcohol.....................................................................................................................................................3

Exercise....................................................................................................................................................3

Medications.............................................................................................................................................3

Physical exam..............................................................................................................................................3

Gastrointestinal assessment....................................................................................................................4

Pulmonary inspection..............................................................................................................................4

Pain assessment..........................................................................................................................................4

Markers of pain.......................................................................................................................................5

System-based approaches...........................................................................................................................5

SBAR model.................................................................................................................................................6

Communication using the SBAR Model...................................................................................................7

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 Assessment Tools....................................................................................................................................7

A-G model...................................................................................................................................................7

References...................................................................................................................................................8

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NSB 103

Health Assessment

Assessment Task 2

Assessment is an imperative part of nursing care since it is necessary for the provision and

planning of patient care. The Nursing and Midwifery Board of Australia defines nursing

assessment as conduction of rigorous and structured through planning nursing care in

coordination with individual or groups and inter-disciplinary teams medical team and it should

react rapidly to unforeseen and rapidly evolving situations(Clinical guidelines(nursing), 2017)

Assembling information about the patient’s sociological and spiritual, physiological and

physiological requirements is an indispensable component of the nursing evaluation. It is the first

phase in a patient’s accurate evaluation. Data assortment which includes both objective and

subjective data is part of the assessment, which includes assessment of vital signs.

Nursing practices include continuous and systematic data collection. The five key stages

involved in nursing care are processing, analyzing, arranging, recording and communicating

data.it is important to plan and develop a patient-centred care strategy that incorporates methods

based on evidence ( Dunham and Maclnnes J, 2018).

A cardiovascular centred assessment is indicated after a detailed assessment point towards a

possible cardiovascular problem. A comprehensive cardiovascular analysis can assist in the

diagnosis of various factors that can affect the cardiovascular system.

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History

Nursing and health care staff should go through current disease, related previous records,

allergies, immunization records, drugs and social and family of a patient.

A thorough cardiovascular history would reveal potential or existing cardiovascular conditions.

Cardiovascular history assessment can be helpful in physical examination. It is crucial to obtain

the patient‘s past medical history. The health history of the patient with cardiovascular problems

elicits information about the increase in blood cholesterol, triglycerides, hypertension, and

congenital heart disease and heart murmurs. The nurse can ask questions related to the history of

heart disease, serum cholesterol levels, stress and surgeries. Ask the questions about past

hospitalization and the type of care and treatment they received there.

Family history

A patient‘s family history is a primary factor in determining the risk for cardiovascular disease.

Investigate any family history of cardiovascular diseases such as coronary artery disease, high

blood pressure or sudden death of a family member suffering from CV disease.

Current lifestyle and psychological issues

Nutrition

Ask about your patient daily diet pattern, their normal weight or either they have observed loss

or gain in weight.

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Smoking

Find out whether your patient inclines to smoke. Estimate the number of packs consumed by

your patient in a year.

Alcohol

Calculate the alcohol consumption by the patient on a regular or weekly basis.

Exercise

Also, ask about the level of activity and exercise performed by the patient. Obtain the

information about the sort of workout they do.

Medications

Obtain all information about medicines and drug they are ingesting including beta-blockers,

calcium channel blockers, anticoagulants and aspirin.

Physical exam

The physical examination should be done in head to toe format. It starts from the head and ends

with the toes (Overview of nursing health assessment, 2014).

The evaluation of other systems such as respiratory or circulatory systems is inevitable to

provide a holistic and comprehensive picture( Focused cardiovascular assessment,2015).

The circulatory assessment includes inspection that involves visual assessment of the circulatory

system. In visual assessment, nurses should observe skin colour, the colour of the tongue, lips

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nail beds. Chronic arterial insufficiency causes redness; cyanosis can cause blue discolouration

to lips. Warm skin causes vasodilation. Arterial functional inadequacy is indicated by the

decrease in hair volume. Heart disease, the disorder of vessels and liver failure can cause

oedema.

The next step in circulatory assessment is auscultation f patient blood pressure. the pressure

generated by the left ventricle is estimated by systolic value. While the diastolic value asses the

pressure in arteries when the heart is in a relaxed position.

In palpitation, nurses palpitate the peripheral arteries that comprise femoral, popliteal, dorsalis

pedis, posterior tibial and brachial artery.

Inspection of the chest for pulsation and auscultation of areas to hear the S1 and S2 sounds are

also performed in circulatory assessment.

Examine the following:

 Carotid artery,

 Palpate the jugular veins,

 Precordium

 Cardiac borders

 Listen to hear sound in a Z pattern

 Recognize S1 and S 2 patterns

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  Feel the dorsalis pedis, femoral, popliteal, brachial, posterior tibial and radial pulses

(Jarvis, 2012).

Gastrointestinal assessment

While examining the digestive system ask the following questions: changes in appetite, difficulty

in swallowing, abdominal pain, vomiting or nausea, constipation, diarrhoea or other changes in

bowel habits. History about stomach issues can also provide essential information about the

current status of GI disorders.

Pulmonary inspection

Examine whether the patient has a pain throat or they have difficulty in breathing (night’s

sweats), history of asthma, lung disorders and allergy in the family ( Overview of nursing health

assessment, 2014).

Pain assessment

PQRST is useful in assessing the t pain while examining the cardiovascular system. It is the

more reliable and informative method that outlines a strategy for efficient communication

between patient and health care. Chest pain is aggravated by workouts that induce chest pressure

is a distinctive symptom of angina. Ischemic pain can be stimulated by emotional discomfort,

smoking, cold and stress. Pain is intensified by swallowing in the oesophagal region. Cardiac

aetiology is indicated by pain that counters to sublingual nitroglycerin. Patients have similar

quality of chest pain that has a history of coronary artery disease. Patients who have myocardial

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ischemia avoid receiving medical care and often deny pain. Squeezing, tightness and heavy

weight on the chest or swelling in the throat are signs of pain. Levine sign in myocardial

infarction patients is illustrated by pain in the chest region. Myocardial ischemia causes pain in

the stomach, lower jaw, teeth, neck and shoulders. Burning infarction is usually a misdiagnosed

indigestion or heartburn.

Markers of pain

 Vomiting.

 Pain.

 Tachycardia or fluctuations in blood pressure.

 Intensification in the rate of breathing (T.J,2020).

The nurse observes the vital signs of patients: blood pressure, temperature, and glucose level and

pulse rate. The nurse inquires about the history, time and duration of heart palpitation and

giddiness, food intake, alcohol intake, medications, physiotherapy and pain. She observed the

skin soars or rashes on the patient’s body. She also asks about the patient family: whether he is

living alone or with his family. The nurse is communicating in a very friendly manner and also

raise questions about physiotherapy. Problems with sensation, tightness or swelling in feet, sit

forwards, use of antibiotics and throat swallowing are also discussed in communication between

nurse and patient.

The nurse would have provided education about the heart palpitation and giddiness problem. The

nurse did not consider the psychological issues. The nurse has not recommended

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diet.modification for the patient. High salt intake can induce palpitations. The nurse has not

documented all the observations. The nurse did not question about kidney system (T.J,2020).

Health care should use a holistic approach to assess problems.

System-based approaches

Health care providers can use this system:

 S-signs and symptom of the disease.

 A-allergies.

 M-medications and drugs.

 P- medical history.

 L-last oral or last meal intake.

 E-events that occur before acute condition.

In nursing assessment, we can adopt the PQRST strategy. This strategy provides an effective

methodology for health care providers. The nurses can assess the symptom and can evaluate the

treatment method (Jarvis, 2012).

 Palliative: it determines the symptoms.

 Quality: it refers to the ailments.

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  Radiation or region: this section tells us about whether symptoms spread or radiate to

other parts of the human body.

 Intensity (S): on a scale of 1-10, symptoms are ranked with 10 being worst.

 Timing: whether illness occurs with association with other conditions.

SBAR model

The SBAR model fulfill the gap between a narrative, descriptive approach and one armed with

exact details. It enables communication between members of the healthcare team.

Communication using the SBAR Model

 Circumstances

 Background

 Assessment

 Recommendation

Assessment Tools

 Daily activities

 Glasgow coma scale or AVPU for assessment of mindfulness

 Health questionnaires such as those that report recent travel and exposure risks

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  Pain scales:Faces Wong-Baker Faces Pain Rating Scale (WBS), Pain Scale (FPS), Visual

Analogue Scales (VAS), Numeric Rating System (NRS), (MPQ) McGill Pain

Questionnaire and Wong-Baker Faces Pain Rating Scale (WBS).

 Cough assessment

 Waterlow or Braden scale for assessing pressure ulcer risk

 CIWA scoring or CAGE assessment

 Dysphagia Screen

 4AT Assessment for Delirium

 NIH Stroke Scale (NIHSS)

 Classic vital sign flow charts for different age groups

 Morse Fall Risk

A-G model

Systematic approach is applied in A-G model which efficiently identifies

patients who are suffering from illness or at risk (Dean and Bowden, 2017).

A-G encompasses breathing, disability, exposure, circulation, additional data

(including family and friends) and targets (Benson, 2017).

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Diagnostic Studies
Driven by findings on the history and physical examination; options include:
 Blood tests (CBC, chemistry, bedside glucose, pregnancy test, urinalysis, cardiac
enzymes, coagulation studies)
 Imaging studies (X-rays, CT, MRI, ultrasound)
 Other diagnostic studies (ECG, EEG, lumbar puncture, etc.,)
Discharge Planning
 Document mode of transport
 Who is accompanying the patient?
 Transfer forms/EMTALA considerations
 Functional status
 Financial considerations
 Discharge medications and instructions
 Follow up information, referrals, hotline numbers, shelter information
 Barriers to learning
 Document verbalization that discharge instructions were understood by caregiver or
surrogate
 Provide translators and language appropriate discharge instructions or paperwork

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References

1. Clinical guidelines (nursing). (2017). The Royal Children’s Hospital Melbourne.

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_assessment

2. Cathala X and Moorley C(2020a). Performing an A-G patient assessment: a step-by-step

guide. Nursingtimes.Net. https://www.nursingtimes.net/clinical-archive/assessment-

skills/performing-an-a-g-patient-assessment-a-step-by-step-guide-06-01-2020/

3. E. (2019). Assessment of patient information needs: A systematic review of measures.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6354974/

4. Focused cardiovascular assessment. (2015). Https://Lms.Rn.Com/Getpdf.Php/1795.Pdf.

https://lms.rn.com/getpdf.php/1795.pdf

5. Hong-Ying PI  and Xin HU (2016). Nursing care in old patients with heart failure:

current status and future perspectives. NCBI.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4984563/

6. Nursing admission assessment and examination. (2020). NCBI.

https://www.ncbi.nlm.nih.gov/books/NBK493211/

7. Overview of nursing health assessment. (2014). AMN HealthcareEducation Services.

https://lms.rn.com/getpdf.php/2051.pdf

8. T. (2010a). Nurse education today. Science. Direct.Com.

https://www.sciencedirect.com/science/article/abs/pii/S026069170900210X?via%3Dihub

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9. T. (2010b). The ‘five rights of clinical reasoning: An educational model to enhance

nursing students’ ability to identify and manage clinically ‘at risk’ patients.

Sciencedirect.Com.

https://www.sciencedirect.com/science/article/abs/pii/S026069170900210X?via%3Dihub

10. T.J. (2020). Nursing Admission Assessment and Examination. NCBI.

https://www.ncbi.nlm.nih.gov/books/NBK493211/

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