Chapter 2. Patient Assessment
In the course of their work doing direct patient care, nurses use a combination of head-to-toe and focused assessments to gather data about the patient. The assessment findings, when considered with some level of clinical judgement and critical thinking, inform the healthcare professional about the patient’s overall condition and form the basis of the plan of care (Potter et al., 2019).
Assessment includes the collection of subjective data – what the patient tells you. Assessment also includes the collection of objective data – what the nurse observes through their senses. Objective data is collected during the physical examination using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013).
Head-to-toe assessments or systems assessments include all the body systems and a systematic approach to collecting data. They provide the nurse with an overall understanding of each patient. They are done when the nurse first meets the patient (for example, when the patient is admitted to the unit and at the beginning of a shift) and when prompted by a change in patient health status.
Focused assessments, sometimes called priority assessments, are often a part of a head-to-toe assessment. They involve the search for detailed information about a specific body system(s). Knowing which system(s) to focus on depends upon the client’s presentation and the nurses’ knowledge of nursing, pathophysiology, pharmacology, and other bodies of knowledge (Potter et al., 2019; RCH, 2017).
Unusual findings must always be considered in relation to the patient’s health history. Some issues may be old and not fixable. New or emerging issues may require action (some rather urgently) to avoid harm to the patient.
The following sections are set up to provide the learner with general guide to objective and subjective data collection starting at the head and following a general systems approach to assessment for an adult. The sections include:
- Head & Neck / Neurological Assessment
- Chest / Respiratory Assessment
- Cardiovascular Assessment
- Abdominal / Gastrointestinal Assessment
- Genitourinary Assessment
- Musculoskeletal Assessment
- Integument Assessment
At the end of each section is additional information outlining details that may be included in a focused assessment should the nurse decide such detail is necessary. This is by no means an exhaustive list. The guide is primarily intended for a student and/or a beginning level nurse. Other more comprehensive texts will help the learner build knowledge around health assessment.
At the end of each section are sample nursing diagnoses to help you begin to understand how assessment findings inform nursing diagnosis.
Critical Thinking Exercises
- Consider why having a systematic approach to assessment might be important.
- Identify two situations where a focused priority assessment might be more appropriate than a full head-to-toe assessment.