Question

Case Study, Chapter 28: Pulling it All Together: Integrated Head-To-Toe Assessment

A 21-year-old male college student attends the health care facility to have a history and physical conducted for work. The client will be working as a camp counselor for the summer. The client’s last physical was a few years ago when he was a freshman in college. The client hands over the camp forms that the nurse needs to complete. The forms ask for a complete physical to be conducted, along with certain blood tests and a chest x-ray. The nurse proceeds with the interview. The client gives a negative history for medical conditions or surgical procedures. He is not on any medication and does not smoke or drink alcohol. Upon interviewing the client, the nurse notes that the client is very shy and does not easily reveal information. The nurse has been working at the health care facility for only a few months and is not sure how to proceed with the physical exam. The nurse goes out of the room to enlist the help of the senior nurse at the facility. (Learning Objectives: 1, 3)

Questions:

a. In order for an interview and a health assessment to be accurately completed, what key elements should be in place?

b. The novice nurse knows that a complete health assessment takes approximately 2 hours; however, the senior nurse completed the exam in 1 hour. How is this possible?

Answer 1

a.The key elements for an effective health assessment are

• There should be a very clear and focused communication or rapport th br developed in order to collect history
• The healthcare professionals though a novice should have a good theoretical knowledge to apply it during assessment before gaining any clinical experience
• Ensure an appropriate place is selected for conducting the interview or health assessment which can give patients privacy and to disclose their health problems
• To use appropriate verbal communication and non verbal communication
• Ensuring all the resources are there for conducting the interview

b.This is because of the experience gained by the senior nurse.They can be very specific and general wherever necessary to collect the necessary information from the patient. Whereas the novice nurse is new to it ,getting through the assessment form and filling in can be a challenge to do it error free and which can costs their time.