- Overall Health Assessment to Promote Wellness
- History and Physical
- Stressor Evaluation
- Evaluation of Spirituality
- Education and Health Education
- Support Assessment
- Medical/Surgical History
- Family History of disease
- Head-to-toe Physical Assessment
- Fitness Assessments – as needed
- Alcohol/Drug Consumption
- Tobacco use
- Current level of stress
- Healthy Coping Mechanisms
- Family involvement with stress
- Belief system
- Cultural implications
- Dietary restrictions
- Example – Jewish or Muslim patient’s don’t eat pork
- Jehovah’s Witnesses don’t commonly accept blood transfusions
- Dietary restrictions
- Spiritual Support
- Health Education
- Highest education level
- Understanding about health and wellness
- Willingness to learn
- What support does the patient have regarding change?
- Does that support believe in change?
- Identify resources for the patient for change
- Patient Education
- Health Promotion
- Health Policy
- Educate patient on needs for wellness and goals for health
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell
In this lesson, we are going to focus on what a health promotion assessment is, and what that means for our patient
When we talk about health promotion assessments, this is our opportunity to look at the patient completely. Yeah, it includes a physical assessment, but it also includes lots of other information.
In order to get a complete picture of our patient, we look at history, different aspects of their lifestyle, stressors and how they handle them, spirituality, education and how well their support system works for them.
Now let’s take a look at these different parts…
When we look at our patients we need to get a great history and physical, which is sometimes called an H&P.
We peer into the patient’s health history to get a more complete picture of what influences their health, which helps us to start planning for them.
We look at things like where they live, their age, gender, race, date of birth, marital status, etc – these are their demographics. . We also look at their medical and surgical history and also how they eat.
A big thing you want to cue in on is family history. There are lots of links between family history and risk of disease. So things like stroke, diabetes, heart disease. They can really give you a great look into potential risks for disease. We also ask them about vaccines, like if they’ve had a recent tetanus or flu shot.
One big thing you always want to ask is about their medications. What medications are they on, what doses, do they take them regularly, etc? This gives us an idea into how compliant they are.
H&P also includes your physical assessment, which is outlined in other lessons, so be sure to check those out. It helps to confirm the information that they told you. If they say they’ve never had any surgeries, and they have a large surgical scar on their abdomen, it helps to get more information.
Once you’re done with your H&P, you can ask your patient about their current lifestyle. So this includes things like what kind of job they have, which gives you insight into their risk or if they’re exposed to hazards regularly.
You can also talk to them about how often they use drugs or alcohol. One thing I like to tell my patients is that I’m not a police officer and this isn’t an investigation and that they won’t get in trouble. Usually results in a few chuckles. But I do reiterate that it’s important for them to be honest so that I can get a better picture of what’s going on with them.
Also be sure to ask them about smoking. So, do they smoke, how many packs a day, and for how many years. This is called pack-years, which helps tell us risk for things like COPD or lung cancer. So, how many packs a day times how many years equals pack years.
Also ask them about exercise and how often.
Another important point of the assessment is to look at current levels of stress and stressors. Find out from your patient how they handle stress and what their current stress level is. This helps with some insight into how they cope with changing situations. Also be sure to ask about what kind of family support they may have. Illness can be stressful, and if they don’t have a solid support system, now is the time to pick up on that, and to be aware of it so you can plan to get them resources.
The spiritual aspect of care can be really important for your patient. Lots of patients have spiritual or cultural beliefs that play a big part in their sense of self. These things help create their identity. For instance, you could have a patient that attends church regularly, and their church family is a big influence in their life. You’ll need to be mindful that that plays a big part of who they are.
Some belief systems have cultural implications, like certain dietary restrictions. So when you begin to ask about their spiritual beliefs, be sure to ask about any food items that they don’t want to eat. It helps to build rapport and trust. It shows the patient that you care about them and who they are as individuals.
Also, some patients like to have spiritual support. It’s not uncommon to have prayer circles for patients, or for the patient to request chaplain, so be sure to acknowledge your patient’s request for them.
When we talk about patient education, we want to understand their highest education level, what they understand about their health or health in general, and things like their willingness or eagerness to learn. There’s an entire lesson on patient education, so check that out.
Support for your patient is really critical for a patient’s success. A great example of this is someone battling substance abuse. If they don’t have a great support system, then they may not succeed in sobriety.
So what’s your job?
Well, you can first help by talking to the patient about who supports them at home. Family, kids, wife, husband, brother, parents? The list goes on. But having the patient first identify who those people are can also help you educate THEM in the process
Next you should take a look at those people. Do they believe in change? Going back to the patient with substance abuse…does their family want them to succeed? If so, then you’re going in the right direction? If not, then you’ll need to educate them.
The other thing you can do for those patients who face barriers is to find resources in the community. So rehab programs would be helpful for this patient, and also sponsorship programs could help with sobriety.
All of our nursing concepts for this lesson really go hand in hand. As the nurse, you’ll continually promote healthy lifestyles through patient education. Also, because health policy is so heavily influenced by health promotion and patient success, the success of those patients determines the success of health policy.
First off, if you head into your health promotion assessments aiming for total wellness, you can quickly identify risks for disease and areas of improvement.
Look at your patient’s medical history, family history and current lifestyle. This’ll give you insights into gaps of health.
Identify your patient’s stressors, current level of stress and support for stress. This can help reduce stress throughout the healing process.
Look for education barriers early. If you do, you can help to get around them quickly and help your patient plan for recovery.
Make sure your patient has support in every corner. From family to members of their own faith, make sure they have people in their corner to help them succeed.
Lots of information on this lesson, but it definitely helps you as a nurse to look at the whole picture of your patient! Check out all the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing!!