3 Comprehensive Health Assessment
Learning Objectives
At the end of this chapter, the learner will:
- explain the purpose of a comprehensive health assessment
- discuss the components of a comprehensive health assessment
- perform a comprehensive health assessment utilizing therapeutic communication
- utilize correct techniques and positioning in performing a comprehensive health assessment
- differentiate normal and abnormal assessment findings when performing a comprehensive health assessment
- document data obtained from a comprehensive heath assessment
Overview of this chapter
This chapter will provide information on the importance of a comprehensive health assessment, the variations of a comprehensive assessments, and a checklist in performing a head-to-toe physical assessment. Learning exercises are included to allow the learner to check and apply knowledge learned.
Purposes of a comprehensive health assessment
A comprehensive health assessment involves collection of subjective and objective data regarding the patient’s health. A health history is obtained, followed by a head to toe assessment. The nurse will vary the comprehensive assessment depending on clinical situations:
- Admission- The nurse performs an admission data base and initial head to toe examination when a patient is first admitted to a patient care unit, or when the patient is first seen in a healthcare facility. The subjective and objective data obtained provides a baseline health status of the patient for a particular time frame.
- Shift Assessment– The nurse will perform a follow up comprehensive assessment to update information obtained at admission. Sometimes also called a bedside assessment, it is performed at the beginning of each shift. This assessment will be shorter and less extensive, but the nurse will perform an interview to update subjective data and a head-to-toe assessment to update objective data. This type of assessment will provide a view of what changed or remained the same regarding the patient’s health situation.
- Emerging clinical situations– any change in patient status will require that the nurse perform a rapid head-to-toe assessment, obtaining both relevant subjective and objective information, patient’s hemodynamic status and the context.
Exercises: Review of previous concept(s)
Definition of health assessment ( subjective and objective data)
Type your exercises here.
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The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition. Any unusual findings should be followed up with a focused assessment specific to the affected body system. The patient may obtain a health history before the physical examination.
A physical examination involves collecting objective data using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). A head-to-toe examination checklist is presented below, but expe