Health Assessment

A thorough patient health assessment is carried out when the patient is admitted to a health facility or an outpatient medical center. The analysis enables the medical practitioners to understand the patient’s body condition. This is established through acts like inspection and analysis of imperative and reported signs and symptoms. The patient's health history and current medications are acquired, coupled with physical scrutiny. Building rapport with the patient is essential in this process since it eliminates any form of tension by the patient. Several methods can be used by medical practitioners in obtaining findings for the assessment. These may be through inspection, palpitation, or impact, among others. Specific steps are followed in the development of a patient's assessment. It starts with the patient's history, followed by the physical exam, carried out in a head-to-toe format. Thus, the data and information obtained in these assessments enable medical practitioners to diagnose patients accurately. Moreover, the need for additional medical care can be identified and prescribed where necessary.

Section A

One has to familiarize oneself with the key terms for a deeper comprehension of the subject matter. According to the World Health Organization’s (WHOs) constitution, health is a situation of total physical, psychological, and social welfare (n.d). In contrast, assessment is gathering and reviewing information to enhance quality, drafting, and decision-making ("Assessment: Definition and Overview | Fredonia.edu," 2022). Health assessment is a process aimed at establishing data concerning a patient's biological, mental, and social aspects to establish a diagnosis that is required in developing a nurse's care routine. This action aims to ensure an improved health status of the patient ("Comprehensive Health Assessments in Nursing," 2019). The nurse can learn a lot about the patient's worries, symptoms, and general health through the assessment. Hence the underlying illnesses and health concerns can be highlighted and addressed by the nurse.

From the thorough evaluation conducted on patients during an assessment, the information acquired by nurses is recorded and maintained. The nurses establish diagnoses based on the data and information gathered from the patient. Formal diagnoses considered relevant to the individual's signs and symptoms are confirmed and guided by the appropriate medical association (Gleason, 2022). The nurses use these records to set specific goals for the patient. For instance, a nurse can make a short-term goal of providing pain relievers to the patient if the latter is experiencing any form of pain. Moreover, long-term goals like estimating the duration to full recovery can be set (Gleason, 2022). Therefore, the nurse can plan for the patient's care to achieve the required goals. For instance, the nurse can determine the frequency of some medical routines that will aid the patient's recovery at the anticipated time.

Section B

The nursing process is dynamic, engaging, teamed up, and globally similar in application. It comprises six steps: assessment, diagnosis, outcome identification, planning, implementation, and evaluation (Hussein, 2020). The assessment stage is a nurse's first step on a patient at a medical facility. The main aim of this stage is to carry out several activities geared towards creating the foundation for the treatment of the patients. These activities include; a structured and constant collection of data, categorizing, assessing, and arranging the data obtained; and the documentation and conveyance of the information gathered (Toney-Butler & Unison-Pace, 2021). A nurse must demonstrate their thinking capabilities at this stage to establish a decision that would guide them in developing a care plan for the patient (Toney-Butler & Unison-Pace, 2021). In addition, the evidence-based practice should be incorporated into the established patient care routines. This way, the patient gets treated with consideration of their cultural, religious, and physiological inclinations and needs (Toney-Butler & Unison-Pace, 2021). For these to be followed and adhered to, the patient’s information will have to be established, emphasizing the importance of the health assessment stage.

The information obtained is social, spiritual, physical, and mental related. This could be reported directly by the patient, care person, a family member, or a spouse and may depend on the patient's status (Lilley et al., 2022). In addition, a third party may provide an incapacitated patient's information. This ensures that the knowledge acquired in the assessment stage is credible and reliable. This stage establishes objective and subjective data (Lilley et al., 2022). Objective data can be seen and quantified based on the client’s health situation (Lapum et al., n.d.). A patient’s posture, feeling of a lump, or listening to the patient’s heartbeat are all examples of objective data. This assessment is carried out after collecting the subjective data, which is the self-reported information provided by the patient. The objective data's importance is distinguishing between usual and unusual findings (Lapum et al., n.d.). Therefore, a clinical decision is approached by combining the two forms of data acquired through assessment.

Section C

Patient profiling is essential in establishing a tailored care approach for the patient. For the case of master B, a six-month-old child, the assessment will be centered on determining the growth process of the child as well as the mother's condition after birth. This forms a part of the post-natal care for the patients. Since the mother is an immigrant, the nurse should ensure they can understand each other with an identified common language. Once this is achieved, the nurse can go ahead and obtain a self-reported assessment from the mother concerning the two's progress since the child's birth. First, the nurse has to confirm the receipt of the appropriate vaccines for the child of that age. Then, any due immunizations must be administered ("Checkup Checklist: 6 months old", 2021). Next, the infant's abnormal feeding habits must be identified and corrected. Since the child is at the age where solid food transition begins, the nurse can advise on the appropriate foods to introduce to the child. If the mother has started introducing these foods, any effects or challenges faced during this process can be addressed to the nurse. Moreover, the medical practitioner should be keen on assessing the infant's developmental progress ("Checkup Checklist: 6 months old", 2021). Certain milestones are expected of this particular age of children, for instance, the development of the baby teeth. Abnormal aspects like frequent cries by the child and tendencies to bite on objects may signify the onset of this milestone. Resultantly, the nurse should communicate to the mother about the possible remedies for the child. The infant's capability to roll over or sit for short periods is also established ("Checkup Checklist: 6 months old", 2021). The child's weight also matters in this assessment since it proves whether the child is feeding well. Therefore, based on information gathered from the evaluation, the nurse can identify the child's presence or lack of abnormalities, thus aiding in the diagnosis.

The case of Mr. A, a seventy-six-year-old man, will have an assessment approach based on geriatrics syndrome. This is a health issue associated with old age, where some body systems fail to function correctly due to reduced ligament strength or immunity. These may cause huge impacts on the older people's quality of life and cause disabilities (Spirgiene & Brent, 2018). The assessment varies in three aspects; it concentrates on the older man with complex issues, pays attention to the patient's functional status, and measures the degree of weakness in the patient. The underlying medical conditions, mental health, and functionality capability are identified in the assessment to establish customized methods of care for the patient (Spirgiene & Brent, 2018). The ability of the older adult to adhere to medication and remember his health obligations should be established. The caregiver's and daughter's assistance during her visit can replace the lack of this ability at the aged care facility. Moreover, the degree of his osteoporosis should be identified to facilitate actions like the need for support while walking. Therefore, the assessment can determine the degree of frailty, and corrective measures can be established to enhance the quality of life.

Health assessment has proven to be an essential step for nurses since it enables them to collect information concerning the patient. This information is documented and analyzed for the provision of nursing diagnoses. Through these, they can lay out treatment and care plans for their patients, ensuring a successful recovery. The information obtained provides a basis for creating rapport between the nurse and the patient. It provides a reference for all the medical practitioners attending to the patient in a given medical facility. Moreover, the ability to distinguish between a patient's normal and abnormal characteristics is enhanced; thus, measures can be developed to mitigate any acquired abnormalities. The approach of various medical cases for assessment is considered different based on the individuals' age, medical condition, and social nature. Ability to effectively assess the patients plays a significant role in the success of the diagnosis and treatment part for the nurses. Evidence based practice must be followed by the nurses to ensure a holistic treatment method while considering factors like cultural and ethnic differences. Therefore, nurses must consider the health assessment aspect with great depth and seriousness. Furthermore, they should aim to improve their assessment skills to succeed in their treatment endeavors.

References

Assessment: Definition and Overview | Fredonia.edu. Fredonia.edu. (2022). https://www.fredonia.edu/about/campus-assessment/assmtinforesources/overview.

Checkup Checklist: 6 months old. HealthyChildren.org. (2021). https://www.healthychildren.org/English/ages-stages/Your-Childs-Checkups/Pages/Your-Checkup-Checklist-6-months-old.aspx.

Comprehensive Health Assessments in Nursing. Texas A&M International University Online. (2019). https://online.tamiu.edu/articles/rnbsn/importance-of-comprehensive-health-assessments.aspx.

Constitution of the World Health Organization. Who. int. https://www.who.int/about/governance/constitution.

Hussein, E. (2020). Implementation of Nursing Process Program and Assessment Factors Affecting Nurses’ Knowledge and Performance. Novelty Journals. https://www.researchgate.net/publication/343413919_Implementation_of_Nursing_Process_Program_and_Assessment_Factors_Affecting_Nurses'_Knowledge_and_Performance.

Gleason, B. (2022). Nursing Care Plans Explained | NurseJournal.org. Nurse Journal. https://nursejournal.org/articles/nursing-care-plans-explained/.

Lapua, J., Hughes, M., St-Amant, O., Garcia, W., Verkuyl, M., & Petrie, P. et al. Physical Examination Techniques: A Nurse's Guide; Objective Assessment. Pressbooks.library.ryerson.ca.  https://pressbooks.library.ryerson.ca/ippa/chapter/chapter-1/.

Lilley, L. L., Collins, S. R., & Snyder, J. S. (2022). Pharmacology and the nursing process E-Book. Elsevier health sciences. http://ndl.ethernet.edu.et/bitstream/123456789/91741/1/Pharmacology%20and%20the%20Nursing%20Process%20.pdf

Spirgiene, L., & Brent, L. (2018). Comprehensive geriatric assessment from a nursing perspective. Fragility Fracture Nursing, 41-52. https://library.oapen.org/bitstream/handle/20.500.12657/23127/1007029.pdf?sequence=1#page=57

Toney-Butler, T., & Unison-Pace, W. (2021). Nursing Admission Assessment and Examination. Ncbi.nlm.nih.gov.  https://www.ncbi.nlm.nih.gov/books/NBK493211/.