A complete nursing assessment is a systematic process designed to gather, verify, and communicate information about a patient’s overall health status. This data collection is the foundational step in the nursing process, providing a comprehensive picture of the patient’s physiological, psychological, and social condition. The primary purpose of this evaluation is to establish a health baseline against which future changes can be measured and to identify actual or potential health problems requiring nursing intervention. The assessment guides the creation of an individualized care plan, ensuring interventions are tailored to the patient’s specific needs. The process requires clinical skill and critical thinking to accurately differentiate between normal and abnormal findings.
Preparing for the Assessment and Gathering Subjective Data
The assessment begins before patient contact, requiring review of the medical record for history, diagnoses, and medications. Establishing a private and comfortable environment encourages open communication, and proper hand hygiene must be performed before the physical examination. This initial phase focuses on gathering subjective data, which is information obtained directly from the patient or a family member that cannot be measured or observed. Subjective data includes the patient’s chief complaint (the main reason for seeking care), along with reported symptoms, feelings, and perceptions of health.
Effective communication is central to obtaining this information, requiring therapeutic techniques like active listening and open-ended questions. Maintaining an open posture and appropriate eye contact demonstrates engagement and builds trust. When a patient reports a specific symptom, such as pain, the interview uses a structured framework like PQRST for analysis. This mnemonic asks about:
- Provocation or Palliation (what makes it better or worse)
- Quality (what the pain feels like)
- Region or Radiation (where the pain is and if it moves)
- Severity (using a scale, 0-10)
- Timing (when it started and how long it lasts)
Asking relevant questions and paraphrasing answers helps clarify details.
Essential Techniques for Objective Data Collection
The physical examination centers on gathering objective data, which are measurable and observable signs collected through the senses. Four fundamental techniques are used sequentially: Inspection, Palpation, Percussion, and Auscultation. Inspection involves a detailed visual observation of the patient’s appearance, posture, movement, and body areas. This visual survey notes characteristics such as skin color, symmetry of the chest wall, general hygiene, and any visible masses or lesions.
Palpation uses touch to determine characteristics like temperature, moisture, texture, and the presence of masses or tenderness. Light palpation uses the finger pads to gently depress the skin one to two centimeters to assess surface abnormalities. Deep palpation requires firmer pressure, depressing the skin four to five centimeters to evaluate internal organs, identifying their size, shape, and consistency. Different parts of the hand are used for specific purposes; the back of the hand is best for assessing temperature due to the skin’s thinness.
Percussion is the technique of tapping the body surface to elicit sounds that indicate the density of the underlying structures. The sound produced helps determine if the area contains air, fluid, or solid tissue. A hollow, low-pitched resonance is heard over the air-filled lungs, while a drum-like, high-pitched tympany is heard over air-filled organs like the stomach. Conversely, a quiet, flat dullness is heard over dense organs such as the liver or bone.
Auscultation involves listening to internal body sounds, usually with a stethoscope. The diaphragm is used for high-pitched sounds like normal heart sounds (S1 and S2) and most lung sounds, while the bell is used for low-pitched sounds, such as certain abnormal heart murmurs. When listening to the lungs, the nurse listens for clear breath sounds and abnormal sounds like crackles (small clicking sounds indicating fluid) or wheezes (high-pitched hissing from narrowed airways).
Organizing the Physical Examination
Objective data collection techniques are applied within a structured framework to ensure no area is overlooked, using either the Head-to-Toe or Body Systems approach. The Head-to-Toe method is a comprehensive, systematic survey that proceeds from the head down to the feet. This method is primarily used upon admission or at the beginning of a shift to establish a health baseline for a stable patient. It ensures all body areas and systems are covered in a consistent sequence.
The Body Systems approach, sometimes referred to as a focused assessment, is organized by physiological systems rather than anatomical region. This is the preferred method when a patient presents with a specific complaint or a change in condition, allowing the nurse to target the evaluation. For example, a patient reporting shortness of breath warrants a focused respiratory assessment, including inspection of respiratory effort and auscultation of lung sounds. A complete physical assessment incorporates a review of all major systems, including:
- Neurological status
- Cardiovascular function
- Respiratory integrity
- Gastrointestinal and genitourinary status
- Musculoskeletal mobility
- Integumentary (skin) condition
Documenting Findings and Moving to Analysis
The final step is the accurate and timely documentation of all collected subjective and objective data. Documentation serves as a legal record of the patient’s condition and ensures continuity of care among the healthcare team. Various structured formats exist for charting, such as SOAP (Subjective, Objective, Assessment, Plan) or DAR (Data, Action, Response). The SOAP format explicitly separates the information gathered from the patient (Subjective) and the measurable findings (Objective).
The Assessment component in SOAP, or the transition from data to analysis, is where the nurse uses clinical judgment to interpret the collected findings. The combined subjective and objective data are analyzed to formulate a nursing diagnosis, which describes a human response to a health condition or life process. This diagnosis is often written using the PES format: Problem, Etiology (related factors), and Signs/Symptoms (the defining characteristics from the assessment). The assessment data supports the nursing diagnosis, which then directs the planning and intervention phases of patient care.