Introduction to Health Observation and Assessment, Cultural Considerations in Health Observation and Assessment, Conducting a Systematic Head-to-Toe Assessment and Primary/Secondary Survey, and Documenting health observation and assessment findings.

Introduction to Health Observation and Assessment

This article is an introduction to health observation and assessment. Use it to create educational essays on health observation and assessment.

Health Observation and Assessment in Nursing practice

What is health observation?

A systematic procedure of collecting data about a patient is called health observation and assessment. This data is utilized to offer information on the patient’s state and to guide the proper care for that patient. Nurses are continually observing and assessing patients’ health in all clinical settings.

The first phase in the nursing care cycle is health observation and evaluation:

  • Health History: the process of gathering subjective information about a patient’s symptoms. An interview with the patient and/or significant people is used to gather data. The information gathered might be primary or secondary.
  • Physical examination: gathering objective data, such as information regarding a patient’s symptoms. The data is gathered by a physical examination of the patient, which includes procedures including inspection, palpation, percussion, and auscultation, as well as vital sign and other critical physical indicators assessment.

Symptoms are the subjective experiences of the patient. A nurse’s signs are what she sees, feels, hears, or measures objectively. Data gathered during health observation and evaluation can be both a symptom and an indicator in some situations. A client could claim she “feels sweaty” (a symptom), and the nurse might see diaphoresis (a sign).

  • Data documentation: data obtained during health observation and evaluation must be documented in order to be utilized to (1) assess the patient’s state and (2) guide the proper care for that patient. Data may be captured in a number of different ways. Documentation must be full, accurate, succinct, readable, and free of prejudice in whatever format.

What are the types of health assessment that a nurse may undertake?

  • A complete health history and physical examination of a client: performed in order to determine all of the person’s health care concerns and needs. Usually done at the time of admission.
  • Problem-based/ focused health assessment: Collecting data relevant to a specific complaint in a problem-based or targeted health examination: Outpatient settings are common.
  • Rapid assessment: gathering information in order to give rapid, life-saving assistance to a patient. Frequently used in emergency situations.
  • Episodic/follow-up assessment: A nurse conducting an episodic or follow-up evaluation on a patient to collect data on a previously diagnosed condition. By evaluating changes in the patient’s health, the purpose is to evaluate how the patient has reacted to care.
  • Screening assessment: Data is collected with the goal of detecting the existence of a certain illness during a screening evaluation.

The sort of evaluation done is determined by (1) the context and (2) the patient’s health care challenges and requirements. A full health examination is typically suitable in an acute care environment with a new client. A fast examination is often more appropriate in an emergency care situation if a patient enters with an obvious, substantial condition.

Cultural Considerations in Health Observation and Assessment

What are the factors that nurses should consider when observing and assessing health?

A person’s culture encompasses more than just their ethnic heritage; it also encompasses how they live in and see the world. People that share a culture have similar values, beliefs, and attitudes on a variety of subjects, including health. Nurses must provide effective care to persons whose health practices, values, beliefs, and attitudes differ greatly from their own.

Nurses must be respectful of a wide range of health practices, values, beliefs, and attitudes. This includes, among other things, learning to be a culturally competent nurse.

Nurses are not required to be experts in all of the cultural groups they interact with’s health practices, values, beliefs, and attitudes. They should also refrain from categorizing their coworkers. Nurses must instead treat each patient as an individual. Nurses are urged to ask probing questions in order to gain a better understanding of their patients’ health behaviors, values, beliefs, and attitudes.

Conducting a Systematic Head-to-Toe Assessment and Primary/Secondary Survey

How should nurses conduct a systemic head-to-toe assessment?

This section introduces the concept of a ‘head-to-toe assessment,’ a physical examination that allows a nurse to examine a client from head to toe in a systematic and complete manner. Nurses analyze each bodily system in turn during a head-to-toe examination to generate a thorough overall grasp of the patient’s condition.

Each nurse uses a different technique when conducting a head-to-toe evaluation. The sole need for a head-to-toe evaluation is that it be rigorous and thorough, with no data being left out.

Observation is the first step in a complete assessment. The nurse should pay attention to the patient’s stride, posture, and ease of mobility, as well as their capacity to communicate, physical appearance, and overall mental awareness/orientation / cognitive process. This is to highlight any evident issues that may need to be addressed before the assessment can begin, or that may shape the emphasis of this health evaluation.

After a nurse has finished observing a patient, they can go on to performing the head-to-toe examination. This is accomplished in two steps:

  • The main survey which involves evaluating the patient’s life-supporting bodily systems.
  • The secondary survey entails a more thorough examination of the patient.

The main survey has four steps that may be memorized using the mnemonic ‘ABCD’:

A Airway This procedure entails determining the airway’s patency. Dyspnoea, excessive upper respiratory secretions, respiratory issues such as coughing/choking, and airway damage, among other things, should be monitored by a nurse.
B Breathing This phase entails determining whether or not the patient’s respiration and gas exchange are adequate. Dyspnoea, paradoxical or asymmetrical motions of the chest wall, auxiliary muscle usage, changes in breath sounds, cyanosis, tachycardia, and other symptoms should be monitored by the nurse.
C Circulation This phase entails determining how well the cardiovascular system is operating and whether the patient has enough blood volume. The nurse should check the pulse’s quality and rate, as well as capillary refill time, skin color, and temperature.
D Disability This phase entails a quick examination of the patient’s neurological system, as well as their degree of awareness. During this phase, another simple mnemonic, ‘AVPU,’ is used to prompt nurses:

A Is patient alert.
V The patient responds to voice.
P The patient responds to pain.
U The patient is unresponsive.

Other limitations, such as noticeable physical or psychological difficulties, may be discovered during this stage of the main survey.

It’s also a good idea to measure and keep track of your vital indicators. After that, the nurse can go on to the secondary survey. This entails employing four main strategies:

  • Inspection: the process of evaluating a portion of the body by looking at it.
  • Palpation: the process of evaluating a region of the body by touch. To determine location, texture, size, consistency, masses, fluids, crepitus, and pulsations, the nurse can utilize their palmar surfaces and finger pads.
  • Percussion: the act of tapping a region in the body to assess its contents. Percussion is used to assess the size, boundaries, and consistency of internal organs, as well as to detect pain and the presence of fluid in a bodily cavity.
  • Auscultation – focusing on sounds

The nurse should anticipate hearing the following noises when percussing the body:

Area Percussed Normal / Expected Sounds
Lungs Resonant tone; loud intensity; low pitch; long duration; hollow quality.
Bone, muscle Flat tone; soft intensity; high pitch; short duration; extremely dull quality.
Viscera, liver Dull tone; medium intensity; medium to high pitch; medium duration; ‘thud-like’ quality.
Stomach, gas in intestines Tympanic tone; loud intensity; high pitch; medium duration; ‘drum-like’ quality.
Air trapped in lungs (e.g. in emphysema) Hyper-resonant tone; very loud intensity; very low pitch; longer duration; booming quality.

The nurse ought to evaluate:

Body Region Examples of Health Observation and Assessment
The head and face
  • The contour, intactness, and tenderness of the skull.
  • The colour and distribution of the hair.
  • The symmetry and intactness of the facial features and bony structures.
  • The texture and tenderness of the skin and sinuses.
  • The condition of the skin.
The eyes
  • The near and peripheral vision.
  • The symmetry, position, closure, blinking, and colour of the eyes.
  • The symmetry of the eye movements.
  • The colour and clarity of the sclera.
  • The transparency of the cornea.
  • The pupillary response to light.
The ears
  • The alignment, position, size, shape, symmetry, intactness of the ears.
  • The external auditory canal.
  • The superficial lymph nodes.
  • The internal auditory canal.
The nose, mouth, and oropharynx
  • The symmetry of the nose.
  • The nasal canal.
  • The lips, mucosa, and gums.
  • The teeth.
  • The floor of the mouth and palates.
  • The oropharynx, uvula, tonsils, pharynx, etc.
  • The tongue.
The neck
  • The symmetry of the neck, trachea, and thyroid.
  • The range of motion of the neck.
  • The carotid pulses.
  • The jugular vein.
  • The lymph nodes.
The upper extremities
  • The skin, temperature, moisture of the hands.
  • The symmetry of the hands.
  • The shape, colour, thickness, cleanliness of the nails.
  • The arms, elbows, wrists.
  • The brachial/radial pulses.
  • The range of motion, muscle strength, and sensation of the arms.
  • The deep tendon reflexes.
The posterior chest
  • The respirations.
  • The shoulders, spine alignment, posture, etc.
  • The skin.
  • The vertebrae.
  • The breath sounds.
The anterior chest
  • The respirations.
  • The skin.
  • The heart sounds.
  • If indicated, the breasts.
  • The lymph nodes.
The abdomen
  • The skin.
  • The abdomen itself, for contour and movement.
  • The bowel sounds.
  • The abdominal quadrants.
The lower extremities
  • The legs, ankles, and feet.
  • The temperature, pulses, pressure, deformities, etc.
  • The range of motion, motor strength, and sensation.
The neurologic system
  • The use of muscles, ease of movement, coordination.
  • The person’s alertness, orientation, thought process.
The genitalia and rectum

(if indicated)

  • The skin and mucosa.
  • The urethra and other openings.

It is critical that nurses follow the policies and procedures of their employers. In order to do an assessment utilizing a certain approach, nurses must be properly trained in both the technique’s proper use and the data it produces.

Introduction to Health Observation and Assessment
Assessment Process

There are a variety of different targeted examinations that may be conducted, such as:

  • Blood glucose levels.
  • Blood laboratory studies.
  • Comprehensive neurological evaluation.
  • Diagnostic imaging studies.
  • Electrocardiogram (ECG) monitoring.
  • Height, weight, and Body Mass Index (BMI).
  • Mental health assessment.
  • Neurovascular function.
  • Pain assessment.
  • Sensory perception.
  • Skin assessment.
  • Urinalysis.

It is critical that nurses are conversant with any equipment that may be utilized in a patient’s evaluation. The following items may be included in this equipment (but are not limited to):

  • Scale.
  • Thermometer.
  • Watch with a second hand.
  • Sphygmomanometer.
  • Stethoscope.
  • Drape sheet.
  • Examination table.
  • Otoscope.
  • Opthalmoscope.
  • Speculum.
  • Tongue blade.
  • Penlight.
  • Examination gloves.
  • Ruler, tape measure.
  • Marking pen.
  • Percussion hammer.
  • Gauze.
  • Speculum.

When examining a patient, it’s critical to be well-organized and equipped with the tools you’ll need. It is critical that you establish a habit and practice it in order to gain confidence.

Documenting health observation and assessment findings

How should nurses document health observation and assessment findings?

Nurses must document, or record in writing format, the data they collect at each stage of the evaluation. This enables data to be utilized to (1) identify the patient’s clinical status and make appropriate treatment decisions, and (2) disseminate among the many experts engaged in the patient’s care.

Data can be captured in a variety of methods, which vary depending on the clinical situation and the organization. Documentation necessary, regardless of how data is recorded:

  • Be complete, accurate, concise, legible, and free from bias.
  • Record facts, without the use of non-committal language.
  • Be written contemporaneously, or as close to the time of collection as possible.
  • Include the name, signature, and designation of the nurse who created it.
  • Be unaltered; if errors are made, these must be struck through with one line and initialed.
  • Be kept securely, and in a way that protects the patient’s right to confidentiality.
  • Avoid using acronyms, abbreviations, jargon, and archaic terms.
  • Use short sentences and simple words.
  • Involve the patient and their significant others, and use language they understand.

“records must provide a detailed account of the assessment made, the care planned and given, and actions taken, including information shared with other health professionals,” according to the National Health Service’s (NHS, 2010: p. 2) CG2 – Record Keeping Guidelines.

It is a legal, ethical, and professional duty for nurses to create and maintain relevant documentation. The sort of examination and care that patients get is documented in their medical records. They’re also crucial clinical tools for ensuring continuity of treatment and making informed decisions.

Conclusion

This article has given you a general overview of health observation and evaluation. It started with a general summary of health observation and evaluation. The procedures for completing a head-to-toe evaluation, which includes a primary and secondary survey to gather data from a patient in an accurate, thorough, and systematic manner, have been outlined. Finally, this chapter discussed how to properly document (or record) data gathered during health observation and evaluation.

Frequently Asked Questions (FAQs)

1. What is health observation and assessment?

Introduction to Health Observation and Assessment
Steps of Health Assessment

A systematic procedure of collecting data about a patient is called health observation and assessment. This data is utilized to offer information on the patient’s state and to guide the proper care for that patient.

2. What are the types of assessment in nursing?

  • A complete health history and physical examination of a client: performed in order to determine all of the person’s health care concerns and needs. Usually done at the time of admission.
  • Problem-based/ focused health assessment: Collecting data relevant to a specific complaint in a problem-based or targeted health examination: Outpatient settings are common.
  • Rapid assessment: gathering information in order to give rapid, life-saving assistance to a patient. Frequently used in emergency situations.
  • Episodic/follow-up assessment: A nurse conducting an episodic or follow-up evaluation on a patient to collect data on a previously diagnosed condition. By evaluating changes in the patient’s health, the purpose is to evaluate how the patient has reacted to care.
  • Screening assessment: Data is collected with the goal of detecting the existence of a certain illness during a screening evaluation.

3. Why is culture important in health assessment?

A person’s culture encompasses more than just their ethnic heritage; it also encompasses how they live in and see the world. People that share a culture have similar values, beliefs, and attitudes on a variety of subjects, including health. Nurses must provide effective care to persons whose health practices, values, beliefs, and attitudes differ greatly from their own.

4. How do you perform a head-to-toe assessment?

This section introduces the concept of a ‘head-to-toe assessment,’ a physical examination that allows a nurse to examine a client from head to toe in a systematic and complete manner. Nurses analyze each bodily system in turn during a head-to-toe examination to generate a thorough overall grasp of the patient’s condition.

Introduction to Health Observation and Assessment

 

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