Reasons for Conducting a Complete Subjective Health Assessment
The aims of the nursing process are to identify main health and illness concerns, determine the underlying issues/etiology, collaborate with the client to address and resolve these concerns and issues, and engage in health promotion. To meet these aims, you engage in a process of diagnostic reasoning by critically exploring and analyzing both subjective and objective data to identify cues that require further investigation and the health needs of the client. The complete subjective health assessment is an important component of this process as it allows insight into the client’s state of health and illness. Depending on the context and the client’s main health needs, the complete subjective health assessment may occupy the bulk of your time with the client.
You should conduct a complete subjective health assessment when a comprehensive overview of the client’s health and illness is needed. For example, you may conduct a complete subjective health assessment when a client moves into a long-term care institution, and depending on the institution, this may be repeated monthly. This assessment is also conducted when a client is admitted to a hospital, and a shortened version of it is often completed at the start of each shift. However, how frequent and how comprehensive the assessment is depends on the client’s needs, the situation, and the institution’s policies.
More focused assessments are required when collecting specific subjective data based on the health issues and/or need to clarify or follow up on previous information provided. Situations that warrant a focused assessment as opposed to a complete subjective health assessment include:
- An emergency (i.e., a situation with imminent catastrophic risk if untreated). In this case, you focus on collecting data that is vital to stabilizing a life-threatening illness; it may be specific to airway, breathing, and circulation. An example is a client who arrives at the emergency department reporting “crushing chest pain.” In this case, a focused assessment is conducted that attends to the reason for seeking care and may focus on questions about the cardiac and respiratory system.
- A continual in-hospital assessment. In this case, you assess a client several times throughout your shift. The assessment focuses on the client’s current main health issues and following up on health issues that were previously addressed.
- Primary care assessment. In this case, you focus your assessment on an emergent issue that has arisen for a client (e.g., a rash, pain in their knee, a fever). However, some primary assessments require a complete subjective health assessment particularly if this is a client you are meeting for the first time or they have a complex health issue.
Test Yourself
Symptoms or signs that signal a potential concern that may need to be investigated further (e.g., headaches)
Assessments specific to a health issue and usually limited to one or two body systems.