NURS 680 B Comprehensive Health Assessment
Students will select a new “patient” (friend or family member) for whom they will perform and document a complete history. This will include a complete head-to-toe review of systems (ROS) and a complete head-to-toe physical examination. This will be documented in a SOAP note format.
The patient should be an adult over the age of 18 with a chief complaint. Please do not choose the same friend or family member from previous course assignments.
Document a working diagnosis and a minimum of 3 differential diagnoses. These are based on the chief complaint (CC) an history of present illness (HPI). All 3 diagnoses Working diagnosis and differential diagnoses must include pertinent positive and negative symptoms. You may also include known diagnoses, such as obesity or hypertension. These do not need pertinent findings.
NOTE: Do not use real names or initials or otherwise identify your “patient.” Failure to maintain privacy will result in a failing score
The Subjective health history and Objective physical exam must contain all required elements as outlined in Jarvis Chapter 27 (except breast and genital exams) and the attached document. The Assessment, as well as the Plan, will be focused based on CC and HPI.
Read the rubric for the Comprehensive Health Assessment assignment carefully.
The assignment submission should be a single document that contains:
A complete subjective history
A complete objective examination
Working diagnosis with at least 3 differential diagnoses with pertinent findings for each
Plan of care that includes a discussion of the national guidelines for your diagnosis and health maintenance needs for your patient
Comprehensive Health Assessment in Nursing
Published On: July 10, 2020
Anyone who has been to a doctor’s office has undergone a fairly standard experience. Weight and height measures, blood pressure checks, eye and ear scans — these are all typical, regardless of why you went to the doctor in the first place. In nursing, this process is much more complex. During a nurse’s education, a great deal of emphasis is placed on the comprehensive health assessment, often referred to as “head-to-toe” assessment.
Methodical, yet Holistic: Why the Assessment Process Is Not Just “Q&A”
When learning to conduct comprehensive health assessments, it’s important to view them as comprising a holistic process — not just asking questions and documenting results. Nurses must understand how to analyze the data they record and use it to create a patient-based care plan.
One way to look at comprehensive health assessments is as an unfinished map. You have some guidelines as to where your journey is taking you, but you have to gather additional information along the way to identify your final destination. All of those clues inform what the patient ultimately needs.
4 Types of Health Assessments
Terri Zucchero PhD, RN, FNP-BC, is a nurse practitioner at Boston Health Care for the Homeless Program. In a Nurse.org article, she identifies the two main categories under which different types of health assessments fall.
1) Complete health assessment: This detailed examination typically includes a thorough health history and comprehensive head-to-toe physical exam. It is often performed by registered nurses on patients admitted to the hospital or in community-based settings (e.g. a home visit).
2) Problem-focused assessment: This type is based on the patient population and care goals. A specific body system, such as respiratory or cardiac, is the focus of these assessments. Zucchero notes that an ICU nurse would have a different patient population and nursing care goal than one who does maternal-child home visits, for instance.
RN.com’s training document on health assessments includes two additional types: interval or abbreviated assessments and assessments for special populations.
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3) Interval/abbreviated assessments are just as their name indicates and allow for a still-thorough evaluation in a shorter period of time. These assessments are appropriate if a patient has previously been under a nurse’s care. They also apply in certain situations like change of shift or transfer from another unit within the hospital or health system.
4) Special population assessments encompass pregnant patients, infants, children, and the elderly — each requiring specific skills and knowledge.
Diagnostic tools used in a comprehensive health assessment vary. Basic instruments include the blood pressure cuff, thermometer, stethoscope, penlight — all standard fixtures within a clinical setting. Additional “human tools” rely on a nurse’s sight, hearing, and touch. Visual abnormalities, such as concerning moles, are vital to note. Listening for cues from the lungs, heart and even stomach provides additional information.
While touch is required for some physical assessments, such as feeling for swollen glands or palpating certain areas for tenderness, Zucchero advises nurses to avoid any extraneous touching. This solidifies a sense of professionalism and trust between nurse and patient.
“Establishing a personal relationship of trust and respect between the patient and the nurse is vital. It’s important that an assessment is conducted systematically and efficiently to minimize unnecessary touching of the patient,” she states.
Rushed or Incomplete Assessments Pose Patient Risk
The amount of time required to complete a health assessment depends on the type of assessment and the patient’s overall health status. It’s important not to rush the process; the gathering of each piece of information is vital to the overall evaluation and should never be sacrificed due to time constraints.
Missing an abnormality, such as a potentially cancerous mole, or failing to pick up neurological red flags can have disastrous consequences. Even though nurses are not doctors, they bear the responsibility of identifying anomalous symptoms and accurately documenting them, thereby alerting physicians to a possible problem.
Why Non-Verbal Clues Need Attention
While much of the comprehensive health assessment focuses on biological or physiological attributes, nurses also need to be able to pick up on certain aspects from a mental or emotional perspective. Sometimes, what a patient doesn’t say is the most critical piece of information. Non-verbal clues — a patient’s avoidance of eye contact or reluctance to answer questions — can be enlightening.
“The nurse must pay very careful attention to what the patient says and does not say during the visit. Oftentimes, nurses are acting as detectives during patient visits, attempting to put together different findings, conversations, and health histories,” notes Haynes Ferere, DNP, FNP-BC, MPH in the Nurse.org article.
A Mentor’s Promise: With Each Assessment, Confidence Grows
Comprehensive health assessment training is just one essential component of a nurse’s education. Building skill in this area continues throughout one’s nursing career. Seeking out more seasoned nurses as mentors is a good strategy for those who are new to the field.
“Confidence in assessment continues to grow with every completed assessment. Nurses should not be afraid to ask for help when something does not seem right,” shares Ferere, who suggests relying on one’s instincts and training too.
Learn more about Mississippi College’s online RN to BSN program.
Nurse.org: How to Conduct a Head-to-Toe Assessment
RN.com: Overview of Nursing Health Assessment
Cancer.org: What Are Basal and Squamous Cell Skin Cancers?