NSC 209- Health and Physical Assessment

Health assessment is an essential nursing function which provides foundation for quality nursing care and intervention. It helps to identify the strengths of the clients in promoting health. Health assessment also helps to identify client’s needs, clinical problems or nursing diagnoses and to evaluate responses of the person to health problems and intervention. An accurate and thorough health assessment reflects the knowledge and skills of a professional nurse. The focus of nursing care is attainment, sustenance, and recovery of health. Helping clients to achieve, sustain and restore healththe diagnosis and treatment of human responses to actual or potential health problems or life processes. The information obtained from the nursing history and physical examination is used to determine the strengths of the client or responses that the client exhibits in response to health problem. You will obtain a client’s health history and perform a physical examination during the assessment phase of the nursing process. The results of the assessment (1) contribute to a database that identifies the client’s current and past health status and (2) provide a baseline against which future changes can be evaluated. The purpose of the nursing assessment is to enable you to make a clinical judgment or diagnosis about a client’s health status. Although assessment is identified as the first step of the nursing process, it is performed continuously throughout the nursing process to validate nursing diagnoses, evaluate client’s response to nursing interventions, and determine the extent to which client outcomes and goals have been met. An assessment describes a hand-on data collection process, while a database identifies a specific list of data to be collected. The database is all the health information about a client. It includes the nursing history and physical examination, the medical history, and physical examination, results of laboratory and diagnostic tests, and information contributed by other health professionals.