Nursing Assessment Guide: Systematic Patient Evaluation

Nursing Assessment Foundation: Gathering Complete Data

Comprehensive nursing assessment forms the foundation for all clinical care. Systematic collection and interpretation of subjective and objective data enables accurate nursing diagnosis, effective care planning, and quality patient outcomes. Assessment is ongoing and should be updated as patient condition changes.

Assessment Facts:

• Comprehensive assessment takes 30-60 minutes initially
• Focused assessment on specific problems requires 10-15 minutes
• Assessment accuracy directly impacts care quality and patient safety
• Documentation provides legal record of care and patient status
• Reassessment detects early changes in patient condition

Patient History: Subjective Data Collection

Chief Complaint and Presenting Problem

• Chief complaint: Reason for seeking care (patient's own words)
• Duration: How long has problem been present?
• Onset: Sudden or gradual? What was happening when it started?
• Severity: How much does it affect daily activities?
• Precipitating factors: What makes it worse or better?

History of Present Illness (HPI)

• Chronological narrative of current problem
• Include timing, severity, associated symptoms
• What treatments have been tried? Were they effective?
• Impact on function, work, relationships
• Patient's understanding and concerns

Past Medical History (PMH)

• Chronic conditions: Hypertension, diabetes, cardiac disease, respiratory disease
• Previous surgeries: Type, date, complications
• Hospitalizations: Reason, date, outcomes
• Injuries and accidents
• Mental health history: Depression, anxiety, psychiatric treatment

Medication Review

• Current medications: Name, dose, frequency, indication
• Over-the-counter medications and supplements
• Medication adherence: Does patient take as prescribed?
• Medication allergies: Reaction type and severity
• Drug interactions assessment

Family History

• Family health patterns: Cardiovascular disease, diabetes, cancer, mental illness
• Age and cause of death of parents, siblings
• Genetic disorders: Sickle cell, cystic fibrosis, hemophilia
• Familial patterns: Early-onset disease, multiple family members affected

Social History

• Living situation: Home with family, alone, assisted living
• Occupation: Work-related stressors or exposures
• Tobacco: Current, former, or never; pack-years
• Alcohol: Frequency, quantity, impact on health
• Recreational drugs: Type, frequency, route
• Sexual history: Number of partners, practice, STI risk

Physical Examination: Objective Data Collection

General Appearance and Vital Signs

• General appearance: Alert/confused, comfortable/distress, nutritional status
• Vital signs: Temperature, heart rate, respiratory rate, blood pressure, oxygen saturation
• Weight and height: Calculate BMI, compare to prior weights
• Pain assessment: Location, severity (0-10 scale), character, onset

Systematic Physical Examination

Head and Neck Assessment

• Inspect: Symmetry, lesions, hair distribution
• Palpate: Lymph nodes, thyroid, carotid pulses
• Eyes: Visual acuity, pupils reactive to light?
• Ears: Hearing, tympanic membranes
• Nose: Patency, nasal mucosa color
• Mouth: Teeth, gums, oral mucosa, tongue

Cardiovascular Assessment

• Inspect: Chest wall, jugular venous pulsation
• Palpate: Apical impulse, thrills, heaves
• Auscultate: Heart sounds (S1, S2, murmurs, rubs)
• Peripheral: Pulse quality, capillary refill, edema

Respiratory Assessment

• Inspect: Respiratory rate, pattern, accessory muscle use
• Palpate: Tactile fremitus, chest expansion
• Percuss: Lung resonance (normal, dullness, hyperresonance)
• Auscultate: Breath sounds (clear, diminished, adventitious sounds)

Abdominal Assessment

• Inspect: Distention, scars, visible peristalsis
• Auscultate: Bowel sounds (before palpation)
• Palpate: Masses, tenderness, organ size
• Percuss: Liver span, spleen, ascites

Neurological Assessment

• Consciousness: Alert, oriented to person/place/time?
• Cranial nerves: II-XII assessment
• Motor: Strength graded 0-5, coordination
• Sensory: Light touch, pain, proprioception
• Reflexes: Deep tendon reflex assessment

Pain Assessment: Comprehensive Evaluation

Pain Characteristics (PQRST Framework)

• P (Provocative/Palliative): What causes pain? What relieves it?
• Q (Quality): Describe pain (sharp, dull, aching, burning, throbbing)
• R (Region/Radiation): Location and whether pain radiates
• S (Severity): 0-10 pain scale (0=none, 10=worst possible)
• T (Timing): When did it start? Constant or intermittent?

Pain Scales and Assessment Tools

• Numeric rating scale: 0-10 most common in adults
• Verbal descriptor scale: No pain, mild, moderate, severe, worst possible
• Visual analog scale: Line with anchors for pain severity
• FACES scale: Used for children or those with difficulty with numbers
• Functional assessment: How does pain affect daily activities?

Pain Impact Evaluation

• Sleep: Does pain interfere with sleep quality?
• Activities: What activities are limited by pain?
• Emotional: Does pain cause anxiety, depression?
• Social: Impact on relationships and social participation?
• Work: Ability to work or perform occupational duties?

Documentation: Recording Assessment Findings

Documentation Standards

• Accuracy: Record exactly what you observe, not assumptions
• Completeness: Include all relevant findings and patient statements
• Timeliness: Document as soon as possible after assessment
• Legibility: Use clear handwriting or electronic documentation
• Legal requirement: If not documented, legally it wasn't done

Focused Documentation Format

• Chief complaint: Patient's reason for visit
• HPI: Chronological narrative of current problem
• PMH/Medications: Relevant past and current treatments
• Vital signs: Temperature, HR, RR, BP, SpO2
• Physical exam: System-by-system findings
• Assessment: Nursing diagnoses identified
• Plan: Interventions and follow-up care

Key Takeaways: Assessment Mastery

• Conduct systematic, comprehensive patient assessment
• Gather complete history using appropriate questions
• Perform thorough physical examination systematically
• Assess pain comprehensively using standardized tools
• Identify patterns and abnormal findings
• Document findings accurately and completely
• Perform reassessment and update as patient status changes
• Communicate findings appropriately to team