Learning How to Do a Health Assessment
When I worked as a home health nurse and received a new patient assignment, I always did a health assessment the first time I met the patient. The purpose of the health assessment was to check out the patient from head to toe to see for myself if everything was in good working order. I looked at each part of the body and asked about the functioning of each body system. I checked out the patient’s mental status, including their ability to follow instructions and remember information. As you can imagine, evaluating someone’s health status requires asking a lot of questions.
As a caregiver, you will want to know how to tell if something is wrong with your family member or if anything has changed since your last visit with them. I’ve written out some sample assessment questions to help you know what to ask when assessing various body parts and functions. Some of these you would not apply if you saw the family member regularly but might be helpful if you took care of a distant relative.
General Knowledge: What are your current medical conditions? Which ones require you to see a doctor each year? Which ones require you to take medicine? Have you had any major surgeries where you had to stay in the hospital a long time or that took you a long time to recover? Are there surgeries that you still see a doctor about now? Do you have any aches, pains, or illnesses that you have not seen the doctor about but are treating? If so, what are you doing for them?
Medications: What medications are you taking daily, weekly, and “as needed.” Do you regularly drink or use any herbal products? What are they? Do you take any vitamins or use health products or other supplements? What over-the-counter medicines or ointments do you use if any? How often, how much, how do you take it, why do you take it, and any side effects? What do you use for pain management?
Eating: What do you usually eat? Are you on any special diet? Do you have any difficulty swallowing, chewing, indigestion, or reflux? Is there a feeding tube? If so, what type, how long has it been there, and what are the care procedures? Any unexplained weight gain or loss. Any bleeding orally? Any nausea or vomiting?
Urinary System: Any issues passing urine? Does the urine smell? What color is it? Do you get up at night? How often do you go? Are catheters used? Are there accidents? If so, when do they occur? How is the skin affected? Any urinary tract infections? Do you have any swelling of your ankles, legs, hands, or elsewhere? Are you on dialysis? Are you on any food or liquid restrictions for dialysis?
Bowels: Any problems with bowels? What about diarrhea or constipation? How do you treat it? Any bleeding rectally? What is the bowel routine? Is there a colostomy? If so, what supplies do you use? How do you care for your colostomy? Do you have any difficulty with leaks around the appliance, and if so, how is the skin affected? Has there been any skin breakdown?
Breathing: How is your breathing? Do you find it difficult to take a deep breath? Do you use oxygen? If so, how much and how often? Do you use an inhaler, a nebulizer, or any other bronchodilator? What is your usual oxygen saturation? Any swelling of ankles or shortness of breath? Do you have a device to make oxygen at home, any oxygen tanks, or other oxygen equipment at home? Do you use a C-PAP or B-PAP machine to help you sleep at night?
Heart: Any chest pain with activity? Do you use anything for chest pain if you get it? Do you have any heart problems, such as irregular heartbeats or leaky heart valves? Do your lips turn blue when you’re tired? Do you get faint or pass out when you stand up? Do you feel your heart beating in your chest? When? How does it feel?
Diabetes: Do you take insulin or any other medication to regulate your blood sugar? What do you take and how often? How is that working for you? What is your current blood sugar? Do you exercise? Do you test your blood sugar, and if so, using what? Could you show me how and what you use? What is your diet? How is your skin? Feet? Circulation?
Eyes: When was your last eye exam? Do you wear glasses or contacts? Can you see with them? Do your eyes hurt, drain, or itch? Do you have cataracts? Can you see objects clearly at night?
Hearing: How well do you hear in each ear? Do you have any ringing? Any dizziness? Do you use a hearing aid? Do they work?
Nose/Smell: How is your ability to smell? Any odors you cannot smell? Are you sensitive to odors? If so, which ones? Do you have allergies? Do you get nasal congestion? If so, how do you treat it? Do you get nose bleeds? Do you need to sit up to sleep? How many pillows do you use?
Taste/Teeth: How is your ability to taste? Is there anything you cannot taste? Do you have your teeth? If not, do you have dentures? How are your gums? Do they bleed? Do you get sores in your mouth? Any issue with bad breath?
Skin: Any breaks in the skin? Bruises, cuts, skin tears, or other skin damage? If so, where is it, and how long has it been there? What are you doing about it? Do you have dry skin? Varicose veins? Does your skin tear easily? Are there any usual bumps, moles, lumps, or growths?
Nerves/Sensation: Do you have any numbness, tingling, loss of strength of limbs, sharp pains, or any new function loss in any area? Does it change with positioning? Does anything else affect it? What do you do to help it? When did it start? Was there an accident associated with it? Had you started any new medicine just before it started?
Activity: What level of activity level can you achieve with comfort? Can you go beyond that point with discomfort, or is that the absolute most you can do? How far can you walk at a continuously steady pace? How many flights of steps could you climb if each flight had five steps between landings?
Communication: Can you read, and write? Do you have difficulty doing either? Understanding either? What is your primary language? How do you prefer to receive your information by telephone, text, or email? How do you like to learn information? By watching someone do something, doing it yourself while someone watches you, reading about it, watching a video, or a combination of these?
Mental Status: What is your mental status like usually, and does it change? If so, what makes it change? Is your memory good? Do you lose things? Have you ever gotten lost? Do you have any other special needs?
Sleep: How much do you sleep? How long do you sleep at one time? Do you nap during the day? Do you fall asleep when just sitting around watching TV or working on something? How much total sleep do you get in 24 hours? How well do you sleep when you do sleep? Do you take anything to help you go to sleep? Do you snore? Is your mouth dry when you awaken?
Speech: Do you have any difficulty with your speech? Forming words? Understanding words? Getting the correct word to come out as you start to say it. Do you stutter? Have trouble with losing your voice? Have a dry mouth a lot? Sore throats? Can others understand what you say, or must you repeat yourself to them frequently? Slur your words? Use the wrong words?
Mental Health: Do you worry about anything? If so, what? Do you feel depressed? Sad? Do you feel hopeless, like life is not worth living any longer? Do you ever want to hurt yourself or anyone else? Do you sometimes lose control of your anger? What happens when you lose control? How do you feel most of the time? Are there days that you can’t do your usual activities? What do you do on those days? Where do you go? What makes you feel better? What makes you feel worse? Do you feel safe? Has anyone hurt you? Do you ever think you see or hear something that later you found out wasn’t there?
After completing your health assessment, develop a plan of care to address any issues you identified.