Question

what principles or guidelines you would take into consideration prior to undertaking a health assessment?

Answer 1

Health assessment is a systematic, deliberative and interactive process by which nurses use critical thinking to collect, validate, analyze and synthesize the collected information in order to make judgement about the health status of individuals, families and communities. The purpose is to gather baseline data about the patient's health status, suppliment, confirm or rebute data from history, identify and confirm nursing diagnosis, to make clinical judgement about a patients changing health status and management and evaluate the outcome of care.

Documentation is very important in health assessment, establish a trust and caring relationship to avoid malpractice claim. Inform each step of physical assessment process to the client, all assessment and procedures including injury during the physical assessment must be documented completely. Institutional policy regarding the patient injury in the work place must be followed.

Principles In planning and performing health assessment, the nurse should consider the following:

1. An accurate and timely health assessment provides foundation for nursing care and intervention.

2. Go for a comprehensive assessment incorporates information about a client’s physiologic, psychosocial, spiritual health, cultural and environmental factors as well as client’s developmental status.

3. The health assessment process should include data collection, documentation and evaluation of the client’s health status.

4. All documentation should be objective, accurate, clear, concise, specific and current.

5. Health assessment is practised in all healthcare settings whenever there is nurse-client interaction.

6. Information gathered from health assessment should be communicated to other health care professionals in order to facilitate collaborative management of clients and for continuity of care.

7. Keep the confidentiality of the client.