Health Assessment NCLEX® Review

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Introduction to Health Assessment

A major component of nursing responsibilities includes performing health assessments on new or returning patients. A health assessment can be general, encompassing past medical history and a head-to-toe assessment, or can be specific and diseases related, such as assessing for cancers or alcoholism. The assessment you provide as a nurse will vary based on your role and based on the setting in which you practice. A health assessment in general will consist of observations and measurements in order to identify problems or keep the patient safe. This Health Assessment NCLEX® Review aims to provide readers with an understanding of health assessment in order to prepare for daily responsibilities as a nurse as well as the NCLEX® exam.

Importance of Health Assessment

Health assessments serve the purpose of identifying current problems, identifying problems the patient is at risk for, keeping the patient alive and/or stable, and treating any current problems. Thorough, accurate health assessments create the pathway for the patient’s treatment and care plan. Performing a health assessment requires organization, focus, and competence with each patient.

Prior to Starting a Health Assessment

Before you start a health assessment, be sure the room or area is clear, that there are no safety precautions and that you have necessary equipment for the assessment. Equipment may include gloves, thermometer, blood pressure cuff, watch, scale, tape measure, light, stethoscope, among other more specialized tools. A health assessment is driven by the needs of the patient.

Head-to-Toe Health Assessment

As you may infer from the name, a head-to-toe health assessment is one that encompasses the entire patient from head to toe. This includes physical and neurological health. The head-to-toe assessment includes the patient’s mental status, head, neck, thorax, abdomen, and extremities. Throughout the exam, observe the skin for color, lesions, temperature, and dryness or moisture2.

Head-to-toe approach for generic physical assessments

Assessment AreaData
General safety surveyAssess: Bed position, call bell positioning, emergency equipment, ambulatory devices, fall hazards
Vital SignsAssess: Temperature, pulse, respirations, BP, oxygen saturation, pain assessment

Subjective data: Have you had any pain in the last 12 hours? Are you having any pain now?

Mental StatusAssess: Level of consciousness, orientation to person, place, and time; confusion assessment, if indicated

Subjective data: What’s the date today? Where are you?

PsychosocialAssess: Patient behavior and affect

Subjective data: How do you feel today? How have you been coping with being in the hospital?

Head, eyes, ears, nose, throat, neckAssess: Eyes, pupils, mouth, speech, carotid arteries, swallowing; facial color, moisture, lesions

Subjective data: Do you wear glasses? Can I get your glasses for you? Do you use a hearing aid? Can I get your hearing aid for you?

Chest anterior/ posteriorAssess: Chest color, moisture, lesions, quality of respirations (depth, effort, symmetry), heart sounds

Subjective data: Have you been coughing? If yes: Is it a dry cough or have you been able to cough up sputum?

AbdomenAssess: Abdomen color, moisture, lesions, bowel sounds. Inspect and lightly palpate for distension and pain/discomfort

Subjective data: When was the last time you ate? When was the last time you moved your bowels and/or urinated? What did your bowel movement/urine look like?

Upper and lower extremitiesAssess: SCATTERS: Skin, Color, Arteries, Temperature, Tenderness, Edema, Refill, Strength and sensation
ActivityAssess: Patient movement and ambulation

Subjective data: Have you been out of bed? How much activity have you been able to do? Can you walk to the sink and back? Do you require assistance with toileting at this tiame?

Therapeutic DevicesAssess: Peripheral and central venous access devices. Supplemental oxygen settings, pacemakers, cardiac monitor, urinary catheters, gastric tubes, chest tubes, dressings, braces, slings

Subjective data: Are any of these devices giving you pain or concern?

Gather data while moving from head to toe, asking related questions along the way. Though this is a general overview of how to conduct a head-to-toe assessment, each patient is unique and may require more investigation into problem areas as the assessment continues.

Health Assessment Pneumonic Tools

It can be overwhelming to remember all of the details that go into performing a thorough health assessment. Pneumonic tools exist for a variety of health assessment components and can help you perform a thorough assessment.

Level of Consciousness Assessment: AVPU4

This assessment tool helps you determine a patient’s level of consciousness by assessing their responsiveness to pain and/or verbal stimulus. The AVPU scale should be used to assess the patients response of their eyes, voice, and motor skills.

  • A: Alert
  • V: Response to verbal stimuli
  • P: Response to pain
  • U: Unresponsive

Health History Assessment: SAMPLE

A health history is important to obtain after life-threatening injuries have been addressed and when the patient has stabilized. SAMPLE can be used to obtain important parts of the patient’s history.

  • S: Symptoms
  • A: Allergies
  • M: Medications
  • P: Past medical history
  • L: Last oral intake
  • E: Events leading up to the illness or injury

Rapid Trauma Assessment: DCAP-BTLS

This rapid trauma assessment is useful when assessing a patient after a traumatic injury.

  • D: Deformities
  • C: Contusions
  • A: Abrasions
  • P: Punctures or penetrations
  • B: Burns
  • T: Tenderness
  • L: Lacerations
  • S: Swelling

Alcoholism Screening: CAGE

CAGE is a questionnaire to determine whether a patient may suffer from alcoholism. A “yes” response to 2 or more questions indicate that alcoholism may be present and the patient should be further treated.

  • C: Have you ever felt that you should CUT down on your drinking?
  • A: Have you ever become ANNOYED by criticisms of your drinking?
  • G: Have you ever felt GUILTY about your drinking?
  • E: Have you ever had a morning EYE OPENER to get rid of a hangover?

Emergency Trauma Assessment: ABCDEFGHI

Trauma patients can be complex and require haste when performing an accurate, in-depth health assessment. Each part of the emergency trauma assessment is intended to save the life of the patient by taking action where it is appropriate.

  • A: Airway
    • Make sure the airway is open and that the patient is able to breathe. Tilt the head back and lift the chin to help open the airway and allow the patient to breathe. Remove any obstructions to avoid respiratory or cardiac arrest.
  • B: Breathing
    • Use look, listen, and feel techniques to ensure that the patient is breathing. Be sure the chest is rising and falling in a normal respiration rhythm, you can hear air movement, and that you can feel air expelling from the mouth or nose. Initiate CPR if the patient is not breathing.
  • C: Circulation
    • If the patient is breathing, check for the patients pulse. If the patient is not breathing, initiate CPR immediately.
  • D: Disability
    • Check that the patient’s neurological status is intact and if there are obvious disabilities and/or deformities.
  • E: Expose and examine
    • The patient’s clothing should be removed to allow you to properly assess all parts of the patient’s body for injury.
  • F: Full set of vital signs
    • Note pulse (carotid, brachial, radial), pupils, breathing, level of consciousness, blood pressure, and skin color or temperature.
  • G: Give comfort measures
    • Patients may be extremely anxious and/or in pain during a traumatic injury. Keep the patient as comfortable as possible so they do not injure themselves further.
  • H: History and head-to-toe assessment
    • SAMPLE is a good pneumonic to insert here in order to get a health history and a head-to-toe assessment.
  • I: Inspect posterior surface
    • Examine the patient for any obvious problems such as deformities, discolorations, wounds, or more.

Seven Warning Signs of Cancer: CAUTION

The seven warning signs of cancer help identify certain problems in order to detect cancer as early as possible. The American Cancer society uses “CAUTION” to identify the warning signs of cancer. These signs should not be used to definitively diagnose cancer, but may impose more testing and investigation.

  • C: Changes in bowel or bladder habits
  • A: A sore throat that does not heal
  • U: Unusual bleeding or discharge
  • T: Thickening or lump in the breast or other parts of the body
  • I: Indigestion or dysphagia
  • O: Obvious changes in a wart or mole
  • N: Nagging cough or hoarseness

Breast Assessment: LMNOP

In addition to the CAUTION warning signs, LMNOP is used to screen for and identify breast cancer, cysts, abscesses, and mastitis. Any changes in breasts or masses warrant a further evaluation.

  • L: Lump
    • Palpate the breast for any signs of lumps.
  • M: Mammary changes
    • Palpate for any dimpling, tenderness, and abnormalities.
  • N: Nipple changes
    • Observe nipple discharge, lesions, or discharges.
  • O: Other symptoms
    • Symmetry, skin appearance, point direction, rashes, ulceration etc.
  • P: Patient risk factors
    • Ask patient about any predisposing factors, family history.

Family History Assessment: BALD CHASM

Family history plays a large role in a patient’s health. Family history can identify diseases the patient is at risk for, chronic illnesses, and diseases that may have been genetically inherited. The following disorders have found to be strongly correlated with a family history of the diseases and should be screened for regularly if a family history is present.

  • B: Blood pressure
  • A: Arthritis
  • L: Lung diseases
  • D: Diabetes
  • C: Cancers
  • H: Heart disease
  • A: Alcoholism
  • S: Stroke
  • M: Mental health disorders

Eye Abbreviations3

Short abbreviations for the eyes can be hard to keep straight. OU stands for both eyes, OD stands for right eye, and OS stands for left eye. The following pneumonic can help you remember which abbreviation stands for which term.

  • YOU look with BOTH EYES
  • The RIGHT dose won’t OD (overdose).
  • The only one LEFT is OS.

Signs vs. Symptoms

Signs and symptoms are both important to identify a patient’s problems and the correct treatment path. Distinguishing between signs and symptoms is important.

  • sIgn: something I can detect even if my patient is unconscious
  • Symptom: something only the patient knows about. Cannot be measured directly.

Pain Assessment: OPQRSTU

Assessing pain is very important to ensure that the patient is comfortable. Pain can be a traumatic feeling for a patient and can lead to further injury, anxiety, and can lengthen the time a patient takes to recover. Pain is subjective to each patient and a thorough assessment must be done.

  • O: Onset
    • When did the pain start? How long does the pain last? How often does the pain occur? What started the pain?
  • P: Provoking or palliating factors
    • What brings it on? What makes it better or worse?
  • Q: Quality
    • What does the pain feel like? (Throb, stab, dull pain)
  • R: Region and Radiation
    • Does the pain radiate? Where does it spread to?
  • S: Severity
    • What is the intensity on a pain scale of 1-10? (or visual scale).
  • T: Time and treatment
    • When did the pain begin? Do you take any medications for the pain?
  • U: Understanding and Impact
    • What do you think is causing the pain? How is this affecting you?

Conclusion:

Health assessments are critical to providing comprehensive care to patients. Performing a head-to-toe assessment, as well as disease-specific assessments, is a crucial responsibility of a nurse and has a large impact on patient care. Health assessments identify injury and disease, prevent disease progression, help curate treatment and therapy plans, and help identify diseases the patient may be at risk for. Health assessments can be overwhelming due to the sheer amount of data that should be recorded with each assessment. This health assessment NCLEX® review serves as an overview of the importance and how to perform health assessments to aid your understanding and help your future practice as a nurse.

References

  1. Lee N. “How to Conduct a Head-to-Toe Assessment”. Nurse.Org. Accessed: May 12, 2020. https://nurse.org/articles/how-to-conduct-head-to-toe-assessment/
  2. Haugh KH. Head-to-toe: Organizing your baseline patient physical assessment. Nursing. 2015;45(12):58‐61.
  3. Vera M. Nursing Health Assessment Pneumonics & Tips. Accessed: May 12, 2020. https://nurseslabs.com/nursing-health-assessment-mnemonics-tips/
  4. Romanelli D, Farrell MW. AVPU (Alert, Voice, Pain, Unresponsive). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020.
  5. Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252(14):1905‐1907. doi:10.1001/jama.252.14.1905
  6. Thim T, Krarup NH, Grove EL, Rohde CV, Løfgren B. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med. 2012;5:117‐121. doi:10.2147/IJGM.S28478
  7. Bleyer A. CAUTION! Consider cancer: common symptoms and signs for early detection of cancer in young adults. Semin Oncol. 2009;36(3):207‐212. doi:10.1053/j.seminoncol.2009.03.004