Chapter 2. Patient Assessment
2.1 Introduction
Assessment is an essential part of the nurse’s role and is the first step in the nursing process (Potter et al., 2019). Care provided is based on the assessment findings that the nurse has collected and thought critically about. Nurses work collaboratively with clients and the healthcare team to create care plans that help optimize client health and help the client achieve their health goals.
Depending on the context, nursing assessment can take many forms. Nurses working in communities may perform community assessments; nurses working with particular populations may perform population related assessment; and nurses working in acute care may perform specific patient assessment. When an assessment is performed, the nurse should do so in a methodical fashion ensuring thoroughness.
This chapter will cover different approaches for nurses to physical health assessment, including health history, vitals, physical assessment with details about focused assessments pertinent to each system, as well as pain assessment and how to do a quick priority assessment. Sample nursing diagnoses are provided to help the learner begin to make connections between assessment and nursing diagnoses.
The skills of physical assessment are powerful tools for detecting both subtle and obvious changes in a patient’s health. Along with this, the ability to think critically and interpret patient behaviours and physiologic changes are essential. The assessment skills outlined in this chapter are meant to provide a framework to develop assessment competencies applicable and salient to everyday practice as recommended by Anderson, Nix, Norman, and McPike (2014).
The content in this chapter is considered basic level for adult assessment. Learners are encouraged to seek other, in-depth resources about assessment to further develop their knowledge and skill.
Learning Outcomes
- Describe four different types of assessment and when they should be used to inform care.
- Describe the purpose of physical assessment.
- Discuss techniques to promote a patient’s physical and psychological comfort during an examination.
- Identify data to collect from the nursing history before an examination.
- Incorporate health promotion and health teaching into an assessment.
- Use physical assessment techniques and skills during routine nursing care.
- Document assessment findings according to agency policy.
- Begin to identify nursing diagnoses following assessment of clients.