NURSING ASSESSMENT

DEFINITION
The systematic collection of all data and information relevant to the care of patients, their
problems, and needs. The initial step of the assessment consists of obtaining a careful and complete
history from the patient. If this cannot be done because the mental or physical condition of the patient
makes communication impossible, the nursing history is obtained from those who have information about
the patient and the reason(s) for his or her need of medical and nursing care. (Medical Dictionary, 2009
Farlex and Partners)
Nursing assessment is an identification by a nurse of the needs, preferences, and abilities of a patient.
Assessment includes an interview with and observation of a patient by the nurse and considers the
symptoms and signs of the condition, the patient's verbal and nonverbal communication, the patient's
medical and social history, and any other information available. Among the physical aspects assessed are
vital signs, skin color and condition, motor and sensory nerve function, nutrition, rest, sleep, activity,
elimination, and consciousness. Among the social and emotional factors included in assessment are
religion, occupation, attitude toward hospital and health care, mood, emotional tone, and family ties and
responsibilities. Assessment is extremely important because it provides the scientific.
TYPES OF NURSING ASSESSMENT
1. INITIAL ASSESSMENT/ ADMISSION ASSESSMENT
The initial assessment, also known as triage, helps to determine the nature of the problem and
prepares the way for the ensuing assessment stages. The initial assessment is going to be much
more thorough than the other assessments used by nurses. Components may include obtaining a
patient's medical history or putting him through a physical exam, or preparing a psychosocial
assessment for a mental health patient. Other components may include obtaining a patient's vital
signs and taking subjective statements from the patient, as well as double-checking the subjective
symptoms with the objective signs of the condition.
An admission assessment should be completed by the nurse with a parent or care giver, ideally
upon arrival to the ward or preadmission, but must be completed within 24hours of admission.
Admission assessment is to be documented on the nursing admission form. Privacy of the patient
needs to be considered all times.
2. FOCUSED ASSESSMENT
The focused assessment is the stage in which the problem is exposed and treated. Due to the
importance of vital signs and their ever-changing nature, they are continuously monitored during

all parts of the assessment. Depending on the malady, initial treatment for pain and long-term
treatment for the root cause of the malady is administered and monitored. Part of the goal of the
focused assessment is to diagnose and treat the patient in order to stabilize her condition. Focused
assessments may also include X-rays or other types of tests.
A detailed nursing assessment of specific body system(s) relating to the presenting problem or

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other current concern(s) is required. This may involve one or more body system.
Focused assessment addresses a particular problem or issue and may be done in response to
changing health status that precludes a full assessment e.g. acute pain or respiratory distress
presentation of an episodic problem such as a sore throat
the need to determine progress of a specific potential or actual health problem
the need to determine the effectiveness of an intervention e.g. relief of pain by position

change and/or medication

The assumption of care by a new care provider e.g. at the beginning of a shift Quick priority
and/or focused assessments are used more often than a comprehensive assessment. The
findings of the more abbreviated assessment(s) may determine the need for a comprehensive
assessment.

The problem-focused assessment is usually indicated after a comprehensive assessment has identified
a potential health problem. The problem-focused assessment is also indicated when an interval or
abbreviated assessment shows a change in status from the most current previous assessment or report
you received, when a new symptom emerges, or the patient develops any distress. An advantage of
the focused assessment is that it directs you to ask about symptoms and move quickly to conducting a
focused physical exam
3. TIME-LAPSED ASSESSMENT/ Ongoing assessment
Once treatment has been implemented, a time-lapsed assessment must be conducted to ensure that
the patient is recovering from his malady and his condition has stabilized. Depending on the
nature of the malady, the time-lapsed assessment may span the length of one or two hours or a
couple of months. During the time-lapsed assessment, the current status of the patient is
compared to the previous baseline during and prior to treatment. Similar to the focused
assessment, the time-lapsed assessment may also include lab work, X-rays or other diagnostic
medical testing.
The time-lapsed assessment is scheduled to compare a patients current status to baseline data
obtained earlier. Periodic time-lapsed assessments are done to reassess health status and to make
necessary revisions in the plan of care.
4. EMERGENCY ASSESSMENT
During emergency procedures, a nurse is focused on rapidly identifying the root causes of
concern for the patient and assessing the airway, breathing and circulation (ABCs) of the patient.
Once the ABCs are stabilized, the emergency assessment may turn into an initial or focused

assessment, depending on the situation. If the nurse is not in a health care setting, emergency
assessments must also include an assessment for scene safety so that no other individuals,
including the nurse himself, are hurt during the rescue and emergency response process.
COMPONENTS OF HEALTH ASSESSMENT
I.

Complete Health History

The purpose of obtaining a health history is to provide you with a description of your patients symptoms
and how they developed. A complete history will serve as a guide to help identify potential or underlying
illnesses or disease states. In addition to obtaining data about the patients physical status, you will obtain
information about many other factors that impact your patients physical status including spiritual needs,
cultural idiosyncrasies, and functional living status. The basic components of the complete health history
(other than biographical information) include:

Chief complaint

Present health status

Past health history

Current lifestyle

Psychosocial status

Family history

Communication during the history and physical must be respectful and performed in a culturally-sensitive
manner. Privacy is vital, and the healthcare professional needs to be aware of posture, body language, and
tone of voice while interviewing the patient (Jarvis, 2008; Caple, 2011).
II.

General Survey

A general survey may be described as an overall review or first impression that the health care provider
has of a persons well being. This could be as simple as a visual observation and encompasses the
following examples and components dependent to some extent on age.

Appearance appears stated age; sexual development appropriate; alert, oriented; facial features
symmetric; no signs of acute distress

Body structure/mobility weight and height within normal range; body parts equal bilaterally;
stands erect, sits comfortably; walk is smooth and well balanced; full mobility of joints

Behavior maintains eye contact with appropriate expressions; comfortable and cooperative with
examiner; speech clear; clothing appropriate to climate; looks clean and fit; appears clean and
well groomed

MEASUREMENTS

Body measurements include length or height, weight, and head circumference for children from
birth to 36 months of age. Thereafter, body measurements include height and weight. The
assessment of hearing, speech and vision are also measurements of an individuals function in
these areas. The Denver Development assessment is a tool to measure an infants and young
childs gross motor, language, fine motor-adaptive and personal-social development. If
developmental delay is suspected based on an assessment of a parents development/behavior
concern or if delays are suspected after a screening of development benchmarks, a written referral
is made to a Physician or First Steps for further evaluation. Other developmental tools include the

developmental screen; benchmarks in the Pediatric Preventive Guidelines may be used.

A patients measurements can be compared with a standard, expected, or predictable
measurement for age and gender. The Body Mass Index (BMI) chart in this section applies to
adults. Age and gender appropriate growth charts in the Forms Section apply to children.
Deviation from standards helps identify significant conditions requiring close monitoring or

referral.
The significance of measurements and actions to take when they deviate from normal
expectations are found in the age-specific Preventive Health Guidelines.

MEASUREMENT PROCEDURES

Height:

Obtain height by measuring the recumbent length of children less than 2 years of age and children between 2 and 3
who cannot stand unassisted. A measuring board with a stationary headboard and a sliding vertical foot piece shall
be used. Lay the child flat against the center of the board. The head should be held against the headboard by the
parent or an assistant and the knees held so that the hips and knees are extended. The foot piece is moved until it
is firmly against the childs heels. Read the measurement to the nearest 1/8 inch.
Obtain a standing height on children greater than 2 to 3 years of age, adolescents, and adults. Measurements may
be accurately made by using a graduated ruler or tape attached to the wall and a flat surface that is placed
horizontally on top of the head. The patient is to be wearing only socks or be bare foot. Have the patient stand
with head, shoulder blades, buttocks, and heels touching the wall. The knees are to be straight and feet flat on the
floor, and the patient is asked to look straight ahead. The flat surface (or moveable headboard) is lowered until it
touches the crown of the head, compressing the hair. A measuring rod attached to a weight scale shall not be used.
If recumbent length is obtained for a two year old, it is plotted on the birth to 36 months growth chart, whereas, if
standing height is obtained for a two year old, plot on the 2 to 18 year growth chart. Plot measurements for
children on age and gender specific growth charts and evaluate accordingly.

Weight:

Balance beam or digital scales are to be used to weigh patients of all ages. Spring type scales are not acceptable.
CDC recommends that all scales should be zero balanced and calibrated. Scales must be checked for accuracy on
an annual basis and calibrated in accordance with manufacturers instructions. Prior to obtaining weight
measurements, make sure the scale is zeroed. Weigh infants wearing only a dry diaper or light undergarments.
Weigh children after removing outer clothing and shoes. Weigh adolescents and adults with the patient wearing
minimal clothing. Place the patient in the middle of the scale. Read the measurement and record results
immediately. Scales should be calibrated annually. Plot measurements on age and gender specific growth charts
(see Forms Section) and evaluate accordingly

Body Mass Index:

The Body Mass Index (BMI) is a measure that can help determine if a person is at risk for a weight-related illness.
Instructions for obtaining the BMI are included within the chart in this section for adults. To calculate BMI for
children, see BMI Tables for Children and Adolescents for guidance.

Head Circumference:

Obtain head circumference measurement on children from birth to 36 months of age by extending a nonstretchable measuring tape around the broadest part of the childs head. For greatest accuracy, the tape is placed
three times, with a reading taken at the right side, at the left side, and at the mid-forehead, and the greatest
circumference is plotted. The tape should be pulled to adequately compress the hair.
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Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.

Vital Signs:

Vital signs, generally described as the measurement of temperature, pulse, respirations and blood pressure, give an
immediate picture of a persons current state of health and well being. Normal and abnormal ranges with
management guidelines follow for children and adults.
III.

Physical Examination/ Review of System

It is the process of examining the patients body to determine the presence or absence of physical problems
The goal of the physical examination is to obtain valid information concerning the health of the patient The
examiner must be able to identify, analyze, and synthesize the accumulated information.
A comprehensive physical examination should be performed according to age specific preventive health guidelines.
American Medical Association clinical practice guidelines recognize the following body areas and organ systems
for purpose of the examination:
Body Areas: Head (including the face); Neck; Chest (including breasts and axillae); Abdomen; genitalia, groin,
buttocks; Back (including spine); and each extremity.
Organ Systems: Constitutional (vital signs, general appearance), Eyes, Ear, Nose, Throat; Cardiovascular;
Gastrointestinal;

Genitourinary;

Musculoskeletal;

Dermatological;

Neurological;

Psychiatric;

Hematological/lymphatic/immunological
Integumentary: Both overall body and organ systems should have skin assessments integrated into them.
Integument includes skin, hair and nails.
Normal and abnormal findings should be recorded on a health history and physical examination form.
ASSESSMENT TECHNIQUES
A. Inspection : is the most frequently used assessment technique. When you are using inspection, you
are looking for conditions you can observe with your eyes, ears, or nose. Examples of things you
may inspect are skin color, location of lesions, bruises or rash, symmetry, size of body parts and
abnormal findings, sounds, and odors. Inspection can be an important technique as it leads to
further investigation of findings.
B. Auscultation - usually performed following inspection, especially with abdominal assessment. The
abdomen should be auscultated before percussion or palpation to prevent production of false bowel
sounds. When auscultating, ensure the exam room is quiet and auscultate over bare skin, listening
to one sound at a time. Auscultation should never be performed over patient clothing or a gown, as
it can produce false sounds or diminish true sounds. The bell or diaphragm of your stethoscope
should be placed on your patients skin firmly enough to leave a slight ring on the skin when
removed.
Be aware that your patients hair may also interfere with true identification of certain sounds.
Remember to clean your stethoscope between patients.

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Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.

The diaphragm is used to listen to high pitched sounds and the bell is best used to identify low
pitched sounds (Jarvis, 2008; Edmunds, Ward & Barnes, 2010).
C. Palpation is another commonly used physical exam technique, requires you to touch your patient
with different parts of your hand using different strength pressures. During light palpation, you
press the skin about inch to 3/4 inch with the pads of your fingers. When using deep palpation,
use your finger pads and compress the skin approximately 1 inches to 2 inches. Light palpation
allows you to assess for texture, tenderness, temperature, moisture, pulsations, and masses. Deep
palpation is performed to assess for masses and internal organs (Jarvis, 2008).
D. PERCUSSION is used to elicit tenderness or sounds that may provide clues to underlying
problems. When percussing directly over suspected areas of tenderness, monitor the patient for
signs of discomfort. Percussion requires skill and practice.
The method of percussion is described as follows: Press the distal part of the middle finger of your
non-dominant hand firmly on the body part. Keep the rest of your hand off the body surface. Flex
the wrist, but not the foreman, of your dominant hand. Using the middle finger of your dominant
hand, tap quickly and directly over the point where your other middle finger contacts the patients
skin, keeping the fingers perpendicular. Listen to the sounds produced (Jarvis, 2008).
These sounds may include: Tympany Resonance Hyperressonance Dullness Flatness
Tympany sounds like a drum and is heard over air pockets.
Resonance is a hollow sound heard over areas where there is a solid structure and some air

(like the lungs).

Hyperressonance is a booming sound heard over air such as in emphysema.
Dullness is heard over solid organs or masses.
Flatness is heard over dense tissues including muscle and bone (Jarvis, 2008).

Page 7 of 35
Adapted from the Kentucky Public Health Practice Reference, 2008 and
Jarvis, C, (2011). Physical examination & health assessment. (6th Ed). Elsevier: St. Louis.MO.