Learning Objective
By the end of this section, you will be able to:
- Explain the key differences in the types of nursing assessments and when to use each type
Nursing practice demands a dynamic and adaptable approach to patient assessments, as these are not one-size-fits-all tools for data collection. Assessments vary depending on a patient’s condition, the clinical setting, and the specific point in the care process. Understanding the different types of assessments is fundamental for nurses, as each type serves a unique and vital purpose in patient care.
This section explores the nuances of various types of assessments and explains when and why each would be appropriate. This knowledge ensures procedural competence as a nurse and enhances critical-thinking and decision-making skills. By understanding the purpose and application of different assessments, nurses are better equipped to respond to the diverse needs of patients, ensuring high-quality care tailored to each individual’s situation.
Different Types of Nursing Assessments
At the heart of nursing is the goal of providing patient-centered care. To achieve this goal, nurses utilize a spectrum of assessment techniques tailored to meet the diverse needs of their patients (Table 12.1). These assessments range from initial evaluations, which provide a comprehensive view of the patient’s health, to more focused assessments targeting specific health problems. Rapid and targeted assessments are crucial in emergencies to address immediate and life-threatening concerns. In contrast, ongoing and time-lapsed assessments help monitor a patient’s progress over time and adjust care plans accordingly (Lloyd-Davies, 2024; Verve College, n.d.).
| Type of Assessment | Description | Example of When to Use |
|---|---|---|
| Initial | Comprehensive assessment performed on admission or entry | When a patient is admitted to a hospital or clinic |
| Problem-focused | Assessment focused on a specific problem or complaint | When a patient complains of chest pain or nausea |
| Ongoing | Continuous assessment performed at regular intervals | During routine rounds or shift changes |
| Emergency | Rapid assessment conducted in critical or life-threatening situations | When a patient experiences cardiac arrest or trauma |
| Time-lapsed | Assessment performed after a longer period to compare changes over time | When checking progress after a week of treatment |
Initial Assessment
The initial assessment is the first extensive evaluation of a patient’s overall health status. This type of assessment is typically conducted on a patient’s admission to a healthcare facility or at the time the patient begins receiving care. The primary goal of the initial nursing assessment is to establish a baseline understanding of the patient’s health condition so that any immediate health concerns or problems can be identified. It involves a comprehensive evaluation of the patient’s physical condition, medical history, and current symptoms.
Typically, an initial assessment begins with collecting basic demographic information, followed by conducting an in-depth review of the patient’s medical and surgical history. This includes any chronic conditions, medications, allergies, past hospitalizations, and surgeries, as well as the patient’s perspective on the issues that brought them to the facility. The nurse also inquires about the patient’s lifestyle choices, such as diet, exercise habits, and tobacco or alcohol use, which can significantly impact health. The nurse also investigates social determinants of health (societal and environmental conditions in which individuals live and work), encompassing factors like housing stability, socioeconomic status, access to health care, and social support networks, to gain a comprehensive understanding of the patient’s health needs within the context of their environment.
Physical examination forms a significant part of the initial assessment. The nurse conducts a head-to-toe exam to systematically evaluate each body system. This examination includes assessing vital signs such as blood pressure, heart rate, and temperature. The nurse will also observe the patient for signs of distress or discomfort (Nightingale College, 2022).
Link to Learning
A checklist is a useful tool for ensuring the nurse conducts a comprehensive physical examination. This sample checklist provided by Nightingale College details the steps in a typical head-to-toe assessment.
The initial assessment sets the stage for all future healthcare interactions and decisions for the patient. It provides a comprehensive view of the patient’s health and helps identify any immediate health concerns that need addressing. Even for patients who are healthy and well, this assessment serves as a baseline to which future assessments can be compared to monitor for changes. Effective communication skills are essential, as establishing trust and rapport with the patient is necessary for obtaining accurate and complete information. During this process, the nurse must be attentive, empathetic, and sensitive to the patient’s needs and concerns.
Establishing a Complete Database
The initial assessment is also an opportunity to begin compiling a complete database for the patient. This database serves as the cornerstone for all subsequent nursing care and interventions. It includes detailed information about the patient’s physical, psychological, and emotional status, which form the basis for developing an individualized care plan.
The process of creating a patient database involves gathering both subjective and objective data. The patient’s descriptions of their symptoms, feelings, and perceptions are known as subjective data. Subjective data may also include relevant descriptions from friends or family members. The measurable and observable information collected during a physical examination, such as blood pressure, heart sounds, and lung sounds, and any data obtained from lab results are called objective data (Lukey, 2023).
In addition to health-related information, a comprehensive dataset includes an assessment of the patient’s social and environmental factors, which encompasses family health history, social relationships, cultural background, and environmental factors like living conditions, financial circumstances, and occupational hazards. These elements are crucial in understanding the broader context of the patient’s health and wellness.
Patient Conversations
Conducting an Initial Assessment
Scenario: Mrs. Sanchez, a 64-year-old Mexican American female, has come to a neighborhood clinic complaining of chest pain. After checking the patient’s vital signs, Nurse Jordan proceeds with the initial examination.
Nurse: Mrs. Sanchez, you mentioned you were experiencing some chest discomfort. How would you describe the pain you are feeling?
Patient: It’s like a heavy pressure, especially when I’m walking.
Nurse: When did you first notice this discomfort?
Patient: About two days ago.
Nurse: Do you have any other symptoms, like shortness of breath, dizziness, or nausea?
Patient: I’ve felt a little short of breath, but no dizziness or nausea.
Nurse: Thank you for sharing that. It’s important information. Have you ever experienced anything like this before?
Patient: No, this is the first time.
Nurse: I see. Let’s talk about your medical history. Do you have any chronic conditions like hypertension or diabetes?
Patient: I’ve had high blood pressure for years. I take medication for it.
Nurse: Tell me the name of your medication, and are you taking it as prescribed?
Patient: It’s lisinopril, I think. I take it most days, but sometimes I forget.
Nurse: Forgetting can happen. Is there someone in your household who could support you in remembering to take your medication?
Patient: Actually, I have lived alone since my partner passed away last year. So, there’s no one around to remind me.
Nurse: I’m sorry to hear that. It’s important to manage your hypertension, especially with your current symptoms. Let’s talk about some strategies that could help you remember to take your medication. Some patients find setting a daily alarm on their phone or using a pill organizer helpful. What do you think about these options?
Patient: An alarm might work. I do have a smartphone.
Nurse: Great! Setting an alarm can be a simple, yet effective reminder. Now, about your support network: do you have family, friends, or neighbors who check in on you? Or someone you feel comfortable reaching out to if you need to?
Patient: My daughter lives out of state, but we talk on the phone. My neighbor, Mrs. Omar, has been kind enough to check on me sometimes.
Nurse: It’s good to have someone to talk to and check in on you. I would encourage you to keep in regular contact with your daughter and perhaps inform Mrs. Omar about your current health condition, just so she’s aware. Having a support system, even if it’s not in-house, can be very beneficial.
Problem-Focused Assessment
A problem-focused assessment is a targeted examination conducted to assess a specific health issue or symptom identified in a patient. This type of assessment is narrower in scope than an initial assessment and is crucial when a patient presents with new or worsening symptoms. It allows nurses to quickly and efficiently address and monitor specific health concerns.
For example, if a patient complains of acute abdominal pain, a problem-focused assessment would involve evaluating the abdomen, including noting the location, nature, and severity of the pain, as well as any accompanying symptoms like nausea or vomiting. The nurse would also review relevant aspects of the patient’s medical history, such as recent surgeries or digestive issues, and check for any changes in vital signs that might indicate a serious underlying problem.
This type of assessment is also key for managing chronic conditions, where it can monitor specific aspects of the patient’s health. For example, in patients with heart failure, regular, problem-focused assessments can be used to monitor fluid status and heart function, ensuring that any changes to the patient’s condition are caught and treated promptly.
Ongoing Assessments
An ongoing assessment is a fundamental subset of problem-focused assessments that involve continuous monitoring and evaluation of the patient’s health status, their response to treatment, and any changes in their condition over time. Unlike the initial assessment, which provides a comprehensive snapshot of the patient’s health at a specific point, ongoing assessment is dynamic and occurs over time. Nurses regularly collect and analyze data, including vital signs, laboratory results, and observations of the patient’s physical, psychosocial, and emotional status. Ongoing surveillance allows nurses to detect subtle changes or deterioration in the patient’s condition promptly, intervene as necessary, and modify care plans to address evolving needs.
When planned at specific intervals, ongoing assessments are critical for patients when regular monitoring is essential for managing a condition, for example, when a patient is recovering from an acute illness or surgery or is living with chronic illness. In a postoperative context, for example, ongoing assessments might include frequent monitoring of wound healing, pain levels, nausea and vomiting, vital signs, and signs of infection.
In acute care settings, such as emergency departments, ongoing assessments ensure timely interventions for patients with rapidly changing conditions. In chronic disease management, such as diabetes, scheduled assessments may include regular monitoring of blood glucose levels, foot examinations, and review of medication adherence. These assessments facilitate the early identification of complications and adjustments in the management plan.
Patient Conversations
Focused Assessment for Feet in Patients with Diabetes
Scenario: Keiko, an emergency room nurse, is caring for Mr. Strout, who presented with hyperglycemia. Mr. Strout has poorly controlled diabetes mellitus and has not seen a healthcare provider for follow-up for several years because he does not have health insurance. The nurse is assessing the patient and is ready to move on to the foot examination.
Nurse: Mr. Strout, I’d like to take a look at your feet next. Can you take your shoes off, or would you like some help?
Patient: My feet? What do you want to look at them for? I’m here ’cause my sugars are bad.
Nurse: Your feet can actually be affected by diabetes. Is it okay with you if I take a look at them? I’ll explain as I go along.
Patient: Well, I guess, if you say so. Could you give me a hand . . . with my feet? Ha!
Nurse: Sure thing.
[The nurse helps Mr. Strout remove his shoes and socks and proceeds with the assessment.]
Nurse: So, what I’m going to look for are signs that there is damage to your feet that could be related to your high blood sugar levels. If there’s damage, you may not be getting enough blood and oxygen flowing to your feet. This can lead to things like discoloration or even ulcers. Have you noticed anything like that?
Patient: No, but I don’t look at my feet very much, honestly.
Nurse: Do you have any pain or feelings like tingling or numbness?
Patient: Well…now that you mention it, they do feel funny sometimes.
[The nurse continues to closely examine Mr. Strout’s feet, looking at the skin and nails for any signs of discoloration, poor healing, or infection. Feeling the feet and pulses gives the nurse an idea of blood flow, and noting any other signs, like an odor, will also be an important part of the assessment. At the same time, the nurse continues to engage with the patient and answer questions and elicit more information about the patient’s foot health.]
Nurse: Can you tell me more about what “funny” feels like?
Patient: You know, like TV static in your foot. Like it falls asleep.
Nurse: How often does that happen?
Patient: I don’t know, exactly. Once in a while.
Nurse: That feeling comes from your nerves. Sometimes, nerves can get damaged by diabetes too. We call that neuropathy. And that can be dangerous in any part of your body, but especially in your feet. Please be sure to tell the provider about those feelings in your feet, and I’ll make a note in your chart.
Patient: Okay . . . sorry I didn’t trim my toenails, didn’t think I’d be getting a pedicure today.
Nurse: Do you trim your nails regularly?
Patient: Yup, if I don’t, they get all ingrown and hurt.
Nurse: Great habit to get into. Foot hygiene is very important, things like keeping them nice and clean and dry, and trimming your nails, making sure you don’t get any fungus . . . that all helps keep them healthy.
Patient: If my sugars don’t get better, could I not be able to walk?
Nurse: Diabetic foot problems can be very serious, Mr. Strout. In severe cases, people are in a lot of pain and can’t walk. When they get bad infections, they may even need to have a foot amputated.
Patient: Yikes! Well, how do they look? My feet?
Nurse: I don’t see any wounds, which is great. But I want you to tell the provider about those tingling feelings. They’ll talk to you more about how you can take care of your feet and work on getting those blood sugars under control.
[The nurse will document the findings and make sure to answer any further questions from the patient before completing the assessment.]
Emergency Assessment
An emergency assessment is conducted when a patient presents with life-threatening or potentially life-threatening conditions. The goal of emergency nursing assessment is to swiftly identify and address immediate threats to the patient’s life or health, initiating appropriate interventions to optimize outcomes and promote patient survival. This type of assessment has a rapid and focused nature and is aimed at identifying and addressing critical health issues promptly. In emergency settings, time is of the essence, and the accuracy of these assessments can have significant implications for patient outcomes.
In critical moments, nurses prioritize the assessment of vital signs and airway, breathing, and circulation (ABCs) to quickly determine a patient’s stability and the need for urgent interventions. This assessment may involve assessing the patient’s level of consciousness, oxygen saturation, heart rate, blood pressure, and respiratory rate. For example, if a patient exhibits signs of a stroke, the nurse quickly assesses for balance, vision changes, facial drooping, arm weakness, and speech difficulties in a timely manner. Following the primary survey, a secondary survey is conducted to gather more detailed information about the patient’s condition and history.
Clinical Judgment Measurement Model
Form a Hypothesis: Emergency Pain Assessment
Identifying cues: John, a 62-year-old male, is brought into the emergency department by ambulance after collapsing at home. On arrival, he is unconscious and unresponsive. His wife, who accompanied him, informs the medical team that John has a history of hypertension and diabetes, for which he takes medications regularly. She reports he has been complaining of severe headaches and dizziness for the past week but attributed it to stress from work. She also mentions that he has been increasingly fatigued and has experienced episodes of confusion and blurred vision.
Analyzing cues:
- unconsciousness and unresponsiveness upon arrival
- history of hypertension and diabetes
- complaints of severe headaches and dizziness for the past week
- increased fatigue and episodes of confusion and blurred vision
Forming a hypothesis: Given John’s medical history, symptoms, and recent complaints, a hypothesis could be that he is experiencing a hypertensive crisis or a diabetic emergency, such as diabetic ketoacidosis or hyperosmolar hyperglycemic state. These conditions are characterized by severe fluctuations in blood pressure or glucose levels, which can lead to neurological symptoms and loss of consciousness if left untreated.
The nurse’s role in an emergency assessment is to swiftly collect critical data and initiate necessary interventions, such as administering oxygen or initiating CPR if required. The ability to make quick, informed decisions is crucial in these high-stakes scenarios. Although nurses can formulate nursing diagnoses and intervene based on their assessments, it is important to acknowledge that the formal medical diagnosis is the responsibility of the healthcare provider.
Physiological Crisis
In emergency nursing assessment, a physiological crisis refers to a critical situation where the patient’s physiological functions are severely compromised, posing an immediate threat to life or health. Conditions such as heart attacks, severe respiratory distress, or major trauma would all fall under this category. When encountering a physiological crisis, nurses must act quickly and decisively to stabilize the patient’s condition and prevent further deterioration. A crisis may manifest in various ways, such as respiratory distress, cardiac arrest, severe bleeding, or neurological deterioration.
Assessment during a physiological crisis typically begins with a rapid evaluation of the patient’s ABCs, which are vital for sustaining life. Nurses assess the patency of the airway, the adequacy of breathing, and the presence of a pulse to determine the patient’s immediate needs. This assessment may involve interventions such as administering oxygen, initiating cardiopulmonary resuscitation (CPR), or controlling severe bleeding. For example, in a patient experiencing a severe asthma attack, the assessment would include evaluating respiratory rate, oxygen saturation, and the presence of wheezing or other abnormal breath sounds. Immediate interventions might include administering bronchodilators or corticosteroids.
In addition to the ABCs, nurses gather pertinent information about the circumstances leading to the crisis, the patient’s medical history, allergies, and medications. This information helps guide the assessment and subsequent interventions. Vital signs such as heart rate, blood pressure, respiratory rate, and oxygen saturation, are closely monitored to assess the patient’s physiological status and response to treatment.
The ultimate goal of the emergency nursing assessment during a physiological crisis is to stabilize the patient’s condition, restore physiological function, and initiate appropriate interventions to prevent further harm. During a physiological crisis, nurses must maintain clear communication with other members of the healthcare team and prioritize interventions based on the patient’s condition and the resources available. Multidisciplinary collaboration is crucial for delivering timely and effective care, especially in high-stakes situations.
Psychological Crisis
A psychological crisis refers to a state of acute emotional or mental distress that significantly impairs an individual’s ability to cope with their current circumstances. These crises may arise due to various factors such as trauma, acute stress, psychiatric disorders, substance abuse, or suicidal ideation. In such cases, the emergency assessment focuses on evaluating the patient’s mental status, ensuring their safety, and identifying immediate psychological needs. Key components include assessing the patient’s level of consciousness, cognition, thought processes, mood, and affect.
When encountering a psychological crisis, nurses must employ compassionate and effective assessment techniques to ensure the safety and well-being of the patient. Nurses utilize active listening skills to allow patients to express their feelings and concerns openly. To ensure a safe environment, the nurse may need to implement measures like constant observation if the patient poses a risk to themselves or others. Recommending a referral to mental health specialists and initiating crisis intervention protocols are often part of the response in such situations.
Time-Lapsed Assessment
A time-lapsed assessment is a systematic process for evaluating a patient’s health status and progress over time, usually every few months. Unlike initial assessments performed on admission or during the early stages of care, time-lapsed assessments occur at regular intervals throughout a patient’s treatment trajectory, allowing nurses to monitor changes, track trends, and adjust care plans accordingly. These assessments serve several purposes, including assessing the effectiveness of interventions, detecting new health issues or complications, evaluating the patient’s response to treatment, and promoting continuity of care.
The frequency and timing of time-lapsed assessments vary depending on factors such as the patient’s acuity level, the nature of their health condition, the goals of care, and institutional protocols. For patients with chronic conditions or complex medical histories, time-lapsed assessments may occur weekly, monthly, or at other predetermined intervals. In contrast, patients with acute conditions or undergoing rapid changes in status may require more frequent assessments.
This type of assessment is common in all settings but is particularly important in chronic disease management and long-term care. For example, in a patient with hypertension, a time-lapsed assessment might include reviewing changes in blood pressure readings over several months, assessing medication effectiveness, and making necessary adjustments in the treatment plan. It also includes reevaluating the patient’s lifestyle changes and the impact of these changes on health outcomes.
Documentation plays a critical role in time-lapsed assessments because it allows nurses to document changes in the patient’s condition, track progress toward goals, and communicate findings with other members of the healthcare team. As they help providers track the improvement or worsening of a condition, time-lapsed assessments support timely interventions and modifications in the care plan. They are integral to ensuring continuity of care and adapting care strategies to meet the evolving needs of the patient.