How can we identify health risks, strengths, and needs in our comprehensive health assessment?
There are numerous ways that we can identify health risks, strengths, and needs in our comprehensive health assessment. First and foremost, obtaining a chief complaint followed by a history of present illness is essential to a comprehensive health assessment. This determines why the patient is seeking care and provides the healthcare provider insight on what patient health concerns exist. Upon beginning a comprehensive health assessment it is also necessary to identify who is the best source to retrieve information from, whether it be the patient or a family member, and to determine if the source is a reliable one or not. This ensures the most accurate and detailed information is collected. Health risks, strengths, and needs can be determined by obtaining a past medical history, social history, family history, and review of systems (Bates, 2021). Proficiently performing a comprehensive health assessment, including a collecting a detailed health history is a core competency of the advance practice registered nurse (APRN) role. It is important to recognize that novice APRN’s face many challenges in collecting detailed health histories. It is evidenced that by clinical practice, simulation, and reflection, skills can be developed to proficient levels (Ingram, 2017).
Give two examples with rationale for each.
Obtaining a family history is a vital component of a comprehensive health assessment to determine health risks and needs. For example, an 19 year old female presents to clinic for her first annual comprehensive health and physical examination. She has not seen a primary care physician since she was established with her pediatrician as a minor. She has never been to a gynecologist. She recently lost her mother to breast cancer and has no other immediate family. She believes her grandmother passed away from some form of gynecological cancer. She denies ever being screened for BRCA. By discovering past family history, it is extremely important to refer this patient for genetic testing and cancer screening. If family history was not addressed, the risk for cancer would not have ever been discovered.
Obtaining a social history is also a vital component of a comprehensive health assessment to determine health risks and needs. For example, a patient presents to clinic with complaints of recent shortness of breath and cough with hematuria present. During collection of a social history, he denies smoking or other inhalants. He is currently unemployed. However, it is determined during inquiry that he was a welder in a chemical plant and has previously been exposed to asbestos. In addition, it is discovered that his insurance is ending due to a loss of job related to his recent symptoms and inability to work. A risk factor for cancer was discovered due to the collection of a social history. Also, the need for social work and case management arose to aid in the facilitation of workman’s compensation, financial assistance, and health insurance.