Midwifery and nursing care has health assessment forms as the foundation. This involves
an ongoing cyclical process where the whole person is evaluated as a functional, psychosocial
and physical being. This is regardless of whether the person is ill or well, old or young. The first
health assessment’s aspect is the midwife or nurse conducting the primary assessment with the
aim of detecting life-threatening conditions. After this, there is a health history, involving
collection of the subjective health information. The information can be acquired from different
sources, including the patient. There can also be use of medical or family documentation, as well
as the client’s significant other. Through the patient’s health history, it is possible to learn about
the cultural, emotional social, physical, spiritual, and developmental identity of the patient, and
this definitely facilitates the person-centered care. This assignment involves a primary health
assessment. Before the assessment, the Health Assessment Explanatory Letter was explained and
after understanding, the client signed the Acknowledgment of Receipt. Participation was
Preparing for the Health Assessment- 900
Purpose of a primary survey and health history assessment
In essence, the health history assessment is a very valuable tool through which nurses can
practice their various skills. Through the assessment, the nurse is able to obtain descriptions from
the patient, and this offers detailed insights about the patient’s state of health, symptoms, and
potential conditions (Jones et al., 2016). Moreover, there is better understanding about the
symptoms’ development. This is the process through which the associated physical findings can
be discovered and this helps in determining the differential diagnosis.
The primary survey and assessment are a very appropriate chance for the healthcare
professional to develop rapport with the patient as well as the family. There is no doubt that the
first impressions are what last. Therefore, through the primary survey and assessment, the
healthcare professional can instill some trust in the patient, which would promote continued
access to the healthcare services. The nurses also understand the patient better during the
assessment, including the religious and cultural practices and believes, therefore ensuring that
appropriate measures are taken for positive outcomes.
Lin, Coffin and O’Sullivan (2016) was keen to note that the primary survey helps the
healthcare professional in detecting the immediate life threats. This is the basic step towards
ensuring that the most important measures are taken. This ensures that danger is deviated from
the patient for health and wellbeing. Essentially, there is also an identification of the patient’
specific needs. McCoy et al. (2016) indicated that knowing the needs is the first step towards
addressing them. The risks of other diseases are detected, promoting early preventive and health
promotion steps. With these two components, there is proper guidance on how to treat and
approach the individual.
The assessment was done on a patient who was suffering from diabetes mellitus 2.
Rationale and purpose; conducting the primary survey was helpful in enabling the healthcare
professional detect the patient’s threats to life that were immediate. Correcting the threats early
would enhance the health and wellbeing (McKnight et al., 2015).
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Poor Fair Good Very
The general impressions
Assessment on the mental status using alertness, verbal,
painful, and unresponsive
State of the pulse
Have you had any challenges with you airway?
Would you rate your breathing as adequate?
How do you feel about your general health and wellbeing?
Rationale and purpose; the biographical data is very important in helping identify the risks the
patients could be facing. This is based on the fact that there are components that help in knowing
more about the patient such as sex, age, and ethnicity, which are important in predicting risks
(Shen et al., 2013). The data will be used for identifying the patient and predicting risks.
Telephone (home and work)
Date of birth
What is your education level?
Are you currently widowed, divorced, separated, married, or single?
What chronic conditions do you have?
Have you been suffering from any disease for an extended period of time?
Current Health Status/Reason for Seeking Care
Rationale and purpose; knowing how the patient feels presently about the state of health can help
in predicting the condition (Gubhaju et al., 2013). Moreover, the needs of the patient would be
identified precisely, which would promote a better intervention (Grantham et al., 2013). It can
help the healthcare professional to know the expectations and, therefore, address them.
- How are you feeling presently about your health status?
- What are the signs and symptoms are you experiencing?
- When did you start experiencing those signs and symptoms?
Perception of Present State of Health (History of Present Health Status)
Rationale and purpose; knowing about the perception of present health that the patient has can
guide the kinds of interventions that are offered. It would also be easier to rate about how the
patient perceives himself in relation to health, which can promote proper guidance and
counseling (Burridge et al., 2016). The patient could even be disturbed psychologically, and such
issues can be addressed.
- Generally, would you rate your health as excellent, very good, good, fair, or poor?
- How have you been coping with self-management and self-care?
- Do you feel that your family has been offering you adequate support in managing your
Past Health/Medical History
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Rationale and purpose; knowing about the medical history of the patient is important as it can
offer some insights about the present health condition. Moreover, the present condition could be
related to other diseases the patient might have suffered from in the past, considering that many
chronic conditions are connected (Tina et al., 2016).
Have you ever suffered from lung or heart-related conditions?
Have you ever been admitted for diabetes-related complications?
Have you ever experienced any challenges with your kidney?
Have you ever experiences any symptoms of renal, neurological, cerebrovascular, or
ophthalmological complications of diabetes?
Have you suffered from any diabetes mellitus complications lately?
Have you any challenges with sexual functions?
Rationale and purpose; knowing about the family history would be essential as it can form a
basis for diagnosis or help in determining the risk for other diseases. The information acquired
can be used for formulating better interventions (Waterworth et al., 2015).
- Has any member of your family suffered from diabetes mellitus?
- Does any member of your family suffer from heart-related conditions? (Fazli et al.,
- Would you say your family engages in appropriate lifestyles?
General Overall Health and Wellbeing
Rationale and purpose; knowing about the general overall health as well as wellbeing of the
patient can help the healthcare professional in knowing more about potential risks faced. This
can help with planning of the interventions (Waterworth et al., 2015).
- Have you recently experienced any challenges with your nerves?
- Do you have any complaints about your health and wellbeing status?
Health and Lifestyle management
Rationale and purpose; knowing about the patient’s lifestyle and health management can guide
the professional in knowing about the factors contributing to the disease for proper adjustments.
Therefore, more appropriate interventions can be incorporated into self-care.
- What positive lifestyle aspects can you say you engage in?
- Do you engage in self-care? (Browne, Scibilia & Speight, 2013).
- Are you determined about maintaining a proper lifestyle for positive health?
Do you think an appropriate lifestyle can benefit your health in the future?
Documenting the Health Assessment- Findings and Participant responses
The general impression obtained on the first instance of interaction was good. Client Y
was dressed appropriately and her communication was efficient. It was even hard to suspect that
she was a patient. Her verbal, alertness, and unresponsive aspects were good. The pulse was
normal, and she reported there were no issues with the airway. She reported having no
challenges with the breathing. According to her, the general wellbeing and health were fair, as
she felt there were deteriorations compared to the past (Glasson, Larkins & Crossland, 2017).
The biographic data led to the realization that client/ patient Y came from a background
where people were financially unstable. Her family and those in the neighborhood lacked
adequate food all the times as the environmental condition was not conducive. There was a high
level of engaging in unhealthy behaviors including eating junk foods, as these were sold at
HEALTH ASSESSMENT 4
cheaper prices in the neighborhood. The Hispanic middle-aged woman had achieved the high
school certificate, and did not proceed any further. She was separated from the husband and was
the sole breadwinner to three children. She was suffering from hypertension.
The client narrated that she was very anxious about the present health status. She was
sure her health condition was deteriorating, since she kept falling ill now and then. She was also
worried about the financial burden of taking care of the adolescents, particularly the education
costs. She was experiencing general body weakness or malaise, and had blurred vision often
(Banfield et al., 2017). Her frequency of urinating had increased to the extent that having a
peaceful sleep was hard. The tingling sensation on her feet and hands had also increased. The
symptoms had increased gradually over the previous one month.
Based on this, she rated the health as fair. She also felt that the responsibilities in her life
were hindering efficient self-care and self-management. It was sad to realize that she was
receiving no support in managing her state of health as her children had no way of doing this.
client Y had never suffered from any heart- or lung-related conditions. A year ago, she had been
hospitalized for high blood pressure (Begley & Pollard, 2016). She stayed at the hospital for
three days, and was advised to manage her stress appropriately to avoid re-hospitalization. She
had never experienced issues to do with the kidneys, or neurological, cerebrovascular, or
From the assessment, I learned that the patient’s grandmother had died from diabetes
mellitus while the father had been treated severally for stroke. Therefore, she was worried that
she could be suffering from any of these conditions. She was open to remark that she never
thought her family members engaged in proper lifestyles. The foods consumed were never
healthy, and mainly constituted of fast foods, fatty, and sugary foods. Actually, it seemed as if
this habit was being passed down through the generations (Alouki et al., 2016).
Client Y reported issues with the nerves. The complaints linked to the wellbeing and
health status included the blurred vision and tingling sensation on the feet and legs. Definitely,
these are linked to the nerves. The client was very worried about losing her sight or being
amputated. These signs had been increasing gradually, making the client really worried. This was
the greatest need identified and, therefore, addressing this was very pertinent. This made her
very worried about the future of her children (Waterworth et al., 2015). At this point, I found it
necessary to reassure her that getting worried was much more likely to cause more harm than
The client narrated that she walked often. However, this level of exercise was very
minimal. Her levels of exercise had to increase for it to be considered adequate. The financial
situation never allowed her to engage in proper diets at all times. Although she was really
determined about practicing positive dietary habit for herself and the children, she often relapsed
due to inadequate resources. Self- care included putting on shoes, taking the blood sugar and
pressure levels regularly, and seeking medical care attention whenever feeling unwell. Client Y
was really keen about maintaining a proper lifestyle, and was ready to make the necessary
HEALTH ASSESSMENT 5
changes. She requested for support and guidance. She was ready to use the limited resources in
making the needed adjustments.
Reflection and future planning- 400
In midwifery and nursing process, reflection forms a very essential component. At the
same time, it helps in improving the response to and awareness to the interactions with family,
patients, and healthcare professionals (Adegbija, Hoy & Wang, 2015). Through the reflection, a
lot of improvements can be planned on and implemented.
The first challenge related to effective communication. This was a challenge in that in
most of the questions, communication barrier was experienced. As such, it was hard for her to
understand some of the aspects that I was questioning on. I had to spend a lot of time explaining.
At the same time, it was a bit hard for me to comprehend the non-verbal communication that she
was using, and vice versa (Schierhout et al., 2016).
Second, there was limited time for conducting the interview. As such, some questions
could not be explored. At the same time, addressing some very pertinent issues or concerns that
the patient had was difficult. As such, both I and the client left the interviewing room feeling
Apparently, the barriers could be attributable to the fact that the client’s level of
education was a bit low. Her ability to understand English was a bit low. Being a Hispanic, her
English speaking ability was quite low.
Since some considerable time had to be spent elaborating as the client could not
understand well, time for exploring other pertinent issues was limited. Therefore, for the entire
interview period, only some aspects were explored in detail while others were not.
Overcoming in future
The communication barrier could be addressed by ensuring that an interpreter is invited
in the future. I would use the interpreter’s services so that the patient can understand everything
being said. This would avoid time wastage (Abouzeid et al., 2014).
To overcome the limited time challenge, using an interpreter would make things easier
therefore saving on time for exploring other pertinent matters. At the same time, prior planning
will be done so as to ensure that there is awareness on the client to be interviewed. The items to
be questioned during the interview should first be listened down and followed. In case the client
tries to deviate from the interview, this would be avoided by sticking to the list. In short, the
interview will be structured.
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