A comprehensive and holistic health assessment includes:

• health history
• physical, psychological, social and spiritual evaluation
• consideration of laboratory and diagnostic test results
• review of other available health information.

first impression

The evaluation begins as soon as you meet your patient. Perhaps without even being aware of it, she is already noticing things like your skin color, speech patterns, and body position. Her education as a nurse gives her the ability to organize and interpret this data. As she moves through the formal nursing assessment, she will collect data in a more structured way. The findings you gather from your evaluation may be subjective or objective.

Group dynamic

By evaluating the assessment data, you will begin to recognize significant points and ask relevant questions. You will probably begin to group related pieces of meaningful evaluation data into clusters that give you clues about your patient’s problem and prompt additional questions. For example, if the data suggests a pattern of poor nutrition, you should ask questions that help uncover the cause, such as:

• Can you describe your appetite?
• Do you eat most meals alone?
• Do you have enough money to buy food?
• On the other hand, if the patient reports frequent nausea, it should be suspected that this may be the cause of their poor diet. Therefore, I would ask questions to get more information about this symptom, such as:
• Do you feel nauseated after meals? Before meals?
• Do any of your medications upset your stomach?

History

The nursing history requires you to collect information about the patient:

• biographical data
• current physical and emotional complaints
• past medical history
• past and current ability to perform activities of daily living (ADLs)
• availability of support systems, effectiveness of previous coping patterns, and perceived stressors
• socioeconomic factors affecting preventive health practices and concordance with medical recommendations
• spiritual and cultural practices, desires, or concerns
• family patterns of illness.

biographical data

Begin your story by obtaining biographical data on the patient. Do this before you start collecting details about your health. Ask the patient for their name, address, telephone number, date of birth, age, marital status, religion, and nationality. Find out who the patient lives with and get the name and number of a person to contact in case of an emergency. Also ask the patient about their medical care, including the name of their general practitioner and any other health professionals or members of the interprofessional team with whom they have contact, for example, an asthma nurse specialist or a social worker.

If the patient cannot provide accurate information, ask for the name of a friend or family member who can. Always document the source of the information you collect, as well as whether an interpreter was needed and present.

current complaints

To explore the patient’s current complaints, ask about the circumstances that have brought him or her into contact with the health care team. Is there any aspect of your health that worries you or is difficult for you? Patient complaints provide valuable data immediately. When you explore these initial complaints, you may uncover additional crucial information.