04 Foundations of Patient Assessment

Assessment and vital signs

Patient assessment is continuous: gather information, compare it with the patient’s baseline and expected findings, recognize meaningful changes, act within your role, and communicate clearly. A single measurement is only part of the picture; appearance, symptoms, trends, and the patient’s own report also matter.

Vital signs commonly include temperature, pulse, respiratory rate, blood pressure, and oxygen saturation (SpO₂) when indicated. Pain is also routinely assessed. Adult resting reference ranges are guides for average healthy adults at rest, not diagnostic cutoffs or universal targets. Age, health conditions, activity, medications, and the patient’s usual values affect interpretation. Follow orders and facility policy, and report findings outside prescribed parameters or concerning trends.

Typical adult resting references include:

• Temperature: $(36.5\text{–}37.3\,^{\circ}\mathrm{C};\ 97.7\text{–}99.1\,^{\circ}\mathrm{F})$. Document the measurement route because readings vary by route.

• Pulse: $(60\text{–}100\ \text{beats/min})$. Note rate, rhythm, and strength. If the pulse is irregular, assess for a full minute and follow policy.

• Respirations: $(12\text{–}18\ \text{breaths/min})$. Observe rate, rhythm, depth, and effort; count discreetly when possible.

• Blood pressure: often about systolic $90$, diastolic $60$, to systolic $120$, diastolic $80\ \mathrm{mmHg}$. Use the correct cuff size, position the arm at heart level, and keep the patient comfortable. Repeat an unexpected reading when safe and with correct technique.

• SpO₂: there is no single target that fits every patient. Interpret it with symptoms, baseline, prescribed target, oxygen device and flow, and signal quality.

Focused assessment

A Focused assessment examines the body systems and symptoms most relevant to the patient’s concern or a new finding. Begin with an open question, such as “What feels different?” Gather subjective information—the patient’s report—and objective findings—what you observe or measure. Compare findings with the patient’s baseline, prior observations, and the other side of the body when appropriate.

Use an organized sequence appropriate to the concern: inspect, palpate, and auscultate as indicated by training and protocol. Describe findings specifically. For example, “respirations $28\ \text{breaths/min}$ with accessory-muscle use” is more informative than “breathing bad.” Record relevant negatives as well as abnormal findings.

For new shortness of breath, assess the patient’s ability to speak, breathing rate and effort, skin color, lung sounds as trained, SpO₂, oxygen equipment, and relevant symptoms such as chest discomfort. For new leg swelling, compare both legs for size, color, warmth, tenderness, and edema; report concerning findings promptly. Do not delay urgent escalation to complete a routine assessment.

Recognizing and responding to change

A Change in condition may appear as an abnormal vital sign, a worsening trend, or a new symptom or behavior. Concerning cues include new confusion or reduced responsiveness, difficulty breathing, chest pain, fainting, sudden weakness, uncontrolled bleeding, severe or rapidly worsening pain, or a marked change from the patient’s usual status. A patient may deteriorate even when one vital sign is within a reference range.

When a change is suspected:

1. Attend to immediate safety. If the condition appears urgent, stay with the patient, call for help, and activate the emergency or rapid-response process according to facility policy.

2. Reassess promptly. Check the patient directly, repeat questionable measurements when safe, and obtain relevant focused findings.

3. Escalate without delay. Notify the appropriate licensed nurse, clinician, or emergency team. Do not wait for the next scheduled observation when the patient is worsening.

4. Follow through. Carry out authorized directions, monitor the response, and escalate again if the concern persists or worsens.

For practical-nursing roles, assessment, reporting, and intervention responsibilities depend on state law, delegation, employer policy, and the situation. Seek immediate direction when the patient’s needs exceed your role or competence.

Pain assessment

Pain is subjective: ask the patient and take the report seriously. A numeric rating alone is not a complete assessment. Use a consistent, appropriate scale and ask about the patient’s comfort or functional goal.

The PQRSTU prompts help structure follow-up questions:

• P — Provocation/palliation: What worsens or relieves the pain?

• Q — Quality: What does it feel like?

• R — Region/radiation: Where is it, and does it spread?

• S — Severity: How severe is it on an appropriate scale?

• T — Timing/treatment: When did it start? Is it constant or intermittent? What has helped?

• U — Understanding: What does the patient think may be causing it?

Ask how pain affects sleep, movement, breathing, or daily activities. When the patient cannot self-report, observe behavior and use an age- and condition-appropriate validated tool according to policy. Behavior is useful evidence, but it does not replace self-report when the patient can provide one. After an intervention, reassess and document pain, function, response, and any concerning effects within the timeframe required by orders and facility policy.

Reporting and documentation

Communicate promptly, clearly, and factually. SBAR provides a useful structure:

• Situation: Identify yourself and the patient, then state the immediate concern.

• Background: Give relevant history, baseline, recent events, medications or treatments, and pertinent results.

• Assessment: Report current findings and how they differ from baseline. State your concern without presenting an unsupported diagnosis.

• Recommendation/request: Say what response or help is needed and how urgently.

For example: “This is Jordan, the practical nurse on the medical unit, calling about Ms. Lee in room $12$. She has new shortness of breath. Her baseline SpO₂ was $96\%$ on room air; it is now $89\%$ on room air, and her respiratory rate is $28$ with increased effort. I’m concerned her condition is worsening. Please assess her now; I’m staying with her and activating our urgent-response process.” Use the facility’s escalation pathway and confirm that the message was received.

Document observations as soon as practical and follow policy. Include the time; actual measurements and units; measurement route or oxygen support where relevant; patient statements in quotation marks when useful; assessment findings; whom you notified and when; instructions received; actions taken; and the patient’s response. Record facts rather than assumptions, and never document an action before it occurs.