Basic Nursing: Foundations of
Skills & Concepts
Chapter 25
ASSESSMENT
Nursing Assessment

A complete nursing assessment is
necessary to analyze each client’s needs
in a holistic manner.

Nursing assessment includes both
physical and psychosocial aspects to
evaluate a client’s condition.
Basic Components

Health History.

Physical Examination.
Health History

A review of the client’s functional health
patterns prior to the current contact with a
health care agency.
Components of Health History
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Demographic
Information.
Reason for Seeking
Health Care.
Perception of Health
Status.
Previous Illnesses,
Hospitalizations, and
Surgeries.
Client/Family Medical
History.
Allergies.
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Immunizations/Exposure
to Communicable
Diseases.
Current Medications.
Developmental Level.
Psychosocial History.
Sociocultural History.
Activities of Daily Living.
Review of Systems.
Demographic Information
Name.
 Address.
 Date of Birth.
 Gender.
 Religion.

Race/Ethnic
Origin.
 Occupation.
 Type of Health
Plan/Insurance.

Reason for Seeking
Health Care

Should be described in client’s own
words.
Perception of Health Status

Refers to the client’s opinion of his or her
general health.
Developmental Level
Knowledge of developmental level is
essential for considering the appropriate
norms of behavior.
 Any recognized theory of growth and
development can be applied for
assessment purposes.

Psychosocial History
The assessment of such dimensions as
self-concept and self-esteem.
 Sources of stress for the client and the
client’s ability to cope.
 Sources of support for clients in crisis,
such as family, significant others, religion,
or support groups.

Sociocultural History
Home environment.
 Family situation.
 Client’s role in the family.

Review of Systems

A brief account from the client of any
recent signs or symptoms associated with
any of the body systems.
Relevant Data Regarding
Symptoms
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Location (area of the body in which symptom, such as
pain, is felt).
Character (the quality of feeling or sensation, e.g.
sharp, dull, stabbing).
Intensity (the severity or quantity of the feeling and its
interference with functional ability).
Timing (onset, duration, frequency, and precipitating
factors of the symptoms).
Aggravating/Alleviating Factors (activities or actions that
make the symptom better or worse).
Physical Examination
Performed head-to-toe using these specific
assessment techniques:
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Inspection (thorough visual observation).
Palpation (touching to assess texture, temperature,
moisture, organ location and size, swelling, etc.).
Percussion (short tapping strokes on the surface of the
skin to create vibrations of underlying organs).
Auscultation (listening to sounds in the body created by
movement of air or fluid).
Positions for Physical
Examination
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Sitting (to examine head,
back, lungs, breast,
heart, extremities).
Supine (to examine
head, neck, lungs,
breast, abdomen, heart,
extremities).
Sims (to examine rectum
and vagina).
Knee-chest (to examine
rectum).
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Dorsal recumbent (to
examine head, neck,
lungs, breast, heart).
Prone (to examine
posterior thorax, lungs,
hip).
Lithotomy (to examine
female genitalia, rectum,
genital tract).
Introduction of the Nurse
Introduction of the nurse at the beginning
of a physical assessment enhances the
ability to accomplish the complete
assessment.
 Special considerations involved during the
physical examination of:
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Elderly.
Disabled clients.
Abused clients.
Vital Signs
“Signs of life” of an individual.
 Include:
 Temperature.
 Pulse.
 Respirations.
 Blood Pressure.
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Terms Pertaining to Pulse
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Pulse rate (indirect measurement of cardiac output
obtained by counting the number of peripheral pulse
waves over a pulse point).
Pulse rhythm (regularity of the heartbeat).
Pulse amplitude (measurement of the strength or force
exerted by the ejected blood against the anterior wall with
each contraction).
Pulse deficit (condition in which the apical pulse rate is
greater than the radial pulse rate).
Terms Pertaining to Respiration
Eupnea (easy respirations with a rate of
breaths-per-minute that is ageappropriate).
 Hypoventilation (shallow respirations).
 Hyperventilation (deep, rapid,
respirations).
 Dyspnea (difficulty in breathing).
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Blood Pressure

Favored site is the brachial artery.
Alternative is popliteal artery, behind the
knee.
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Pulse pressure is the difference between
the systolic and the diastolic blood
pressures.
Height and Weight
Measurements
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As important as assessing the client’s
vital signs.
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Routinely taken on admission to acute
care facilities and on visits to physicians’
offices, clinics, and other health care
settings.
Neurological Assessment
Focuses on:

Level of consciousness.
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Pupil response.
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Hand grasps.
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Foot pushes.
Assessing Affect

When describing a client’s affect, the
nurse must utilize terms that are
descriptive of the specific behavior
observed, not the nurse’s judgment about
the behavior.
Thoracic Assessment
Focuses on:

Cardiovascular status.

Respiratory status.

Wounds, scars, drains, tubes, dressings.

Breasts.
Types of Normal Breath Sounds
Bronchial (loud and high-pitched with a
hollow quality).
 Bronchovesicular (medium-pitched and
blowing).
 Vesicular (soft, breezy, and low-pitched).
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Terms Pertaining to Breath
Sounds
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Adventitious breath sounds (abnormal).
Sibilant wheezes (high-pitched, whistling).
Sonorous wheezes (low-pitched snoring).
Crackles (popping sounds heard on inhalation or
exhalation.
Pleural friction rub (low-pitched grating sound heard on
inhalation or exhalation).
Stridor (high-pitched, harsh sound heard on inspiration
while trachea or larynx is obstructed).
Abdominal Assessment
Focuses on gastrointestinal and
genitourinary status.
 Includes use of inspection, auscultation,
percussion, and palpation within the four
quadrants of the abdomen to establish
bowel function and status.
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Musculoskeletal and Extremity
Assessment

Through observation of client gait and
overall range of movement, the nurse is
able to obtain some knowledge of the
symmetry and strength of muscles.
Assessment of Wounds, Drains,
Tubes, and Dressings
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The nurse must maintain accurate
documentation of the amount of drainage,
color, or other changes.