Discussion: The Professional Nurse and the Comprehensive Health Assessment

Discussion: The Professional Nurse and the Comprehensive Health Assessment

Discussion: The Professional Nurse and the Comprehensive Health Assessment

In this discussion, analyze the components of a comprehensive health assessment and explain the role of the professional nurse in this process. In an initial assessment, how would you interact with a patient who had never seen a healthcare provider before? What kinds of data would you need to collect? Describe which specific techniques you would utilize to collect patient data.

Discussion: The Professional Nurse and the Comprehensive Health Assessment

In response to two of your classmates’ posts, compare and contrast the data collection techniques you described in your post. What are the advantages or disadvantages in the specific data collection techniques used?

To complete this assignment, review the Discussion Rubric document.
In this discussion, analyze the components of a comprehensive health assessment and explain the role of the professional nurse in this process.

A comprehensive health assessment is complete and thorough assessment.  A health history would be completed, which would include previous diagnosis ‘or illnesses, medications, allergies, surgical history, past hospitalizations, family history and perhaps their beliefs and wishes of how they want to be cared for.  Additionally, a complete head to toe physical assessment would be completed at the time of the exam.  This is a time to document and focus on objective data.

In an initial assessment, how would you interact with a patient who had never seen a healthcare provider before?

An initial assessment with a patient that has not seen a healthcare provider before is important.  The interaction with you is the first they will have.  Building trust with the patient is important.  Obtaining trust is important, the patient needs to feel safe talking to you and know that they can trust you in what they tell you and that you will take care of them. Using therapeutic communication, empathy and excellent verbal and nonverbal communication skills will help to build the trust for future encounters.  You should communicate in a way that is nonjudgmental, especially if the patient has a different culture, ethnicity or beliefs than yourself. Allowing the patient to ask any questions and voice any concerns is important.  Explaining to the patient everything that you intend to do and ask permission before doing it is also important. Reassurance should be given, as a patient that has never been to a provider before will be nervous and may come with high anxiety.  A patient that has decided to seek care is the perfect opportunity for the professional nurse to provide education about preventative health measures.

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What kinds of data would you need to collect? Describe which specific techniques you would utilize to collect patient data.

Initial data collection for the new patient would include a complete health history.  This would be collecting subjective data by asking the patient about known family history, previous health problems or illness, medications they may take, allergies, surgeries, risk behaviors such as sexual, alcohol, tobacco and recreational drug use and lifestyle habits. It is important during the verbal part of the assessment that you use therapeutic communication. “In therapeutic communication, the interaction focuses on the patient and the patient’s concerns.” (Jensen, p. 18)

After collecting the subjective data, you would want to complete a head to toe assessment and collect your objective data.  Before beginning your exam, hand hygiene is important to remember, letting the patient know each area you are going to palpate, percuss, inspect or auscultate is also important.  All information collected, both subjective and objective should be document accurately and timely in the patient electronic medical record.

Undergraduate Discussion Rubric

Overview
Your active participation in the discussions is essential to your overall success this term. Discussion questions will help you make meaningful connections
between the course content and the larger concepts of the course. These discussions give you a chance to express your own thoughts, ask questions, and gain insight from your peers and instructor.

Directions
For each discussion, you must create one initial post and follow up with at least two response posts.

For your initial post, do the following:
• Write a post of 1 to 2 paragraphs.
• In Module One, complete your initial post by Thursday at 11:59 p.m. Eastern.
• In Modules Two through Eight, complete your initial post by Thursday at 11:59 p.m. of your local time zone.
• Consider content from other parts of the course where appropriate. Use proper citation methods for your discipline when referencing scholarly or popular sources.

For your response posts, do the following:
• Reply to at least two classmates outside of your own initial post thread.
• In Module One, complete your two response posts by Sunday at 11:59 p.m. Eastern.
• In Modules Two through Eight, complete your two response posts by Sunday at 11:59 p.m. of your local time zone.
• Demonstrate more depth and thought than saying things like “I agree” or “You are wrong.” Guidance is provided for you in the discussion prompt.

Rubric

Critical Elements Exemplary Proficient Needs Improvement Not Evident Value
Comprehension Develops an initial post with an organized, clear point of view or
idea using rich and significant detail
(100%) Develops an initial post with a point of view or idea using adequate organization and
detail (85%) Develops an initial post with a point of view or idea but with some gaps in organization and
detail (55%) Does not develop an initial post with an organized point of view or idea (0%) 40
Timeliness N/A Submits initial post on time (100%) Submits initial post one day late (55%) Submits initial post two or more days late (0%) 10
Engagement Provides relevant and meaningful response posts with clarifying
explanation and detail (100%) Provides relevant response posts with some explanation
and detail (85%) Provides somewhat relevant response posts with some
explanation and detail (55%) Provides response posts that are generic with little
explanation or detail (0%) 30

Critical Elements Exemplary Proficient Needs Improvement Not Evident Value
Writing
(Mechanics) Writes posts that are easily understood, clear, and concise using proper citation methods
where applicable with no errors in
citations (100%) Writes posts that are easily understood using proper
citation methods where applicable with few errors in
citations (85%) Writes posts that are understandable using proper citation methods where
applicable with a number of
errors in citations (55%) Writes posts that others are not able to understand and does not use proper citation
methods where applicable (0%) 20
Total 100%

Chapter 2: Obtaining a Health History
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Introduction

The collection of a health history from a patient – that is, subjective data which focuses on the patient’s symptoms – is the first step in health observation and assessment, and is a fundamental skill for nurses working in all clinical areas. This chapter introduces the knowledge and skills required by nurses to collect a comprehensive health history from a patient. It begins with an explanation of the place of health history in the health observation and assessment process, a description of the different types of health histories and their uses, and a detailed overview of the components of a comprehensive health history. This chapter goes on to explain the importance of therapeutic communication and rapport in the health history interview, and the use of questioning, interpersonal skills and other communication techniques to facilitate data collection. Finally, this chapter considers a variety of barriers and challenges to effective communication in the health history interview, and how nurses can respond effectively to these.

Learning objectives for this chapter

By the end of this chapter, we would like you:

-To explain the place of the health history in the health observation and assessment process.

-To discuss the different types of health histories, and their uses in different clinical contexts.

-To list the components of a comprehensive health history.

-To explain the use of therapeutic communication and rapport in the health history interview.

-To describe the importance of effective questioning, and the use of a variety of interpersonal skills and communication techniques, in the health history interview.

-To describe the various barriers and challenges to effective communication in the health history interview, and effective responses to these to facilitate data collection.

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