What Is a Health Assessment?

Nurses often represent the first point of contact for patients at a health care facility. As such, it falls to the nurse to ascertain some baseline information about the patient’s condition and medical history, as well as other relevant data points that may direct the patient’s initial diagnosis and treatment. This process is called a health assessment. Health assessments can provide the basis for a patient’s entire clinical care experience.

Individuals who pursue a degree in nursing will learn what a health assessment is and develop a comprehensive sense of how to perform one with accuracy, empathy, and expediency. Additionally, they can master different types of assessments that are needed for unique clinical situations.

The Importance of Health Assessments

The term “health assessment” denotes the process by which a nurse seeks to gain relevant information about a patient and their condition. This information may provide insight into not just the patient’s physical condition but also the state of their mental and emotional health. Nurses arrive at this information by applying a combination of clinical skills, medical knowledge, and critical thinking abilities. 

After gleaning the necessary information, the nurse relays it to the attending physician or other members of the care team, and they use it to ensure they order the right diagnostic tests and consider the correct treatment plan for the patient. If the health assessment reveals the patient’s status to be precarious or urgent, it may also lead to the immediate administration of medication, first aid, or life support systems. Ultimately, health assessments play an essential role in the delivery of quality care, and in the development of effective treatment plans.

What Is a Health Assessment Meant to Determine? 

While different nurses may ask different questions during their health assessments, there are several common lines of inquiry. Some of the most common information included in a health assessment relates to the patient’s:

• Vital signs
• Overall health concerns, including any symptoms or pain they are currently experiencing
• Medications
• Allergies
• Medical history
• Habits involving tobacco products and alcohol consumption
• Nutritional habits and basic diet
• Physical activity, as well as sedentary activity, such as how much time they spend at a desk or on the couch each day
• Emotional or mental health concerns, including any symptoms of depression or anxiety

What Are the Different Types of Health Assessments?

Health assessments are varied and there are several types, geared toward different types of information. The type of health assessment required can depend on the patient’s needs as well as factors such as whether a day shift or night shift nurse is performing it.

Initial Assessment

The initial assessment may sometimes be called triage, and it represents the nurse’s opening questions to help determine the source and nature of the patient’s problem. The information obtained during the initial assessment is used to ascertain what the next stages of assessment should be. The information that’s gleaned during the initial assessment is foundational to the rest of the treatment process, making this an essential step in the patient’s journey.

Focused Assessment

A focused assessment happens only after the initial assessment and is more targeted toward the specific problem that’s been identified. During the focused assessment, the nurse may pay special attention to the patient’s vital signs and overall stability, as well as their level of physical discomfort.

Emergency Assessment

During emergency or life-saving situations, nurses need to perform rigorous and expedient assessments of the patient’s airway and breathing, as well as their blood flow and circulation.

Ongoing Assessment

Ongoing assessments, also called time-lapsed assessments, may be performed days, weeks, or even months after the initial treatment plan has begun. These assessments are intended to verify that the treatment is working as intended and to address any unintended side effects.

Tips for Performing Health Assessments

Performing effective health assessments is an essential skill for nurses to develop, and should be considered as important as mastering the use of state-of-the-art nursing technology . Guidelines to ensure effective assessments include:

• Connect: While nurses have limited time during initial assessments, they need to do whatever is possible to form a personal connection with the patient. Being friendly, candid, and empathetic can go a long way toward making the rest of the patient care process go more smoothly.
• Document: Nurses should ensure they clearly and accurately record all the information the patient provides.
• Evaluate: Nurses need to carefully consider all the information the patient has provided before deciding what the next step should be in the patient’s care.
• Confirm: Nurses should repeat what the patient has reported back to them, to confirm that the nurse understood what the patient said.

What Is a Health Assessment? Learn More About Key Nursing Skills

Knowing what a health assessment is and how to conduct one are essential skills for any nurse to master. Knowing how to perform different types of assessments ensures nurses provide targeted and efficient care, and can also help keep patients safe throughout their treatment. 

Individuals with a bachelor’s degree in a field other than nursing who are interested in moving into a career as a nurse should consider enrolling in The University of Tulsa’s Accelerated Bachelor of Science in Nursing (ABSN) program. Explore how the program can provide you with the foundation for a successful nursing career by providing you with vital skills in patient intake, triage, and care.

Recommended Readings

The Most Important Leadership Skills for Nurses

The Benefits of Making a Career Change to Nursing

How to Become a Research Nurse

Sources:

Agency for Healthcare Research and Quality, Health Assessments in Primary Care

FreshRN, “Types of Nursing Assessments Every Nurse Needs to Know”

Indeed, “The 4 Types of Nursing Assessments”

Nurseslabs, Head-to-Toe Assessment: Complete Physical Assessment Guide

StatPearls, “Nursing Admission Assessment and Examination”

Super Health Chatswood Medical Centre, “Learn the Purpose of Health Assessment and Its Benefits”