Conducting patient health assessments may seem like a routine nursing duty, but it is a vital contribution to the continuum of care. Without an accurate portrayal of the patient’s personal health history and status, effective care decisions are difficult to make. An online Registered Nurse to Bachelor of Science in Nursing (RN to BSN) program, like that at the University of Louisiana Lafayette, includes coursework on health and physical assessments.
What Types of Health Assessments Do Nurses Perform?
Nurses typically perform two different types of health assessments: complete and problem-focused.
A complete health assessment is detailed, thorough and often used to screen patients who are admitted to a hospital, nursing home or other inpatient setting, as well as during an initial home visit. This type of assessment typically includes a review of the patient’s full health history and a comprehensive physical exam.
A problem-focused health assessment is narrower in scope and is used when a complete exam is unnecessary or prohibitive, such as in emergent situations, like a broken limb, or certain routine visits. Problem-focused health assessments typically include a brief review of the patient’s pertinent health history (such as allergies and current medications) and a limited examination, focused on just one or two body systems, to address the presenting problem, concern or care goal.
Why Is Health Assessment Accuracy Important?
Accurate and complete assessments are essential to the provision of safe, quality care. They are instrumental in identifying the needs and status of the patient and any potential limitations preventing treatment compliance. Healthcare professionals must conduct assessments in a structured and systematic fashion, as others on the healthcare team will rely on each assessment as part of a patient’s medical record to discern treatment plans and make decisions.
What Are the Top Health Assessment Tips for Nurses?
While you will ultimately hone your assessment skills through repetition and practice, the following tips are excellent reminders for any stage of your career:
Engage the patient. Some patients are reluctant to share key information, especially if they are feeling unwell. Establish a baseline of rapport and trust with the patient by explaining why this information is needed and how it is used to guide their care.
Always verify; never assume. You must always complete your own assessment and verify the information for accuracy. This serves as a safeguard to quickly catch common errors, such as the listing of an incorrect medication or dosage.
Take note of nonverbal cues. Patients may not report pain, but a grimace when receiving care can clue you in otherwise. Pay attention to nonverbal cues, like body language, and ask follow-up questions to develop a more robust assessment.
Create a mnemonic. Nurses collect a great deal of information when performing assessments. To prompt your recall and ensure you cover the necessary body systems each time, consider creating a mnemonic — one for each type of assessment. For example, SAMPLE is a common mnemonic used for an assessment that is limited in scope:
Signs and symptoms
Past medical history
Last meal or oral intake
Events leading up to the illness or injury
Refine Your Assessment Skills
Health assessments are a core nursing responsibility and a critical component of quality, evidence-based care. Although you will develop and refine your patient interviewing and data collection skills over time and with practice, you can get a much-needed jumpstart by completing the coursework in an RN to BSN program. The Health and Physical Assessment course in the online RN to BSN program at UL Lafayette helps you rapidly expand a skill set that is foundational to providing optimal care.
Learn more about UL Lafayette’s RN to BSN online program.