Health Assessment Unit 1 Objectives Worksheet Mastering the Essentials

1. Effective Data Collection and Interviewing Techniques

When gathering information throughout a health assessment, one must ascertain the distinction between subjective and objective data:

Subjective data consists of information that a patient would give through reports or feelings, like pain, dizzy, or tired.

• Facilitating Conversation: Use strategies like open-ended questions to encourage dialogue and close-ended questions to clarify specifics.

Techniques to Use:

Comfort with Silence: Give the patient time to think and talk.

Reflection: This involves reiterating what has been said by the patient in order to acknowledge his understandings and to further encourage him to elaborate.

Conducive to the Narrative: Lead the conversation without dominating it.

Clarification: Ask for clarification if anything is unclear.

Objective data may be described as the data that you, the nurse, can see for yourself, through:

Inspection: What you visually check.

Palpation: feels for abnormalities.

Percussion: Tapping to outline underlying structures.

Auscultation: Listening with a stethoscope.

Remember that it is always necessary to ask for permission before touching the patient in an attempt to build trust and maintain professionalism.

Pitfalls of Interviewing and Data Gathering

Providing false assurance

Giving unsolicited advice

Using authority or avoidance language

Distancing yourself emotionally

Using professionals' jargon or leading questions

Sometimes, interrupting or talking too much

Asking “why” questions that come off as accusatorial

For more tips on effective data collection and interviewing techniques, reach out to us.

2. Focused Clinical Findings: Priority Levels Explained

The art of prioritization among nurses involves knowing which clinical finding comes first. Here’s a breakdown:

ABC’s

1. Airway
2. Breathing
3. Circulation

These are the most critical and must, as a matter of priority, receive attention if the survival of the patient is to be assured.

PPP’s

1. Pee
2. Poop
3. Pain

These concern problems of an elimination nature or acute pain that need attention, but not immediate need.

Other Concerns

1. Lack of knowledge
2. Problems in mobility
3. Family coping issues
4. Mental changes include
5. Infection risk
6. Abnormal laboratory studies
7. Risk of safety or security concerns

Proper prioritization insures that the patient receives the right level of care in a very timely manner. Check out more prioritization examples at this course page.

3. Understand Evidence-Based Practice

Evidence-based practice integrates best evidence available with clinical expertise, considering the preferences and values of each patient. This approach:

• Has been repeatedly practiced by him and fine-tuned for the best outcome.
• Is like following a “recipe” for optimal patient care.

EBP is the basis for effective nursing; it ensures that the care is current but that it is based upon the very best research available. Learn more about how you can apply EBP in your clinical practice at NSG 3160.

4. Types of Health Assessments Nurses Will Obtain and Document

Complete or Total Health Check-up:

• Provided in a primary care setting-for example, private practice, college health services, or by visiting nurses.
• It provides a general overview of the patient’s health status.

Problem-Focused or Focused Assessment:

• A “mini” database dealing with one specific problem.
• Used in all healthcare settings to focus on acute issues.

Follow-Up Assessment:

• Assesses the status of a previously identified problem.
• Completed on a regular basis in all settings to show progress or changes.

Emergency Evaluation:

• It involves a quick gathering of important information.
• Used in emergency settings to address urgent needs.

5. Examples of Scenarios for Various Health Assessments

• Total or Complete Health Check Up: This is done in an annual checkup in a private practice setting.
• Focused or problem-centered examination: done when a patient presents to the ER with acute chest pain.
• Follow-Up Test: It is employed in a clinical setting to monitor the blood sugar level of a diabetic patient continuously.
• Emergency Assessment: This is an immediate assessment that is conducted for a patient who comes to the ER with severe trauma.

An understanding of such fundamentals lays the foundation for health assessment. Accordingly, a nurse professional can endeavor to improve the delivery of nursing care to their clients. More information and comprehensive guidelines on health assessment practices may be found at acenursingprogram.com.