A comprehensive assessment is the first part of the nursing process, and will form the basis of the patients care plan, management and treatment.
The essential requirement of accurate assessment is seeing the person in front of you as an individual and identifying their real needs. However, if we are not structured in our approach, we may lack direction and the consultation may be more time consuming than we would hope for, and less productive.
- Getting started
- Presenting Complaint
- History of Presenting Complaint
- Patient History
- On examination
- Differential Diagnosis
Before any consultation I find it useful to think about the purpose of the patient’s visit.
For example, it might be because of a symptom or concern, they may have been referred for screening, advice, review or education or there may be diagnostic doubt. Although it is important not to let anyone else’s opinion influence your review or findings, it may be useful to read any secondary sources of information to give you some background.
To start, I make sure that the consulting room is not only private, but welcoming. Remember to greet the person consulting by meeting their eyes and smiling. Introduce yourself and ensure they can sit comfortably. Establish up front your understanding of the purpose of the consultation.
If you’re running the session virtually, this article on digital consultations might be helpful too.
Presenting Complaint (PC)
Start by asking what has brought the person in to see you. Try and keep the person focused – they may have saved up a lot of concerns before coming to speak to you.
Check that your understanding is the same as the patient: reflect back their concerns. Let the person know that you are going to ask some background questions, starting with open questions before narrowing it down to specifics.
TIP: Talk to the person, not the computer.
History of Presenting Complaint (HPC)
This entails asking about how long the complaint has been going on for.
If it’s been a long time, I ask why they are consulting now. It may be useful to ascertain if there have been previous consults for this complaint and whether they have had anything similar before.
Check whether the complaint is intermittent or persistent, and what makes it better or worse. Finally, find out whether they take anything for the complaint and whether it works, remembering this might be over the counter or a prescribed treatment.
TIP: Make sure you document the complaint(s). If it’s not written down, it didn’t happen.
TIP: Often the person has an idea about what they think the complaint is caused by and they may have expectations of a certain treatment. This will need to be considered.
Past Medical History (PMH)
I find this helps me in my considerations. I start with the person as a baby as knowing about early history and prematurity may be useful, plus any childhood illnesses, and operations or hospitalisations. I also capture any current illnesses which it is useful to document. Weight gain or loss may be useful to know about.
TIP: Often people can be vague about their past medical history and may not remember dates. You may need to prompt them.
Family History (FHx)
Some of the family history I ask about are parental and sibling illnesses or deaths, and family history of atopy or allergy. This will help with familial or hereditary conditions.
TIP: Document if the person is unaware of their family history, which can happen in cases where a patient has had an early loss of parents or is adopted.
Social History (SHx)
Occupation is important in many respiratory complaints, so ask about present and past occupations. I find it helps to think about the ‘red flag’ occupations and exposure to asbestos, fumes or dusts.
Hobbies may also shed light on underlying problems. I also ask about pets, especially birds and cats, and this may lead on to questions about any allergies. I also ask about tobacco consumption and any other substances smoked or taken as well as alcohol consumption.
Current living arrangements and support networks are important to find out about as many respiratory illnesses can co-exist with – or cause – anxiety and depression. Finally, I check if the patient is in receipt of any benefits for disability or blue badge status which may be useful to find out about.
TIP: A change in symptoms can be due to changes in job process rather than an actual job change.
Drug History (DHx)
A good drug history will require asking about prescribed, over the counter and ‘herbal’ remedies. I also ask about what the patient has taken previously, as some medications may be linked to present symptoms.
If inhalers are taken always check inhaler technique – there’s a piece on top tips for inhaler technique here on Together in Respiratory too.
TIP: Beliefs or concerns about medications are important to understand as it may influence a patient’s willingness to take or use any suggestions for treatment.
On Examination (OE)
For me, this will involve a good look at the patient. I’m looking for simple things like how they walk, breathe, talk, their cleanliness, whether I can smell smoke etc. These all give me a picture of a person.
I’ll also examine the hands for joint issues, finger clubbing and nicotine staining, as well as whether the hands appear cold or hot. I always put a finger on the pulse as atrial fibrillation is common and can cause breathlessness.
The patient’s colour may be indicative of anaemia or cyanosis. I’ll also ask about ankle swelling or any joint pains. I’ll count respiratory rate and ask about any sputum production.
TIP: Many of our observations of someone are made as we are talking to them. Examination supports our findings.
Common things occur commonly, as the saying goes, and a good consultation should point us in the right direction.
I consider the most likely diagnosis, and then consider if I can confirm or exclude this. If I need more tests or investigations, I explain this to the patient.
In layman’s terms, I explain the diagnosis and check their understanding: reinforcing perhaps with written information or other media, remembering that for many people English is not their first language.
TIP: People can live with honest uncertainty if you are up front about the fact that you need further affirmation, investigations or tests.
This is about what discussions you’ve had with the patient you’ve consulted, and what path you’ve agreed upon. Support personal choices and remember medication changes need to be agreed on.
TIP: Remember when the person leaves your consult room, they may well forget much of what you said, and not everything they remember will be accurate. Always keep good and accurate records.
For me, a good comprehensive assessment is both structured and second nature, meaning it can be both effective for the patient and time efficient for the healthcare professional.
Any advice given and opinions expressed in this article are those of the author and do not reflect the view of Chiesi Limited (Chiesi). All content in this article is for informational and educational purposes only. Although Chiesi strives to always provide accurate information, it is not responsible for and does not verify for accuracy any of the information contained within.
 Medistudents. History Taking. Available at: https://www.medistudents.com/osce-skills/patient-history-taking
 NHS. Atrial fibrillation. Available at: https://www.nhs.uk/conditions/atrial-fibrillation/#:~:text=Symptoms%20of%20atrial%20fibrillation,shortness%20of%20breath%20and%20tiredness