Health Assessment Part 1

Health Assessment

• Types of health assessments: Initial Comprehensive, Problem-Focused, Ongoing, and Emergency Assessment

Initial Comprehensive Assessment

• Describes the client's medical, physical, and psychosocial condition and needs
• Identifies service needs, barriers to service access, and services not adequately coordinated
• Evaluates the client's resources and strengths, including family and other close supports
• Components include:
  • Obtaining a patient's medical history
  • Performing a physical exam
  • Preparing a psychosocial assessment for a mental health patient
  • Obtaining a patient's vital signs
  • Taking subjective statements from the patient
  • Double-checking subjective symptoms with objective signs of the condition
• Includes client health history, health status, and health-related needs, such as:
  • HIV disease progression
  • Allergies to medications
  • Dental care
  • Vision care
  • Home care
  • Current health care providers
  • Engagement in and barriers to care
  • Clinical trials
  • Complementary therapy
• Also includes client's status and needs related to:
  • Nutrition
  • Financial resources and entitlements
  • Housing
  • Transportation
  • Support systems
  • Identification of children and separate assessment of children's needs
  • Identification of collaterals
  • Determination of collaterals needing case management assessment and services
  • Parenting needs
  • Partner notification needs
  • Employment/education
  • Knowledge, attitudes, and beliefs about HIV disease
  • Current risk behaviors
  • Prevention of transmission
  • Activities of daily living
  • Legal needs
  • Domestic violence

Problem-Focused Assessment

• Collects data about a specific problem that has already been identified
• Has a narrower scope and shorter time frame than the initial assessment
• Determines whether the problem still exists and whether the status of the problem has changed
• Includes a brief reassessment of the client's normal body system
• Process of collecting and using standardized information to assess progress towards objectives, resource usage, and achievement of results and impacts

Ongoing Assessment

• Takes place after the initial assessment to evaluate any changes in the client's functional health
• Steps include:
  • Reassessing and recording vital signs
  • Repeating focused assessment regarding patient complaints and injuries
  • Checking on interventions/treatment in progress

Emergency Assessment

• Takes place in life-threatening situations in which the preservation of life is the top priority
• Focuses on rapidly identifying the root causes of concern for the patient and assessing the airway, breathing, and circulation (ABCs) of the patient
• May also include an assessment for scene safety
• Often involves abrupt changes in self-concept (suicidal thoughts) or roles or relationships (social conflict leading to violent acts)