NURS 680B Comprehensive Health Assessment

Students will select a new “patient” (friend or family member) for whom they will perform and document a complete history. This will include a complete head-to-toe review of systems (ROS) and a complete head-to-toe physical examination. This will be documented in a SOAP note format.

The patient should be an adult over the age of 18 with a chief complaint. Please do not choose the same friend or family member from previous course assignments.

Document a working diagnosis and a minimum of 3 differential diagnoses. These are based on the chief complaint (CC) an history of present illness (HPI). All 3 diagnoses Working diagnosis and differential diagnoses must include pertinent positive and negative symptoms. You may also include known diagnoses, such as obesity or hypertension. These do not need pertinent findings.

NOTE: Do not use real names or initials or otherwise identify your “patient.” Failure to maintain privacy will result in a failing score

Assignment Details

The Subjective health history and Objective physical exam must contain all required elements as outlined in Jarvis Chapter 27 (except breast and genital exams) and the attached document. The Assessment, as well as the Plan, will be focused based on CC and HPI.

Read the rubric for the Comprehensive Health Assessment assignment carefully.

The assignment submission should be a single document that contains:

A complete subjective history

A complete objective examination

Working diagnosis with at least 3 differential diagnoses with pertinent findings for each

Plan of care that includes a discussion of the national guidelines for your diagnosis and health maintenance needs for your patient

A comprehensive health assessment gives nurses insight into a patient’s physical status through observation, the measurement of vital signs and self-reported symptoms. It includes a medical history, a general survey and a complete physical examination.

The general survey consists of a patient’s age, weight, height, build, posture, gait and hygiene. Nurses use health assessments to obtain baseline data about patients and to build a rapport with them that can ease anxiety and lead to a trusting relationship.

A comprehensive health assessment is generally conducted at the time of admission into an acute care facility or during the first visit to an outpatient clinic. When nurses perform an assessment, they may use techniques such as:

Inspection

This is the most frequently used method for assessment. Nurses look for indications of a health problem by using their eyes, ears and nose. They may inspect skin color, lesions, bruises or rashes as well as pay attention to abnormal sounds and odors.

Auscultation

Nurses listen to the sounds of the abdomen by placing the diaphragm or bell of a stethoscope on the bare skin of a patient.

Palpation

Nurses apply varying degrees of pressure on the patient with different parts of their hands. Palpation allows nurses to assess for texture, tenderness, temperature, moisture, pulsations and the presence of masses.

Percussion

Nurses firmly press on sections of a patient’s body with the distal part the middle finger on their non-dominant hand. The technique is used directly over suspected areas of tenderness to check a patient’s level of discomfort.

What Steps Are Involved In A Comprehensive Health Assessment?

Typically, a comprehensive assessment begins with documenting a patient’s health history before starting a physical exam. According to , the health history includes: the patient’s medical complaint, present state of health, past health record, current lifestyle, psychosocial status and family history.

The health history provides nurses with in-depth information about symptoms, childhood illnesses, related medical experiences and risks for developing certain diseases.

After the health history data is recorded, a physical is conducted which covers a review of the patient’s body systems. A head to toe examination includes assessments of the following:

Skin
Neurological function
Ears, eyes, nose and throat
Respiratory function
Cardiac-pulmonary system
Abdomen
Muscles and joints
Limbs, shoulders, hips, ankles and feet
Reproductive system
Nutrition

A thorough and accurate assessment is important because it helps differentiate the normal condition of the patient from the abnormal. And, a comprehensive health assessment establishes if a patient needs diagnostic testing or additional medical care.

How Can Earning A BSN Improve A Nurse’s Assessment Skills?

Nurses learn assessment skills in nursing school. An like the one offered by Eastern Illinois University (EIU) includes the course Advanced Nursing Health Assessment that prepares students to perform precise examination. The curriculum builds on a nurse’s basic nursing assessment proficiencies. Once nurses earn the BSN, they are prepared to give a comprehensive health assessment and apply the knowledge to make sound clinical judgements.

A comprehensive health assessment is a crucial component in the nursing practice. Without it, nurses can have a difficult time pinpointing a patient’s medical requirements. It is not enough for patients to tell nurses what is wrong. Instead, nurses need to rely on the observations they record from physical examinations to decide on a course of action. By completing a systematic and efficient assessment, nurses are able to communicate with patients and help them take measures to maintain or manage their health.