{"id":182,"date":"2021-08-26T11:35:09","date_gmt":"2021-08-26T15:35:09","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/guiding-approaches-of-health-assessment\/"},"modified":"2025-05-15T09:52:58","modified_gmt":"2025-05-15T13:52:58","slug":"guiding-approaches-of-health-assessment","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/guiding-approaches-of-health-assessment\/","title":{"raw":"Guiding Approaches of Health Assessment","rendered":"Guiding Approaches of Health Assessment"},"content":{"raw":"<p style=\"text-align: left\"><span style=\"color: #000000\">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 <strong>context of the situation. <\/strong>As you become more experienced, you will also be able to pick up on cues that require additional assessment.<\/span><\/p>\r\n\r\n<h1 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Health Assessment Frequency<\/strong><\/span><\/h1>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">The frequency of a health assessment is determined by the<strong> setting<\/strong> (e.g., primary care, long term care, acute care) and the <strong>health <\/strong>and<strong> clinical status<\/strong> of the client.<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">The frequency of a <strong>primary<\/strong>\u00a0<strong>care<\/strong> visit depends on the client\u2019s 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 healthcare needs (such as multiple <strong>[pb_glossary id=\"348\"]morbidities[\/pb_glossary]<\/strong>) will need to see their primary care practitioner more often than a healthy adult.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">The frequency of assessment in a <strong>long-term care<\/strong> setting is often determined by concerns voiced by the client, the personal support worker (PSW), or the registered practical nurse (RPN). PSW and RPN typically have more 1:1 contact with clients in long-term care settings and will draw the registered nurse\u2019s attention to concerns that may require further assessment.<\/span><\/li>\r\n \t<li style=\"font-weight: 400\"><span style=\"color: #000000\">The frequency of assessment in <strong>acute care<\/strong> (such as medical or surgical units) will be at least every four hours. In critical care, this frequency is increased to usually every 1\u20132 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 policy, you must be aware that escalation of care and increased frequency may be needed based on the nurse\u2019s assessment and the client\u2019s 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).<\/span><\/li>\r\n<\/ul>\r\n<h1><strong>Brief Scan<\/strong><\/h1>\r\n<span style=\"color: #000000\">A brief scan is a type of health assessment that is typically conducted with each patient at the<strong> start of your shift<\/strong> and\/or each time you see them. A brief scan provides a <strong>quick <\/strong>and <strong>general overview<\/strong> of the client. It can be performed when the client enters the room or alternatively when you are entering the room. Your initial observations provide insight into how the client may need to be supported during the assessment, ways you may need to modify the assessment, and cues that require further investigation.<\/span>\r\n\r\n<span style=\"color: #000000\">The brief scan may be referred to by some practitioners as, and include components of, the <strong>general survey <\/strong>and <strong>mental health assessment<\/strong>. How the brief scan is performed in practice will depend on the client population and institution (e.g., long term, acute, primary care). The brief scan may be tailored to a particular body system as you will see throughout this learning resource.<\/span>\r\n\r\n<span style=\"color: #000000\">For the purposes of this chapter, a brief scan will include the following four components:<\/span>\r\n<h2><span style=\"color: #000000\"><strong>(1) Mobility and body positioning<\/strong><\/span><\/h2>\r\n<ul>\r\n \t<li><span style=\"color: #000000\">Does the client move independently and\/or have any mobility aids?<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Are there any mobility or gait impairments observed?<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Are there any concerns based on the client\u2019s movements or lack of movements?<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Is the client sitting or standing upright or are they slumped forward or to the side?<\/span><\/li>\r\n<\/ul>\r\n<h2><span style=\"color: #000000\"><strong>(2) Bodily and physical appearance<\/strong><\/span><\/h2>\r\n<ul>\r\n \t<li><span style=\"color: #000000\">If not in a gown, is the client wearing appropriate clothing for the temperature outside?<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Is the client appropriately groomed with no hygiene issues of concern?<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Is there a change in the client\u2019s bodily and physical appearance?<\/span><\/li>\r\n<\/ul>\r\n<h2><span style=\"color: #000000\"><strong>(3) Level of consciousness<\/strong> <\/span><\/h2>\r\n<span style=\"color: #000000\">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: <\/span>\r\n<ul>\r\n \t<li><span style=\"color: #000000\">Alert and oriented: This means that the client is awake (or easily arouses to your voice), engages appropriately in interactions with you, responds appropriately to your questions, and oriented to person, place, time, and self.\u00a0<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Confused and disoriented: This means that the client shows altered cognition such as difficulty in memory retention, difficulty following commands, uncertain about the environment around them, 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.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">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, slow to respond to your questions, but answers appropriately and are oriented.\u00a0<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">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 to respond 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.\u00a0<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Unconsciousness: This means that the client does not respond to any stimuli and has no purposeful motor responses.<\/span><\/li>\r\n<\/ul>\r\n<h2><span style=\"color: #000000\"><strong>(4) Level of orientation<\/strong> <\/span><\/h2>\r\n<span style=\"color: #000000\">Leve of orientation is assessed by asking the client questions related to: <\/span>\r\n<ul>\r\n \t<li><span style=\"color: #000000\">Place (questions 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?).<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">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?).<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">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).<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">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?).<\/span><\/li>\r\n<\/ul>\r\n<span style=\"color: #000000\">A normal response is that the client is alert and oriented to place, time, person and self. <\/span><span style=\"color: #000000\">If they are disoriented, you indicate what they are disoriented to. You may indicate oriented to place, person and self, 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 or year.<\/span>\r\n\r\n&nbsp;\r\n<div class=\"textbox shaded\">\r\n<h2 style=\"text-align: center\"><span style=\"color: #000000\">Contextualizing Inclusivity<\/span><\/h2>\r\n<span style=\"color: #000000\">It is important to integrate considerations of age, fashion style, and socioeconomic status that may affect your assessment of appearance. Appearance can be a personal and unique component of each person and thus, your own bias may influence what you identify as \u201cnormal\u201d versus \u201cabnormal\u201d findings related to appearance. Additionally, socioeconomic status may affect a client\u2019s capacity to maintain appropriate hygiene and grooming as well as clothing appropriate to the temperatures outside. Use unconditional positive regard and cultural humility to explore any concerns you may have.<\/span>\r\n\r\n<\/div>\r\n<div class=\"textbox textbox--learning-objectives\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title no-indent\" style=\"text-align: center\"><strong>Priorities of Care<\/strong><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<p style=\"text-align: left\">It is important to consider cues that are a <strong>priority of care<\/strong>. This means they require your attention first (out of all of your assessment findings) because they are concerning and\/or they suggest that the client may be about to [pb_glossary id=\"3845\"]deteriorate[\/pb_glossary] or is deteriorating. In terms of the brief scan, <strong>new onset<\/strong> of abnormal findings should draw your attention as a priority of care. For example, new onset altered level of consciousness and\/or disorientation 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 - details on how to conduct a primary survey are provided below in <strong>Table 5<\/strong>.<\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n<h1 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Other Health Assessment Types<\/strong><\/span><\/h1>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">In addition to the brief scan, there are several other 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 <strong>Table 5<\/strong>, the type of health assessment to be performed is determined based on the context of the situation.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Table 5<\/strong>: Types of health assessment<\/span><\/p>\r\n\r\n<table class=\"lines\" style=\"border-collapse: collapse;width: 100%;height: 75px\" border=\"0\">\r\n<tbody>\r\n<tr>\r\n<td style=\"width: 50%;text-align: left;vertical-align: top\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Type of Assessment<\/strong><\/span><\/p>\r\n<\/td>\r\n<td style=\"width: 50%;text-align: left;vertical-align: top\">\r\n<p class=\"no-indent\"><strong><span style=\"color: #000000\">Recommendations<\/span><\/strong><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 15px\">\r\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Primary survey\r\n<\/strong>Airway (patency)<\/span>\r\n<span style=\"color: #000000\">Breathing (respiratory rate, work of breathing, oxygen saturation)<\/span>\r\n<span style=\"color: #000000\">Circulation (pulse rate\/rhythm, BP, urine output)<\/span>\r\n<span style=\"color: #000000\">Disability (level of consciousness, speech, pain)<\/span>\r\n<span style=\"color: #000000\">Exposure (temperature, skin integrity, pressure injuries, wounds, dressings, drains, lines, ability to transfer\/mobilise, bowel movements)<\/span>\r\n<span style=\"color: #000000\">(Douglas et al., 2016)<\/span><\/p>\r\n<\/td>\r\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">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 &amp; 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\u2019 <strong>[pb_glossary id=\"350\"]rapid response systems[\/pb_glossary]<\/strong> (Considine &amp; Currey, 2014).<\/span><\/p>\r\n<p class=\"no-indent\"><span style=\"color: #000000\">This recommendation marks a change from the tradition of beginning an assessment with vital sign measurement (Considine &amp; 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.<\/span><\/p>\r\n<p class=\"no-indent\"><span style=\"color: #000000\">This change in assessment practice is still relatively new. Thus, you may encounter healthcare professionals who are not familiar with this shift in practice and the primary survey. It can provide an opportunity for discussion and learning.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 15px\">\r\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Focused assessment\r\n<\/strong>An assessment that is specific to a health concern\/reason for seeking care.<\/span><\/p>\r\n<\/td>\r\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">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.<\/span><\/p>\r\n<p class=\"no-indent\"><span style=\"color: #000000\">For example, a client\u2019s reason for seeking care may be an \u201cachy knee.\u201d Thus, the nurse\u2019s 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 <strong>follow-up assessment<\/strong>: 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.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 15px\">\r\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Head-to-toe assessment (abbreviated)\r\n<\/strong>A head-to-toe assessment follows a [pb_glossary id=\"352\"]cephalocaudal[\/pb_glossary] approach, assessing several body systems, and provides an overview of the client\u2019s current health status.<\/span><\/p>\r\n<\/td>\r\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">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.<\/span><\/p>\r\n<p class=\"no-indent\"><span style=\"color: #000000\">A head-to-toe assessment usually includes attention to overall wellbeing\/needs, pain, vital signs, specific assessments related to neurological, cardiovascular, peripheral vascular, skin, respiratory, gastrointestinal, genitourinary, activity\/rest, and wounds\/dressings, IV sites, drains\/tubes, and oxygen.<\/span><\/p>\r\n<p class=\"no-indent\"><span style=\"color: #000000\">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.<\/span><\/p>\r\n<p class=\"no-indent\"><span style=\"color: #000000\">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).<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 15px\">\r\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Complete health assessment\r\n<\/strong>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\u2019s current health status.<\/span><\/p>\r\n<\/td>\r\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\r\n<p class=\"no-indent\"><span style=\"color: #000000\">A complete health assessment may take 30\u201360 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.<\/span><\/p>\r\n<p class=\"no-indent\"><span style=\"color: #000000\">This kind of assessment can vary based on the client situation, developmental stage, reason for seeking care, and institution\/unit.<\/span><\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Clinical Tip\u00a0<\/strong><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">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.<\/span><\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\">Activity: Check Your Understanding<\/span><\/h2>\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>[h5p id=\"141\"]<\/strong><\/span><\/h2>\r\nReferences\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Considine, J., &amp; Currey, J. (2014). Ensuring a proactive, evidence-based, patient safety approach to patient assessment.\u00a0<em>Journal of Clinical Nursing<\/em>,\u00a0<em>24<\/em>, 300-307.<\/span><span>\u00a0<\/span><a href=\"https:\/\/doi.org\/10.1111\/jocn.12641\" target=\"_blank\" rel=\"noopener\">https:\/\/doi<\/a><a href=\"https:\/\/doi.org\/10.3928\/01484834-20060601-04\" target=\"_blank\" rel=\"noopener\">.org\/<\/a><a href=\"https:\/\/doi.org\/10.1111\/jocn.12641\" target=\"_blank\" rel=\"noopener\">10.1111\/jocn.12641<\/a><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">Douglas, C., Booker, C., Fox, R., Windsor, C., Osborne, S., &amp; Gardner, G. (2016). Nursing physical assessment for patient safety in general wards: Reaching consensus in core skills.\u00a0<em>Journal of Clinical Nursing<\/em>,\u00a0<em>25<\/em>, 1890-1900.\u00a0<\/span><a href=\"https:\/\/doi.org\/10.1111\/jocn.13201\" target=\"_blank\" rel=\"noopener\">https:\/\/doi<\/a><a href=\"https:\/\/doi.org\/10.3928\/01484834-20060601-04\" target=\"_blank\" rel=\"noopener\">.org\/<\/a><a href=\"https:\/\/doi.org\/10.1111\/jocn.13201\" target=\"_blank\" rel=\"noopener\">10.1111\/jocn.13201<\/a><\/p>","rendered":"<p style=\"text-align: left\"><span style=\"color: #000000\">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 <strong>context of the situation. <\/strong>As you become more experienced, you will also be able to pick up on cues that require additional assessment.<\/span><\/p>\n<h1 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Health Assessment Frequency<\/strong><\/span><\/h1>\n<p style=\"text-align: left\"><span style=\"color: #000000\">The frequency of a health assessment is determined by the<strong> setting<\/strong> (e.g., primary care, long term care, acute care) and the <strong>health <\/strong>and<strong> clinical status<\/strong> of the client.<\/span><\/p>\n<ul style=\"text-align: left\">\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">The frequency of a <strong>primary<\/strong>\u00a0<strong>care<\/strong> visit depends on the client\u2019s 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 healthcare needs (such as multiple <strong><button class=\"glossary-term\" aria-describedby=\"182-348\">morbidities<\/button><\/strong>) will need to see their primary care practitioner more often than a healthy adult.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">The frequency of assessment in a <strong>long-term care<\/strong> setting is often determined by concerns voiced by the client, the personal support worker (PSW), or the registered practical nurse (RPN). PSW and RPN typically have more 1:1 contact with clients in long-term care settings and will draw the registered nurse\u2019s attention to concerns that may require further assessment.<\/span><\/li>\n<li style=\"font-weight: 400\"><span style=\"color: #000000\">The frequency of assessment in <strong>acute care<\/strong> (such as medical or surgical units) will be at least every four hours. In critical care, this frequency is increased to usually every 1\u20132 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 policy, you must be aware that escalation of care and increased frequency may be needed based on the nurse\u2019s assessment and the client\u2019s 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).<\/span><\/li>\n<\/ul>\n<h1><strong>Brief Scan<\/strong><\/h1>\n<p><span style=\"color: #000000\">A brief scan is a type of health assessment that is typically conducted with each patient at the<strong> start of your shift<\/strong> and\/or each time you see them. A brief scan provides a <strong>quick <\/strong>and <strong>general overview<\/strong> of the client. It can be performed when the client enters the room or alternatively when you are entering the room. Your initial observations provide insight into how the client may need to be supported during the assessment, ways you may need to modify the assessment, and cues that require further investigation.<\/span><\/p>\n<p><span style=\"color: #000000\">The brief scan may be referred to by some practitioners as, and include components of, the <strong>general survey <\/strong>and <strong>mental health assessment<\/strong>. How the brief scan is performed in practice will depend on the client population and institution (e.g., long term, acute, primary care). The brief scan may be tailored to a particular body system as you will see throughout this learning resource.<\/span><\/p>\n<p><span style=\"color: #000000\">For the purposes of this chapter, a brief scan will include the following four components:<\/span><\/p>\n<h2><span style=\"color: #000000\"><strong>(1) Mobility and body positioning<\/strong><\/span><\/h2>\n<ul>\n<li><span style=\"color: #000000\">Does the client move independently and\/or have any mobility aids?<\/span><\/li>\n<li><span style=\"color: #000000\">Are there any mobility or gait impairments observed?<\/span><\/li>\n<li><span style=\"color: #000000\">Are there any concerns based on the client\u2019s movements or lack of movements?<\/span><\/li>\n<li><span style=\"color: #000000\">Is the client sitting or standing upright or are they slumped forward or to the side?<\/span><\/li>\n<\/ul>\n<h2><span style=\"color: #000000\"><strong>(2) Bodily and physical appearance<\/strong><\/span><\/h2>\n<ul>\n<li><span style=\"color: #000000\">If not in a gown, is the client wearing appropriate clothing for the temperature outside?<\/span><\/li>\n<li><span style=\"color: #000000\">Is the client appropriately groomed with no hygiene issues of concern?<\/span><\/li>\n<li><span style=\"color: #000000\">Is there a change in the client\u2019s bodily and physical appearance?<\/span><\/li>\n<\/ul>\n<h2><span style=\"color: #000000\"><strong>(3) Level of consciousness<\/strong> <\/span><\/h2>\n<p><span style=\"color: #000000\">Level of consciousness is the client&#8217;s state of awareness and response to stimuli (voice\/sound or physical). Their level of consciousness is described as: <\/span><\/p>\n<ul>\n<li><span style=\"color: #000000\">Alert and oriented: This means that the client is awake (or easily arouses to your voice), engages appropriately in interactions with you, responds appropriately to your questions, and oriented to person, place, time, and self.\u00a0<\/span><\/li>\n<li><span style=\"color: #000000\">Confused and disoriented: This means that the client shows altered cognition such as difficulty in memory retention, difficulty following commands, uncertain about the environment around them, 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.<\/span><\/li>\n<li><span style=\"color: #000000\">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, slow to respond to your questions, but answers appropriately and are oriented.\u00a0<\/span><\/li>\n<li><span style=\"color: #000000\">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 to respond 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.\u00a0<\/span><\/li>\n<li><span style=\"color: #000000\">Unconsciousness: This means that the client does not respond to any stimuli and has no purposeful motor responses.<\/span><\/li>\n<\/ul>\n<h2><span style=\"color: #000000\"><strong>(4) Level of orientation<\/strong> <\/span><\/h2>\n<p><span style=\"color: #000000\">Leve of orientation is assessed by asking the client questions related to: <\/span><\/p>\n<ul>\n<li><span style=\"color: #000000\">Place (questions 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?).<\/span><\/li>\n<li><span style=\"color: #000000\">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?).<\/span><\/li>\n<li><span style=\"color: #000000\">Person (question to ask: Do you know who I am? They may say &#8220;yes&#8221;, 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).<\/span><\/li>\n<li><span style=\"color: #000000\">Self (question to ask: Do you know who you are? If they respond &#8220;yes&#8221;, you should probe with the question, can you tell me your name?).<\/span><\/li>\n<\/ul>\n<p><span style=\"color: #000000\">A normal response is that the client is alert and oriented to place, time, person and self. <\/span><span style=\"color: #000000\">If they are disoriented, you indicate what they are disoriented to. You may indicate oriented to place, person and self, 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 or year.<\/span><\/p>\n<p>&nbsp;<\/p>\n<div class=\"textbox shaded\">\n<h2 style=\"text-align: center\"><span style=\"color: #000000\">Contextualizing Inclusivity<\/span><\/h2>\n<p><span style=\"color: #000000\">It is important to integrate considerations of age, fashion style, and socioeconomic status that may affect your assessment of appearance. Appearance can be a personal and unique component of each person and thus, your own bias may influence what you identify as \u201cnormal\u201d versus \u201cabnormal\u201d findings related to appearance. Additionally, socioeconomic status may affect a client\u2019s capacity to maintain appropriate hygiene and grooming as well as clothing appropriate to the temperatures outside. Use unconditional positive regard and cultural humility to explore any concerns you may have.<\/span><\/p>\n<\/div>\n<div class=\"textbox textbox--learning-objectives\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title no-indent\" style=\"text-align: center\"><strong>Priorities of Care<\/strong><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p style=\"text-align: left\">It is important to consider cues that are a <strong>priority of care<\/strong>. This means they require your attention first (out of all of your assessment findings) because they are concerning and\/or they suggest that the client may be about to <button class=\"glossary-term\" aria-describedby=\"182-3845\">deteriorate<\/button> or is deteriorating. In terms of the brief scan, <strong>new onset<\/strong> of abnormal findings should draw your attention as a priority of care. For example, new onset altered level of consciousness and\/or disorientation 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 &#8211; details on how to conduct a primary survey are provided below in <strong>Table 5<\/strong>.<\/p>\n<\/div>\n<\/div>\n<h1 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Other Health Assessment Types<\/strong><\/span><\/h1>\n<p style=\"text-align: left\"><span style=\"color: #000000\">In addition to the brief scan, there are several other 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 <strong>Table 5<\/strong>, the type of health assessment to be performed is determined based on the context of the situation.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Table 5<\/strong>: Types of health assessment<\/span><\/p>\n<table class=\"lines\" style=\"border-collapse: collapse;width: 100%;height: 75px\">\n<tbody>\n<tr>\n<td style=\"width: 50%;text-align: left;vertical-align: top\">\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Type of Assessment<\/strong><\/span><\/p>\n<\/td>\n<td style=\"width: 50%;text-align: left;vertical-align: top\">\n<p class=\"no-indent\"><strong><span style=\"color: #000000\">Recommendations<\/span><\/strong><\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 15px\">\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Primary survey<br \/>\n<\/strong>Airway (patency)<\/span><br \/>\n<span style=\"color: #000000\">Breathing (respiratory rate, work of breathing, oxygen saturation)<\/span><br \/>\n<span style=\"color: #000000\">Circulation (pulse rate\/rhythm, BP, urine output)<\/span><br \/>\n<span style=\"color: #000000\">Disability (level of consciousness, speech, pain)<\/span><br \/>\n<span style=\"color: #000000\">Exposure (temperature, skin integrity, pressure injuries, wounds, dressings, drains, lines, ability to transfer\/mobilise, bowel movements)<\/span><br \/>\n<span style=\"color: #000000\">(Douglas et al., 2016)<\/span><\/p>\n<\/td>\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\n<p class=\"no-indent\"><span style=\"color: #000000\">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 &amp; 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\u2019 <strong><button class=\"glossary-term\" aria-describedby=\"182-350\">rapid response systems<\/button><\/strong> (Considine &amp; Currey, 2014).<\/span><\/p>\n<p class=\"no-indent\"><span style=\"color: #000000\">This recommendation marks a change from the tradition of beginning an assessment with vital sign measurement (Considine &amp; 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.<\/span><\/p>\n<p class=\"no-indent\"><span style=\"color: #000000\">This change in assessment practice is still relatively new. Thus, you may encounter healthcare professionals who are not familiar with this shift in practice and the primary survey. It can provide an opportunity for discussion and learning.<\/span><\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 15px\">\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Focused assessment<br \/>\n<\/strong>An assessment that is specific to a health concern\/reason for seeking care.<\/span><\/p>\n<\/td>\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\n<p class=\"no-indent\"><span style=\"color: #000000\">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.<\/span><\/p>\n<p class=\"no-indent\"><span style=\"color: #000000\">For example, a client\u2019s reason for seeking care may be an \u201cachy knee.\u201d Thus, the nurse\u2019s 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 <strong>follow-up assessment<\/strong>: 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.<\/span><\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 15px\">\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Head-to-toe assessment (abbreviated)<br \/>\n<\/strong>A head-to-toe assessment follows a <button class=\"glossary-term\" aria-describedby=\"182-352\">cephalocaudal<\/button> approach, assessing several body systems, and provides an overview of the client\u2019s current health status.<\/span><\/p>\n<\/td>\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\n<p class=\"no-indent\"><span style=\"color: #000000\">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.<\/span><\/p>\n<p class=\"no-indent\"><span style=\"color: #000000\">A head-to-toe assessment usually includes attention to overall wellbeing\/needs, pain, vital signs, specific assessments related to neurological, cardiovascular, peripheral vascular, skin, respiratory, gastrointestinal, genitourinary, activity\/rest, and wounds\/dressings, IV sites, drains\/tubes, and oxygen.<\/span><\/p>\n<p class=\"no-indent\"><span style=\"color: #000000\">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.<\/span><\/p>\n<p class=\"no-indent\"><span style=\"color: #000000\">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).<\/span><\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 15px\">\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\n<p class=\"no-indent\"><span style=\"color: #000000\"><strong>Complete health assessment<br \/>\n<\/strong>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\u2019s current health status.<\/span><\/p>\n<\/td>\n<td style=\"width: 50%;height: 15px;text-align: left;vertical-align: top\">\n<p class=\"no-indent\"><span style=\"color: #000000\">A complete health assessment may take 30\u201360 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.<\/span><\/p>\n<p class=\"no-indent\"><span style=\"color: #000000\">This kind of assessment can vary based on the client situation, developmental stage, reason for seeking care, and institution\/unit.<\/span><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Clinical Tip\u00a0<\/strong><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p style=\"text-align: left\"><span style=\"color: #000000\">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.<\/span><\/p>\n<\/div>\n<\/div>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\">Activity: Check Your Understanding<\/span><\/h2>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong><\/p>\n<div id=\"h5p-141\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-141\" class=\"h5p-iframe\" data-content-id=\"141\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Ch 1: Guiding Approaches of Health Assessment\"><\/iframe><\/div>\n<\/div>\n<p><\/strong><\/span><\/h2>\n<p>References<\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Considine, J., &amp; Currey, J. (2014). Ensuring a proactive, evidence-based, patient safety approach to patient assessment.\u00a0<em>Journal of Clinical Nursing<\/em>,\u00a0<em>24<\/em>, 300-307.<\/span><span>\u00a0<\/span><a href=\"https:\/\/doi.org\/10.1111\/jocn.12641\" target=\"_blank\" rel=\"noopener\">https:\/\/doi<\/a><a href=\"https:\/\/doi.org\/10.3928\/01484834-20060601-04\" target=\"_blank\" rel=\"noopener\">.org\/<\/a><a href=\"https:\/\/doi.org\/10.1111\/jocn.12641\" target=\"_blank\" rel=\"noopener\">10.1111\/jocn.12641<\/a><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">Douglas, C., Booker, C., Fox, R., Windsor, C., Osborne, S., &amp; Gardner, G. (2016). Nursing physical assessment for patient safety in general wards: Reaching consensus in core skills.\u00a0<em>Journal of Clinical Nursing<\/em>,\u00a0<em>25<\/em>, 1890-1900.\u00a0<\/span><a href=\"https:\/\/doi.org\/10.1111\/jocn.13201\" target=\"_blank\" rel=\"noopener\">https:\/\/doi<\/a><a href=\"https:\/\/doi.org\/10.3928\/01484834-20060601-04\" target=\"_blank\" rel=\"noopener\">.org\/<\/a><a href=\"https:\/\/doi.org\/10.1111\/jocn.13201\" target=\"_blank\" rel=\"noopener\">10.1111\/jocn.13201<\/a><\/p>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"182-348\" hidden><p>refers to having more than one disease or condition.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"182-3845\" hidden><p>refers to a patient's health\/condition getting worse.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"182-350\" hidden><p>refers to an institution\u2019s approach to an urgent situation of managing a deteriorating client. It typically involves a team of critical care providers who are available to rush to the bedside of any deteriorating client.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"182-352\" hidden><p>an approach that moves from head down to the toes.<\/p>\n<\/div><\/div>","protected":false},"author":34,"menu_order":6,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by-nc"},"chapter-type":[],"contributor":[61],"license":[56],"class_list":["post-182","chapter","type-chapter","status-publish","hentry","contributor-61","license-cc-by-nc"],"part":170,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/182","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":14,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/182\/revisions"}],"predecessor-version":[{"id":3846,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/182\/revisions\/3846"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/parts\/170"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/182\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/media?parent=182"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapter-type?post=182"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/contributor?post=182"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/license?post=182"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}