Patient health assessments are essential nursing responsibilities. They are a critical component of every care plan, track status change and goal progression. To conduct accurate assessments, nurses must have strong attention to detail and a deep understanding of body systems. Nurses should continue to expand and refine their assessment skills throughout their careers.
An advanced nursing degree, like a Registered Nurse (RN) to Bachelor of Science in Nursing (BSN) program, can equip healthcare professionals with necessary health assessment skills.
Why Must Nurses Have Strong Health Assessment Skills?
Health assessments form the basis of the patient care plan and way to collect information on vital signs, pain levels, mobility levels, personal hygiene and more. Assessments help nurses objectively identify the unique needs and concerns of each patient as well as any potential barriers to care that may affect compliance and outcomes. They then use these assessments to supply physicians and other healthcare providers with the information necessary to develop appropriate treatments and interventions.
What Types of Health Assessments Do Nurses Perform?
Nurses perform several different health assessments, though it typically varies based on the setting and patient demographic. Some common assessments include:
Comprehensive or complete health assessment: Nurses collect a patient’s full health history and complete a physical exam. This type of assessment is generally conducted when a patient is admitted to a hospital or long-term care facility or for new patient encounters at physician offices and outpatient clinics.
Comprehensive holistic health assessment: To provide patient-centered care across the lifespan, comprehensive holistic health assessments are an increasingly preferred method. It incorporates general assessment techniques with a detailed review of the patient’s overall, lifelong risk profile and the influence of cultural, sociological and familial attributes.
Interval or abbreviated health assessment: Shorter than a comprehensive assessment, nurses rely on an interval assessment when the patient is already under their care. These are performed at shift changes, when the patient is transferred in-house to another unit or for follow-up visits at a physician’s office.
Problem-focused assessment: If a possible health issue is identified during a comprehensive assessment, nurses may also perform a problem-focused assessment to dig deeper into the concern. This is used only after a comprehensive evaluation is completed and a baseline is established. It is helpful when a patient develops a new symptom or experiences a change in status.
Special population assessment: Certain populations — such as pregnant women, infants and children, and the elderly — warrant targeted assessments that consider their specific life stage.
What Skills Help Nurses Perform Accurate Health Assessments?
Conducting health assessments will be a more fruitful endeavor if nurses establish a sense of trust and rapport with their patients. They should explain what they are doing and why, including how the assessment can improve the patient’s health. Individuals are more likely to share their symptoms and health concerns if they feel valued and seen as unique individuals.
Nurses must also have well-developed physical examination skills, such as percussion and auscultation, and know which findings are within normal limits and those that demand further investigation. This requires a solid knowledge of anatomy and physiology, extensive clinical expertise and an understanding of body language and nonverbal cues. A commitment to patient-centered care is key, too.
A Vital Skill Set
Although health assessments are performed regularly and routinely, they must be conducted and documented with great thoroughness and attention to detail. Nursing assessments inform each step of the patient’s care plan. Therefore, nurses have a tremendous responsibility to ensure they have the necessary skill sets to perform accurate evaluations for all patients.