HEALTH ASSESSMENT INTRODUCTION

• Explain the purpose and scope of health assessment in nursing practice.
• Describe the sequence of a patient-centred clinical interview.
• Demonstrate respectful communication that promotes trust and participation.
• Identify key components of a comprehensive health history.
• Organise subjective information using Gordon’s Functional Health Patterns.
• Explain how assessment findings contribute to nursing diagnosis, planning, intervention, and evaluation.
• Document collected information clearly, accurately, and confidentially.

Health assessment is a structured, systematic process for collecting, organising, and interpreting information about a person’s health status. It is the crucial first step in the nursing process and forms the foundation of all subsequent patient care.

• Subjective data: What the patient reports (e.g., feelings, pain levels, health history).
• Objective data: What the nurse observes or measures (e.g., vital signs, physical exam findings, laboratory results).
• Health history and review of systems: A comprehensive background check of past and current medical issues.
• Physical examination and vital signs: The hands-on, clinical measurement of the patient's physical state.
• Recognition of normal and abnormal findings: Utilizing clinical judgment to distinguish between expected health baselines and pathological deviations.

• Establishes a baseline: Provides a starting point to measure future changes in the patient's condition.
• Identifies actual and potential health problems: Allows the nurse to see what is currently wrong and anticipate what could go wrong (risk factors).
• Supports clinical reasoning and prioritisation: Helps the nurse decide which issue is the most life-threatening or urgent to address first (e.g., Airway before Pain).
• Guides the nursing care plan: Assessment data dictates the specific nursing diagnoses and interventions required.
• Provides information for communication and continuity of care: Ensures that when a patient is handed over to another shift or department, their full health picture is clearly communicated.

Think of health assessment as a continuous clinical reasoning cycle. It is not a one-time event, but an ongoing process throughout patient care.

1. Prepare: Environment, privacy, equipment.
   • Elaboration: Before seeing the patient, ensure the room is quiet, well-lit, and at a comfortable temperature. Gather all necessary tools (stethoscope, thermometer, penlight) to avoid interrupting the interview later.
2. Communicate: Introduce, identify, explain, consent.
   • Elaboration: Establish a therapeutic relationship immediately. State your name, confirm the patient's identity (using two identifiers), explain exactly what you are going to do, and ask for their permission to proceed.
3. Collect: History, observations, measurements.
   • Elaboration: Gather both subjective (interviewing) and objective (physical exam, vital signs) data methodically.
4. Analyse: Recognise patterns and abnormal findings.
   • Elaboration: Group related data together. If a patient has a cough, fever, and crackles in the lungs, these findings form a respiratory pattern indicative of potential infection.
5. Prioritise: Identify urgent and important concerns.
   • Elaboration: Sort findings by acuity using frameworks like ABCDE (Airway, Breathing, Circulation, Disability, Exposure) or Maslow's Hierarchy of Needs.
6. Act & Document: Care plan, report, record, reassess.
   • Elaboration: Implement necessary interventions, accurately chart your findings so the entire healthcare team is informed, and continuously re-evaluate the patient to see if your interventions worked.

Communication is a highly technical clinical skill—not just casual conversation. It is the primary tool used to gather subjective data and build a trusting nurse-patient relationship.

A consistent, professional opening reduces patient anxiety and dramatically improves the quality of the information you receive.

1. Prepare the environment: Ensure privacy, comfortable seating (preferably eye-level), appropriate lighting, and minimal interruptions.
2. Introduce yourself and your role: "Hello, my name is Sarah, and I am the nursing student who will be assessing you today."
3. Confirm patient identity: Use appropriate identifiers (Name and Date of Birth).
4. Explain the purpose of the interview and what will happen: "I need to ask you some questions about your health history and why you came in today so we can plan the best care for you. This will take about 15 minutes."
5. Establish consent and invite questions: "Is it okay if we begin? Do you have any questions before we start?"
6. Begin with a broad, patient-centred opening question: "What brings you to the clinic today?" or "How have you been feeling lately?"
7. Allow the patient to describe the main concern in their own words: Let them speak without interruption for the first minute before narrowing down the questions.

Small communication errors can severely reduce the quality of the assessment and damage rapport.

During the interview, move logically from the patient’s main concern to a structured, detailed description of the problem.

• Record the patient’s main reason for seeking care.
• Use the patient’s own description in quotes where appropriate (e.g., Patient states, "It feels like an elephant is sitting on my chest.").
• Establish exactly when the problem started.

To thoroughly explore the presenting complaint, nurses often use acronyms like PQRST or SOCRATES. The core elements to gather include:

• Onset and progression: When did it start? Was it sudden or gradual? Is it getting worse?
• Previous facility/hospital visits: Have they sought care for this specific issue before?
• Treatment already tried: Have they taken any over-the-counter medications, home remedies, or prescribed drugs for this? Did it help?
• Relieving and aggravating factors: What makes it better? What makes it worse?
• Associated symptoms: Are there other issues accompanying the main problem? (e.g., If the complaint is a headache, do they also have nausea or visual changes?)
• Relevant system review and possible clinical considerations: Exploring related body systems to rule out complications.

Use a logical sequence while allowing the patient’s story to emerge organically.

1. Patient identification and demographic information: Name, age, gender, occupation, marital status.
2. Presenting complaint and history of presenting complaint: (As detailed above).
3. Past medical history (PMH): Chronic illnesses (diabetes, hypertension), childhood illnesses, previous infectious diseases.
4. Past surgical and hospitalisation history (PSH): Operations, dates, trauma, obstetric history for females.
5. Medication history and allergies: Current prescriptions, OTC meds, supplements, and true allergic reactions (differentiate side effects from anaphylaxis).
6. Family history: Genetic risk factors (heart disease, cancer, mental health disorders in first-degree relatives).
7. Social and lifestyle history: Smoking, alcohol, drug use, diet, exercise, living arrangements, occupational hazards.
8. Functional assessment and daily activities (ADLs): Ability to bathe, dress, eat, and mobilize independently.
9. Review of systems (ROS): Head-to-toe questioning of symptoms.
10. Patient perspective: Exploring the patient's concerns, expectations of the visit, and their understanding of their health condition.

A focused review helps identify symptoms that may not have emerged in the opening story. Use relevant questions rather than mechanically asking every possible symptom if it doesn't fit the clinical picture.

• Respiratory: Cough, sputum production (color/amount), dyspnoea (shortness of breath), chest symptoms, history of asthma/COPD.
• Cardiovascular: Chest symptoms (pain/pressure), palpitations, orthopnea, swelling (oedema) in the lower extremities.
• Gastrointestinal: Appetite changes, nausea/vomiting, abdominal symptoms (pain/bloating), bowel/stool changes (diarrhoea, constipation, melena).
• Neurological: Headache, dizziness, vertigo, seizures, numbness, tingling, or other neurological symptoms.
• Musculoskeletal: Joint pain, stiffness, weakness, movement problems, history of fractures.
• Skin: Rash, itching (pruritus), changes in moles, dryness, or colour changes.
• ENT (Ear, Nose, Throat): Hearing loss, tinnitus, nasal congestion, discharge, oral lesions, sore throat, difficulty swallowing (dysphagia).

Created by Marjorie Gordon, this is a highly effective framework for organising assessment information across major areas of health and functioning. It supports holistic assessment rather than focusing strictly on the medical disease model.

• Provides a structured way to avoid missing important areas of the patient's life.
• Helps connect physical symptoms with function, behaviour, and social context.
• Supports holistic assessment (treating the whole person, not just the disease).
• Can be adapted according to the patient’s specific condition, age, and clinical setting.

It is vital to keep the two types of information distinct in your documentation and clinical reasoning.

Assessment is the foundation of the entire remaining nursing process. Clinical reasoning depends entirely on accurate, relevant, and well-documented assessment data. If the assessment is flawed, the diagnosis, planning, and interventions will also be flawed.

Golden Rule: Document what was obtained—not what you assume. If it isn't documented, legally, it wasn't done.

• Record information clearly, accurately, and objectively. Avoid vague terms like "normal" or "good".
• Use appropriate clinical terminology, but include the patient’s own words in quotation marks when important (e.g., Patient states, "I feel like I'm drowning").
• Strictly separate reported symptoms (subjective) from observed or measured findings (objective).
• Record relevant positive findings (symptoms the patient has) AND negative findings (symptoms the patient denies having, which rules out certain conditions).
• Document the exact date, time, and other required identifiers according to the clinical setting's protocol.
• Protect confidentiality and avoid unnecessary identifying details if using cases for educational purposes.
• Communicate significant or urgent findings promptly through the appropriate clinical channel (e.g., verbally reporting critical lab values to the physician immediately, not just writing it in the chart).

Scenario: A patient presents with a new health complaint. Your task is to begin the interview and establish the main concern. Do not rush to a diagnosis. Start broadly, then clarify the history using focused questions.

• How will you introduce yourself?
• What will you say about privacy and the purpose of the interview?
• What open-ended question will you use first?
• Which follow-up questions will clarify onset, progression, and associated symptoms?
• How will you summarise what the patient has told you to ensure accuracy?

• A. Therapeutic introduction: Pair practice—introduction, identity confirmation, explanation, and privacy.
• B. Opening question: Practise using an open-ended question and demonstrating active listening.
• C. Focused history: Move from the presenting complaint to the History of Present Illness (HPI) using specific follow-up questions.
• D. Gordon’s patterns: Organise selected clinical information under the relevant functional health patterns.
• E. Documentation: Write a concise subjective assessment note from a short case study.
• F. Feedback: Engage in peer/instructor feedback using the competency scale: Observe / Practise / Simulate / Competent / Independent / Review.

• Health assessment is systematic, patient-centred, and continuous.
• Good, therapeutic communication is absolutely essential for accurate assessment.
• Always start with the patient’s story (open-ended), then clarify with focused questions.
• Use a structured health history format to ensure important areas are not missed.
• Gordon’s Functional Health Patterns provide an excellent framework for holistic assessment.
• Accurate, objective documentation supports clinical reasoning, safe nursing care, and continuity across shifts.
• Always fiercely protect patient privacy, dignity, and confidentiality.

• Reflect: Name one communication skill improved today. Which part of the health history needs more practice? Name one way to protect patient dignity and privacy.
• Prepare for practice: Review the health history sequence. Practise open-ended and focused questions. Review Gordon’s Functional Health Patterns. Bring questions from skills practice to the next session.