Foundations of Health Assessment

TL;DR

Health assessment is a systematic process to gather information about a patient's health status. It combines subjective data (what the patient tells you) and objective data (what you observe) to form a comprehensive picture. This information helps you make clinical judgments and plan patient care.

1. The Mental Model

Think of health assessment like detective work. You're gathering clues (data), both from the 'witness' (patient) and the 'crime scene' (physical exam), then piecing them together to understand the full story of their health.

2. The Core Material

Health assessment forms the bedrock of patient care. It's a continuous process that involves collecting data, using critical thinking to interpret it, and then making sound clinical judgments. It's not just about finding what's wrong; it's also about understanding a person's overall well-being, their strengths, and their functional abilities.

Components of Health Assessment

Photo by Thirdman on Pexels

There are two main types of data you'll collect:

• Subjective Data: This is what the patient tells you. It includes their feelings, perceptions, and concerns. You'll get this through a health history interview. Think symptoms, past medical history, family history, lifestyle, and psychosocial factors.
• Objective Data: This is what you observe, measure, or feel during the physical examination. It's quantifiable and observable. Think vital signs, appearance, physical findings, and laboratory results.

The Nursing Process and Assessment

Photo by RDNE Stock project on Pexels

Assessment is the first step of the ADPIE nursing