Basic Guidelines for Conducting a Health Assessment

Basic Guidelines for Conducting a Health Assessment

People who seek health care for a specific problem often feel anx-ious. Their anxiety may be increased by fear about potential di-agnoses, possible disruption of lifestyle, and other concerns. With this in mind, the nurse attempts to establish rapport, put the per-son at ease, encourage honest communication (Fuller & Schaller-Ayers, 2000), make eye contact, and listen carefully to the person’s responses to questions about health issues (Fig. 5-1).

When obtaining the health history or performing the physical examination, the nurse must be aware of his or her own nonver-bal communication as well as that of the patient. The nurse takes into consideration the educational and cultural background as well as language proficiency of the patient. Questions and in-structions to the patient are phrased in a way that is easily under-standable. Technical terms and medical jargon are avoided. In addition, the examiner needs to be aware of the patient’s disabil-ities or impairments (hearing, vision, cognitive, and physical lim-itations) and takes these into consideration during the history as well as the physical examination. At the end of the assessment, the examiner may summarize and clarify the information ob-tained and ask if the person has any questions; this provides an opportunity to correct misinformation and add facts that may have been omitted.