A complete and holistic health assessment includes the:
- health history
- physical, psychological, social and spiritual assessment
- consideration of laboratory and diagnostic test results
- review of other available health information.
Assessment begins as soon as you meet your patient. Perhaps without even being aware of it, you're already noting such aspects as their skin color, speech patterns and body position. Your education as a nurse gives you the ability to organize and interpret this data. As you move on to conduct the formal nursing assessment, you'll collect data in a more structured way. The results you collect from your assessment may be subjective or objective.
When evaluating the assessment data, you'll start to recognize significant points and ask pertinent questions. You'll probably find yourself starting to group related bits of significant assessment data into clusters that give you clues about your patient's problem and prompt additional questions. For instance, if the data suggest a pattern of poor nutrition, you should ask questions that will help elicit the cause, such as:
- Can you describe your appetite?
- Do you eat most meals alone?
- Do you have enough money to buy food?
- On the other hand, if the patient reports frequent nausea, you should suspect that this may be the cause of his poor nutrition. Therefore, you'd ask questions to elicit more information about this symptom, such as:
- Do you feel nauseated after meals? Before meals?
- Do any of your medications upset your stomach?
The nursing history requires you to collect information about the patient's:
- biographical data
- current physical and emotional complaints
- past medical history
- past and current ability to perform activities of daily living (ADLs)
- availability of support systems, effectiveness of past coping patterns and perceived stressors
- socioeconomic factors affecting preventive health practices and concordance with medical recommendations
- spiritual and cultural practices, wishes or concerns
- family patterns of illness.
Begin your history by obtaining biographical data from the patient. Do this before you begin gathering details about his health. Ask the patient their name, address, telephone number, birth date, age, marital status, religion and nationality. Find out who the patient lives with and get the name and number of a person to contact in case of an emergency. Also ask the patient about their health care, including the name of their general practitioner and any other health care professionals or members of the interprofessional team they have contact with, for example an asthma nurse specialist or social worker.
If the patient can't give accurate information, ask for the name of a friend or relative who can. Always document the source of the information you collect as well as whether an interpreter was necessary and present.
To explore the patient's current complaints, ask the patient about the circumstances that have brought them into contact with the health care team. Is there an aspect of their health that is concerning them or proving challenging? Patient complaints provide valuable data immediately. When you explore these initial complaints, you may uncover crucial additional information.