Prof. Maria Susan Z.

Maglaqui
Definition/Introduction
 The initial nursing assessment, the first step in the five
steps of the nursing process, involves the systematic
and continuous collection of data; sorting, analyzing,
and organizing that data; and the documentation and
communication of the data collected.
 The nursing assessment includes gathering information
concerning the patient's individual physiological,
psychological, sociological, and spiritual needs.
 The purpose is to establish data base
 It is the first step in the successful evaluation of a
patient.
 Subjective and objective data collection are an
integral part of this process.
Part of the assessment
 data collection by obtaining vital signs such
as temperature, respiratory rate, heart rate,
blood pressure, and pain level using an age
or condition appropriate pain scale.
 Assessment identifies current and future care

needs of the patient by allowing the

formation of a nursing diagnosis.
 The nurse recognizes normal and abnormal

patient physiology and helps prioritize

interventions and care
Issues of Concern

 The function of the initial nursing assessment

is to identify the assessment parameters and
responsibilities needed to plan and deliver
appropriate, individualized care to the patient.
 This includes documenting:
 Appropriate level of care to meet the client's or

patient’s needs in a linguistically appropriate,

culturally competent manner
 Evaluating response to care
 Community support
 Assessment and reassessment once admitted
 Safe plan of discharge
Nursing Admission Assessment
 Documentation: Name, medical record number, age, date, time,
probable medical diagnosis, chief complaint, the source of
information (two patient identifiers)
 Past medical history: Prior hospitalizations and major illnesses

and surgeries
 Assess pain: Location, severity, and use of a pain scale

 Allergies: Medications, foods, and environmental; nature of the

reaction and seriousness; intolerances to medications; apply

allergy band and confirm all prepopulated allergies in the
electronic medical record (EMR) with the patient or caregiver
 Medications: Confirm accuracy of the list, names, and dosages of

medications by reconciling all medications promptly using

electronic data confirmation, if available, from local pharmacies;
include supplements and over-the-counter medications
 Valuables: Record and send to appropriate safe storage or send

home with family following any institutional policies on the secure

management of patient belongings; provide and label denture
cups
 Rights: Orient patient, caregivers, and family to location, rights,

and responsibilities; goal of admission and discharge goal

Activities During Assessment
 Collection of Data – Gathering of information
about the client ,considering the physical
,psychological ,emotional ,socio-cultural ,and
spiritual factors that may affect his/or her
health status .
 Type of Data

a. Subjective data (symptoms )Can be described

by the person experiencing it
Ex. Vertigo,pain,tinnitus
b.Objective data (signs) That can be observed
and measured Ex. Pallor ,diaphoresis
,Bp=120/80,reddish urine
Methods of Collection
 1. Interview Planned purpose conversation
 2. Observation-Eg use of senses use of units

of measure, physical examination technique,

laboratory results
 Sources of Data

a. Primary : Patient /Client

b. Secondary : Family Members significant others
Verifying /Validating data –Making sure
information is accurate
Organizing data –Clustering facts into groups of
information
Nursing Admission Assessment

 Activities: Check daily activity limits and need for mobility aids
 Falls: Assess Morse Fall Risk and initiate fall precautions as
dictated by institutional policy
 Psychosocial: Evaluate need for a sitter or video monitoring,
any signs of agitation, restlessness, hallucinations,
depression, suicidal ideations, or substance abuse
 Nutritional: Appetite, changes in body weight, need for
nutritional consultation based on body mass index (BMI)
calculated from measured height and weight on admission
 Vital signs: Temperature recorded in Celsius, heart rate,
respiratory rate, blood pressure, pain level on admission,
oxygen saturation
 Any handoff information from other departments
Physical Exam
 Cardiovascular: Heart sounds; pulse irregular, regular, weak, thready,
bounding, absent; extremity coolness; capillary refill delayed or
brisk; presence of swelling, edema, or cyanosis
 Respiratory: Breath sounds, breathing pattern, cough, character of
sputum, shallow or labored respirations, agonal breathing, gasps,
retractions present, shallow, asymmetrical chest rise, dyspnea on
exertion
 Gastrointestinal: Bowel sounds, abdominal tenderness, any masses,
scars, character of bowel movements, color, consistency, appetite poor
or good, weight loss, weight gain, nausea, vomiting, abdominal pain,
presence of feeding tube
 Genitourinary: Character of voiding, discharge, vaginal bleeding (pad
count), last menstrual period or date of menopause or hysterectomy,
rashes, itching, burning, painful intercourse, urinary frequency,
hesitancy, presence of catheter
 Neuromuscular: Level of consciousness using AVPU (alert, voice, pain,
unresponsive); Glasgow coma scale (GCS); speech clear, slurred, or
difficult; pupil reactivity and appearance; extremity movement equal or
unequal; steady gait; trouble swallowing
 Integument: Turgor, integrity, color, and temperature, Braden Risk
Assessment, diaphoresis, cold, warm, flushed, mottled, jaundiced,
cyanotic, pale, ruddy, any signs of skin breakdown, chronic wounds
 Which provides the diagnosis most often:
history, physical, or diagnostic tests?
 History: 70%
 Physical: 15% to 20%
 Diagnostic tests: 10% to 15%
History Taking Techniques
 Record chief complaint
 History of the present illness, presence of pain
 Pain Assessment
 Pain, or the fifth vital sign, is a crucial component in
providing the appropriate care to the patient. Pain
assessment may be subjective and difficult to measure.
Pain is anything the patient or client states that it is to
them. As nurses, you should be aware of the many factors
that can influence the patient's pain. Systematic pain
assessment, measurement, and reassessment enhance the
ability to keep the patient comfortable. Pain scales that are
age appropriate assist in the concise measurement and
communication of pain among providers. Improvement of
communication regarding pain assessment and
reassessment during admission and discharge processes
facilitate pain management, thus enhancing overall
function and quality of life in a trickle-down fashion.
P-Q-R-S-T Tool to Evaluate Pain
 P: What provokes symptoms? What improves or
exacerbates the condition? What were you doing when
it started? Does position or activity make it worse?
 Q: Quality and Quantity of symptoms: Is it dull, sharp,
constant, intermittent, throbbing, pulsating, aching,
tearing or stabbing?
 R: Radiation or Region of symptoms: Does the pain
travel, or is it only in one location? Has it always been
in the same area, or did it start somewhere else?
 S: Severity of symptoms or rating on a pain scale. Does
it affect activities of daily living such as walking, sitting,
eating, or sleeping?
 T: Time or how long have they had the symptoms. Is it
worse after eating, changes in weather, or time of day?
Indicators of Pain
 Restlessness or pacing
 Groaning or moaning
 Crying
 Gasping or grunting
 Nausea or vomiting
 Diaphoresis
 Clenching of the teeth and facial expressions
 Tachycardia or blood pressure changes
 Panting or increased respiratory rate
 Clutching or protecting a part of the body
 Unable to speak or open eyes
 Decreased interest in activities, social gatherings, or
old routines
Psychosocial Assessment

 The primary consideration is the health and emotional needs of

the patient.
 Assessment of cognitive function, checking for hallucinations
and delusions, evaluating concentration levels, and inquiring
into interests and level of activity constitute a mental or
emotional health assessment.
 Asking about how the client feels and their response to those
feelings is part of a psychological assessment.
 Are they agitated, irritable, speaking in loud vocal tones,
demanding, depressed, suicidal, unable to talk, have a flat
affect, crying, overwhelmed, or are there any signs of substance
abuse?
 The psychological examination may include perceptions,
whether justifiable or not, on the part of the patient or client.
 Religion and cultural beliefs are critical areas to consider.
 Screening for delirium is essential because symptoms are often
subtle and easily overlooked, or explained away as fatigue or
depression.
Safety Assessment

 Ambulatory aids
 Environmental concerns, home safety
 Domestic and family violence risk, human

trafficking risks, elder or child abuse risk

 Fall risk
 Suicidal ideation (initiate suicide precautions

as directed by institutional policy)

Cultural Assessment

 The cultural competency assessment will identify factors

that may impede the implementation of nursing diagnosis
and care. Information obtained should include:
 Ethnic origin, languages spoken, and need for an
interpreter
 Primary language preferred for written and verbal
instructions
 Support system, decision makers
 Living arrangements
 Religious practices
 Emotional responses
 Special food requirements, dietary considerations
 Cultural customs or taboos such as unwanted touching or
eye contact
Physical Examination Techniques
 Initial evaluation or the general survey may include:
 Stature
 Overall health status
 Body habitus
 Personal hygiene, grooming
 Skin condition such as signs of breakdown or chronic
wounds
 Breath and body odor
 Overall mood and psychological state
 Initial vital sign measurements: temperature recorded in
Celsius in most institutions, respiratory rate, pulse rate,
blood pressure with appropriate sized cuff, pulse
oximetry reading and note if on room air or oxygen;
accurately measured weight in kilograms with the proper
scale and height measurement, so body mass index (BMI)
is calculable for dosing weights and nutritional guidelines
Secondary Assessment

 Cardiovascular
 Pulmonary
 Gastrointestinal
 Musculoskeletal
 Neurological
 Genitourinary/Pelvic
 Integumentary
 Mental status and behavioral
Techniques of Physical Examination

 Inspection
 Look at all areas of the skin, including those under clothing

or gowns
 Ensure patient is undressed, allowing for privacy, uncover one

body part at a time if possible

 Lighting should be bright
 Be alert for any malodors from the body including the oral

cavity; fecal odor, fruity-smell, odor of alcohol or tobacco on

the breath
 Compare one side to the other, and ask the patient about any

asymmetrical areas
 Observe for color, rashes, skin breakdown, tubes and drains,

scars, bruising, burns

 Grade any edema present
 Document pertinent normal and abnormal findings
Techniques of Physical Examination
 Palpation
 Texture
 Size
 Consistency
 Crepitus
 Any masses
 Turgor
 Tenderness 
 Temperature and moisture (warm, moist or cool, and

dry)
 Distention
 Tactile fremitus
Techniques of Physical Examination
 Percussion
 Good hand and finger technique

 Good striking and listening technique

 Especially important in the pulmonary and

gastrointestinal systems
 Dull, flat, resonance, hyper-resonance, or

tympany sounds
 Percussion is an advanced technique requiring a

specific skill set to perform. Therefore, it is a skill

practiced by advanced practice nurses as opposed
to a bedside nurse on a routine basis
Techniques of Physical Examination
 Auscultation
 Listening to body sounds such as bowel

sounds, breath sounds, and heart sounds

 Important in examination of the heart, blood

pressure, and gastrointestinal system

 Listen for bruits, murmurs, friction rubs, and

irregularities in pulse
 What are important things to remember about the physical exam?
 Physical exam length can vary depending on complexity
 Physical exam extends from passive observation to hands-on 
 Be systematic and thorough
 Ensure privacy and comfort
 Warm hands for patient comfort
 Avoid long fingernails to prevent patient injury during the exam
 Palpate areas that are tender or painful last
 Be alert for any signs of maltreatment or abuse, and follow

mandatory reporting guidelines

 Abdominal assessment follows the techniques in this sequence:

inspection, auscultation, percussion, and palpation

 Auscultate bowel sounds for at least 15 seconds in each

quadrant using the diaphragm of the stethoscope, starting with

the lower right-hand quadrant and moving clockwise
 If a fistula is present for hemodialysis, assess for a thrill or bruit,

document presence or absence. Notify managing healthcare

provider immediately if absent
 Steps in a comprehensive lung exam include PIPPA; Positioning of

the patient, Inspection, Palpation, Percussion, Auscultation

References :
 Dillon M. Patricia Nursing Health
Assessment : A Critical Thinking Case Studies
Approach,FA Davis Company,2003
 Le Fevre –Rosalinda Alfaro, Applying Nursing

Process :A tool for Critical Thinking 2010

 Tammy J. Toney-Butler; Wendy J. Unison-

Pace.
Nursing Admission Assessment and
Examination ,September 2, 2020.
 Weber Janet ,Kelly Jane 4th Edition, Health

Assessment Nursing