6 Assessment Fundamentals
Learn how to collect and interpret patient health information through interviews, observation, vital-sign measurements, and introductory physical assessment.
Purpose and foundations
Assessment is the systematic collection of information about a person's health. It combines —the patient's reports—with —the clinician's observations and measurements. The findings establish a baseline, identify concerns, and guide follow-up. Assessment continues over time, so new symptoms or changes in condition call for reassessment.
A sound assessment brings together the patient's account, careful observation, and accurate measurements. Findings should be compared with the person's baseline and overall condition, documented clearly, and significant changes promptly escalated.
Taking a
A is a focused conversation about the patient's concerns, health background, and daily functioning. Begin by introducing yourself and your role, confirming the patient's identity according to policy, explaining the interview's purpose, and providing privacy. Use a qualified medical interpreter when needed; do not assume a family member should interpret.
Ask one question at a time, listen without interrupting, and begin with open-ended questions before moving to more specific ones. Explore the reason for seeking care, including what brought the patient in and what matters most to them. Focused symptom questions can cover when symptoms began, where they occur, what they feel like, their severity, what improves or worsens them, and how they affect daily life.
A basic history commonly covers:
Current and past health: Relevant conditions, hospitalizations, surgeries, injuries, and treatments.
Medications and allergies: Prescription and nonprescription medicines, supplements, how they are taken, and the nature of any reported allergy or reaction.
Family and social history: Relevant family conditions and, as appropriate to the concern, living situation, supports, work, and health-related habits.
Function and review of systems: Everyday activities and relevant symptoms across body systems, with questions tailored to the patient's age, condition, and reason for care.
The patient is usually the primary source of subjective information. If a care partner provides information, document who provided it. Record the patient's words accurately when useful, and distinguish reported symptoms from observed signs. For example, a patient may report, “I feel dizzy,” while the clinician observes an unsteady gait when the patient stands.
Observation and immediate priorities
Observation begins with the first interaction and continues throughout the encounter. Note general appearance, alertness, speech, ability to communicate, posture, movement, visible discomfort, and signs of breathing difficulty. Observe respectfully and describe what you see rather than making assumptions; for example, document “speaks in short phrases and pauses to breathe” rather than labeling the patient “anxious.”
If the patient appears acutely unwell—for example, with severe difficulty breathing, chest pain, or altered responsiveness—prioritize immediate assessment and obtain help according to emergency procedures rather than continuing a routine interview. Perform hand hygiene, follow required precautions, protect privacy, and use two approved identifiers before providing care or documenting findings.
are measurements of key body functions. Commonly assessed measures are temperature, pulse, respiratory rate, blood pressure, and oxygen saturation. Pain is also routinely assessed as a significant patient-reported measure. Interpret findings in context: age, activity, symptoms, baseline, medications, measurement conditions, and clinical setting all matter. A single reading is not a diagnosis.
For a resting adult, commonly cited reference ranges include a pulse of about beats per minute, a respiratory rate of about breaths per minute, and a temperature around (). These are guides, not universal targets. Blood pressure and oxygen saturation also require interpretation in light of the patient's condition, baseline, and applicable clinical guidance.
Measurement principles
Temperature: Use an approved thermometer and route. Record both the value and the route because results can differ by measurement site.
Pulse: Palpate an appropriate pulse site, commonly the radial artery. Assess rate and rhythm, and assess strength when relevant. If the rhythm is irregular, follow training and policy for a full-minute count and additional assessment.
Respiratory rate: Observe chest movement and count breaths without prompting the patient to change their breathing. Note rate, rhythm, depth, and effort, and report visible distress.
Blood pressure: Use a cuff that fits the patient. When circumstances allow, have the patient rest seated with feet flat, back supported, and arm supported near heart level. Place the cuff on a bare upper arm and follow the device or manual technique. Record the reading, arm, position, and relevant circumstances. An incorrectly sized cuff or unsupported arm can affect the result.
Oxygen saturation: Apply the pulse-oximeter sensor as directed and check that its signal is reliable. Interpret the displayed value alongside the patient's appearance, symptoms, and usual baseline; do not let a number override signs of acute distress.
Compare measurements with prior readings and the patient's presentation. When appropriate, recheck an unexpected result using correct technique, and promptly report concerning findings or deterioration under local policy. Document values with units and relevant measurement details. Nurses remain responsible for evaluating findings and ensuring appropriate follow-up, even when a measurement is delegated.
Physical assessment techniques
A physical assessment is systematic and adapted to the patient's condition, comfort, and consent. Its core techniques are:
: Look carefully and systematically for visible characteristics, symmetry, movement, skin changes, and signs of distress.
: Use touch to assess features such as skin temperature, tenderness, swelling, or pulse. Begin gently and explain what you are doing. When clinically appropriate, avoid palpating a painful area until the surrounding assessment is complete.
: Listen with a stethoscope for sounds such as heart, lung, or bowel sounds. Reduce background noise when possible and place the stethoscope on the skin when appropriate.
: Tap the body surface to assess underlying structures. This is a more specialized technique and should be used only when trained and appropriate to the assessment.
A general examination often proceeds from to , , and . The abdominal examination is a key exception: inspect, auscultate, percuss, then palpate, because can alter bowel sounds. Follow the sequence taught for the specific body system and local practice.