4.2 Guiding Approaches of Health Assessment
The guiding approaches of health assessment refer to specific conventions of when and what type of health assessment to perform. For example, how often should you perform an assessment on the client? What type of assessment should you perform and how comprehensive should it be? Approaches always depend on the context of the situation. As you become more experienced, you will also be able to pick up on cues that require additional assessment.
Health Assessment Frequency
The frequency of a health assessment is determined by the setting (e.g., primary care, long term care, acute care) and the health and clinical status of the client.
- The frequency of a primary care visit depends on the client’s age and their health status and needs. For example, guidelines have been established for the frequency of well-baby and childhood visits and maternal health visits. Also, clients with complex health care needs (such as multiple morbidities) will need to see their primary care practitioner more often than a healthy adult.
- The frequency of assessment in a long-term care setting is often determined by concerns voiced by the client, care provider, assistant, tech, or nurse.
- The frequency of assessment in acute care (such as medical or surgical units) will be at least every four hours. In critical care, this frequency is increased to usually every 1–2 hours at least. Clients in critical care are usually on a monitor in which their heart rhythm and vital signs such as oxygen saturation and heart rate are constantly monitored and alarm bells will signal if there is an abnormal change. Although there may be a standard for the frequency of assessment based on the unique population you care for or the institution’s policy, you must be aware that escalation of care and increased frequency may be needed based on the nurse’s assessment and the client’s clinical status. For example, at times clients may require constant observation (e.g., post-surgery, in critical care environments, a client who is unstable or may show signs of deterioration, or a client in mental health distress with suicide ideation or post-attempt).
Health Assessment Types
There are several ways to describe health assessment types. In this chapter, we refer to four types including: primary survey; focused assessment; head-to-toe (abbreviated version); and complete health assessment. As per Table 4.1, the type of health assessment to be performed is determined based on the context of the situation.
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Type of Assessment |
Recommendations |
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Primary survey Airway (patent or compromised) Breathing (respiratory rate, work of breathing, oxygen saturation, oxygen flow rate, need for oxygen supplementation) Circulation (pulse rate/rhythm [radial or carotid], skin color, moisture, temperature) Consciousness (alert, drowsy, disoriented, restless, agitated, unconscious) Safety (name band and allergy band, oxygen saturation, suction working, check bed, side rails, call light, fall risk, dysphagia)
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According to current recommendations, all assessments should begin with a primary survey because this structured assessment helps nurses recognize and act on signs of clinical deterioration (Considine & Currey, 2014) that are correlated with death (Douglas et al., 2016). A primary survey collects data in order of importance, and it is aligned with most institutions’ rapid response systems (Considine & Currey, 2014). This recommendation marks a change from the tradition of beginning an assessment with vital sign measurement (Considine & Currey, 2014) or doing a head-to-toe assessment. A primary survey will help you determine if urgent intervention is needed or whether you should perform a focused assessment or a head-to-toe assessment. This change in assessment practice is still relatively new. Thus, you may encounter health care professionals who are not familiar with this shift in practice and the primary survey. It can provide an opportunity for discussion and learning. |
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Focused assessment An assessment that is specific to a health concern/reason for seeking care. |
This type of assessment is performed in all areas of care (e.g., primary care, emergency, long-term care, medical, surgical). Because of its specificity, it usually involves a focus on a limited number of body systems based on the health concern, similar to an episodic database. For example, a client’s reason for seeking care may be an “achy knee.” Thus, the nurse’s assessment will be focused on the musculoskeletal system. Another example may be chest pain. Because there are multiple causes of chest pain, you may need to do a cardiac, respiratory, and musculoskeletal assessment. Another example is a follow-up assessment: a client may have been prescribed a new medication for high blood pressure and needs a follow-up assessment a couple of weeks later to determine the effects. |
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Head-to-toe assessment (abbreviated) A head-to-toe assessment follows a cephalocaudal approach, assessing several body systems, and provides an overview of the client’s current health status. |
Typically, a head-to-toe assessment should take about 10 minutes and should be performed at the beginning of your shift and when you first interact with a client. There are variations of this assessment based on the client situation, reason for seeking care, and institution/unit. A head-to-toe assessment usually includes attention to overall well-being/needs; pain; vital signs; specific assessments related to neurological, cardiovascular, peripheral vascular, skin, respiratory, gastrointestinal, and genitourinary systems; activity/rest; and wounds/dressings, IV sites, drains/tubes, and oxygen. Based on the collected data, this type of assessment may influence the need for a more focused examination of a specific body system. For example, you may notice the client has a bloated and hard abdomen. Based on these cues, you should complete an abdominal assessment. A more complete assessment/head-to-toe may be needed in certain situations when a comprehensive assessment is warranted (see next section on complete health assessment). |
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Complete health assessment A complete health assessment is similar to a head-to-toe assessment, but it is more comprehensive. It involves a subjective and objective assessment of all body systems. It provides a full overview of the client’s current health status. |
A complete health assessment may take 30–60 minutes depending on the client and the complexity of their health issues. It may be performed for several reasons, often when clients have complex care needs. It is often performed upon admission to a long-term care home or rehabilitation, and sometimes in a primary care setting with new clients. It may also be performed in acute settings when a client has complex health problems and diagnoses have been problematic. This kind of assessment can vary based on the client situation, developmental stage, reason for seeking care, and institution/unit. |
Clinical Tip
When you are new to a work environment, you should inquire about the typical conventions surrounding assessment frequency and type. It is also always helpful to ask your clinical instructor/preceptor about their approach to assessment.
When conducting these assessments, it is important to assess the client’s level of consciousness and level of orientation. New-onset disorientation and/or a decrease in level of consciousness are important cues that could indicate clinical deterioration and thus, require immediate intervention. If not yet completed, a primary survey should be done and findings shared with the physician or nurse practitioner.
Level of consciousness is the client’s state of awareness and response to stimuli (voice/sound or physical). Their level of consciousness is described as:
- Alert: This means that the client is awake (or easily arouses to your voice).
- Lethargic: This means that the client is slow/sluggish to arouse to stimuli. For example, you need to say their name loudly or multiple times or physical shake their arm. They are sleepy, lack energy, and are slow to respond to your questions, but answer appropriately and are oriented.
- Obtunded: This means that the client has a significant impairment in their level of consciousness and requires a significant and continuous stimuli (loud voice, vigorous shaking of the arm). They have difficulty responding because of the impairment, need constant coaxing to respond, can only answer very simple questions with one-word responses that are difficult to hear and understand. Without stimuli, they will immediately return to sleep.
- Unconsciousness: This means that the client does not respond to any stimuli and has no purposeful motor responses.
Level of orientation is assessed by asking the client questions related to:.
- Place (question to ask: Do you know where you are? They may know they are in a hospital because of the room. Thus, you may probe with the question, do you know what hospital you are in?).
- Time (questions to ask: Do you know what date it is? Do you know what day of the week it is? Do you know what month it is? Do you know what year it is?).
- Person (question to ask: Do you know who I am? They may say “yes,” but you should probe with the question, can you tell me who I am? They may be able to identify you as a nurse, but forget your name in some cases); Self (question to ask: Do you know who you are? If they respond “yes,” you should probe with the question, can you tell me your name?).
- Situation (questions to ask: What brought you in? Why are you here?).
A normal response is that the client is oriented to place, time, person and situation. If they are disoriented, you indicate what they are disoriented to. You may indicate oriented to place, person and situation, disoriented to time. It is important to consider context when assessing level of orientation. For example, a client may not be aware of the specific date, but knows the day of the week or month. The term “confused and disoriented” is sometimes used in health care settings. It means that the client shows altered cognition, such as difficulty in memory retention, difficulty following commands, uncertainty about the environment around them, and inattention, and shows signs of disorientation in terms of person, place, time, and self. They may have delayed or inappropriate/incorrect responses to your questions.
References
Considine, J., & Currey, J. (2014). Ensuring a proactive, evidence-based, patient safety approach to patient assessment. Journal of Clinical Nursing, 24, 300-307. https://doi.org/10.1111/jocn.12641
Douglas, C., Booker, C., Fox, R., Windsor, C., Osborne, S., & Gardner, G. (2016). Nursing physical assessment for patient safety in general wards: Reaching consensus in core skills. Journal of Clinical Nursing, 25, 1890-1900. https://doi.org/10.1111/jocn.13201
Attribution
This section contains material taken from Introduction to Health Assessment for the Nursing Professional – Part I and is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
- Clinical Procedures for Safer Patient Care Copyright © 2015 by Glynda Rees Doyle and Jodie Anita McCutcheon is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted. ↵
