Nursing assessments are critical to the nursing process, and there are several different types of assessments that nurses need to be able to perform. They may be broad in scope or more focused on a single body system or issue.
The purpose of these assessments is to identify current and potential care needs and changes for your patient by using critical thinking to recognize the normal versus abnormal.
All healthcare providers on the healthcare team complete some form of patient assessment. The nursing assessment (especially a head-to-toe assessment) is one of the most thorough. Here’s some background and other information you need about each type of nursing assessments.
- Types of Nursing Assessments Every Nurse Needs To Know
- Similarities And Differences Between The Different Types Of Nursing Assessments
- More Resources for Nursing Assessments
Types of Nursing Assessments Every Nurse Needs To Know
As a nurse, the types of assessments you perform will change based on the reason for the patient coming in and the information that any previous assessments have provided.
Head-To-Toe Admission Assessment
The initial assessment is one of the most comprehensive nursing assessments to conduct and is usually done when a patient first arrives for care. It’s essentially a thorough review of why the patient is seeking care, a medical history, an exam, etc. This is performed to give a baseline of the baseline of the patient’s overall health status and prepare the plan of care.
Let’s go over what you need to look for as a nurse in a head-to-toe nursing assessment in order to understand your patient’s physical, emotional, and mental needs.
The exact order of the physical assessment is up to the individual nurse, but many nurses prefer go from top to bottom (or, head to toe!). If your nursing assistant has not taken a set of vitals already, this would be a great time to do so.
There are several key components to a nursing assessment including several physical examinations. Here’s a basic checklist:
- Vital signs- heart rate, respiration rate, blood pressure, vital signs, temperature, pulse oximetry, pain, etc.
- Neuro – observe their level of consciousness, ask orientation questions, see if they can move all 4 extremities with equal strength and tone (push-pull with hands, dorsi-plantar flex with feet). Do they make eye contact? Is there any facial dropping or lack of symmetry?
- Face – look at the coloration of the face, lips, and mouth, note any visual deficits (field-cuts, nystagmus, etc), and if the face is symmetrical
- Respiratory – listen to lung sounds, note any abnormalities and consider your vital sign findings (pulse ox) with this. Note if they require any supplemental oxygen and if that’s changed recently. Note the respiratory rate.
- Cardiac – listen for abnormal rhythm, check the rate, and check the pulse in arms, legs, and feet.
- Abdomen – inspect and listen for abnormal sounds, distention, firmness, and pain.
- Extremities – check the arms and legs for a range of motion, strength, sensation, and capillary refill.
- Skin – check for coloration, lesions, rashes, abrasions, tenderness, and lumps. Is the skin consistent for their ethnicity? (Meaning, do they look pale, flushed, etc.?) Are there any foul odors or pressure wounds?
- Psycho-social – do they feel safe in their living environment? Are there any spiritual or religious beliefs we need to observe? Do they have what they need to take care of their health needs (walker, shower chair, can they afford their meds?)? Are they using illicit drugs? How much alcohol do they consume regularly?
- Safety – ensure their call light is nearby, they know how to contact a nurse, the bed is in the lowest and locked position, non-skid socks are on or near them, etc.
Upon admission, a very thorough skin assessment is crucial. This is especially true if the patient has decreased mobility and may sit or lay in one position for extended periods. We need to catch if the patient has any pressure ulcers, sores, or breakdown because we don’t want to make it worse and should evaluate if it needs to be seen by the wound team and brought to the attention of the physician.
What you find in your head-to-toe assessment may lead you to performing one or more focused assessments. Be sure to pay attention to subtle details like skin color, temperature, and the rate of and depth of respirations.
Routine Head-To-Toe Assessment
In addition to completing a comprehensive head-to-toe assessment when patients are admitted, they are also re-assessed at routine intervals (depending on the unit). If the patient is in a med-surg type of nursing unit, typically a routine head-to-toe assessment is performed once per shift and with any change in status. If the patient is in ICU, reassessments are often required every 4 hours.
This assessment is basically identical to the previous assessment, except you won’t be asking all of those psycho-social home assessment questions repeatedly.
Focused Nursing Assessments
Comprehensive assessments are a routine part of nursing care observing all major health systems in the body. In contract, focused assessments are nursing assessments that target the specific body system where the patient demonstrates a medical diagnosis, problem, disorder, or concern. This can relate to one or multiple body systems. You’ll most often see these performed in emergency departments when a patient presents for a specific issue, or on a regular nursing unit when a change occurs (like a new neuro change). Their goal is to identify and address a specific issue, not a comprehensive medical evaluation for all possible factors that could be impacting a person.
Nurses should use their best clinical judgement to determine which focused assessments pertain to their patient based on a previous head-to-toe assessment as well as input from the patient. (Typically in an urgent situation for inpatients and for most emergency department patients).
Nurses can perform focused assessments in any of these areas:
- Neurological assessment – I have a free neuro assessment checklist here, and a free email course walking you through neuro checks in more detail here
- Respiratory assessment
- Cardiovascular assessment – I have a free cardiac assessment checklist you can download here
- Gastrointestinal assessment
- Renal assessment
- Musculoskeletal assessment
- Skin assessment
- Eye assessment
- Head and Neck / Ears Nose and Throat (ENT) assessment
- Cultural assessment
- Psychosocial assessment
- Abdominal assessment
While completing a focused assessment, a nurse should ensure the patient remains stable overall and not become overly fixated on that one aspect of the assessment. For example, if a patient complains of eye pain, but shortly thereafter begins complaining of shortness of breath, the nurse should not wait to address the shortness of breath until the eye assessment and interventions are complete. Pivot as the clinical picture evolves and requires it.
Knowing that emergencies can happen at any time, this nursing assessment is continually performed during the course of caring for a patient until the emergency is over. Being able to leverage critical thinking skills to prioritize and complete these assessments in stressful situations is vital
Using the acronym ABCCS, nurses perform emergency assessments when they meet a patient and repeat them anytime they determine that their patient’s condition could be becoming unstable.
Here’s what the acronym stands for:
- A = airway – ensure the airway is not obstructed or compromised
- B = breathing – ensure patient is breathing, and if it is absent or labored to intervene immediately
- C = circulation – check to ensure the patient has a pulse, and if patient is on cardiac monitoring (which they should be if circulation is a concern!) then check the patients heart rhythm
- C = consciousness – check their level of consciousness and observe for any abrupt changes
- S = safety – ensure that the patient is safe from risk of harm
Once the patient stabilizes, the nurse may discontinue emergency assessments and transition to an initial or focused assessment, depending on the situation.
Med-Surg Nursing Assessments
Patients on the medical surgical unit may be preparing for a surgical procedure or recovering from one. Or they may have an illness that requires close monitoring by a med-surg nurse to watch for any changes in their condition or the need for a higher level of care.
Every shift, a med-surg nurse must complete a head-to-toe assessment, and also after any changes (like a code or if the patient went to surgery and came back). This head-to-toe nursing assessment aims to alert nurses to anything that may indicate a problem for the patient. It’s imperative to do this regularly (most policies say once per shift and with changes) so the providers and nursing staff know how the patient is doing continuously, and detect changes faster.
It is a bit more abbreviated than an admission head-to-toe assessment, as previously described. While your routine skin assessment does not need to be quite as thorough, you will want to check the following additional items:
- Intake and output
- Assess any lines, tubes, drains, and airways
- Compare current vitals and labs to previous trends
- Ensure anything that can be discontinued is promptly removed
- Any meds continuously infusing into an IV are at the correct rate, dose, and is the correct med
- Any oxygen is hooked up appropriately, flowing, and at the correct level
- Any necessary equipment (like sequential compression devices) are connected
I dive deep into med-surg assessments in this course.
ICU assessments are very similar to but very different from a general head-to-toe assessment because they’re more detailed due to the critical nature of the care the patient needs. You’ll do this type of assessment for each patient when you come on shift, and it begins as soon as you see your patient.
First, check monitors, drips, ventilator, and medications to verify settings, levels, labels, drawing labs if needed, and ensuring alarms are set appropriately. ICU assessments also include general neural assessments, checking tubes, suction, dressings, heart sounds, lung sounds, bowel sounds, catheters, and extremities.
This type of assessment involves checking much more than a simple head-to-toe assessment because the patient requires a much higher level of care than a general patient or even a med surg patient.
Similarities And Differences Between The Different Types Of Nursing Assessments
Performing assessments is vital component of patient care and one of the fundamentals of nursing. A single nurse may perform many assessments in the course of one shift. Head-to-toe assessments are much more comprehensive and completed in a non-urgent and routine manner. They are done at a minimum of once per shift (therefore twice in a 24 hour period) and enable the nurse to compare their current findings to the previous nurse’s findings. The admission head-to-toe assessment is extremely important to establish a baseline so that all nurses assessing the patient after that point have something reliable to compare their current findings to.
Focused assessments are often done in urgent and emergent situations. There is a previously identified issue or concern (that could have occurred during a head-to-toe assessment, from patient notification, or from the nurse/staff identifying a need for a closer look) requiring attention.
Knowing a patient’s baseline is important. Every assessment will build upon the previous to help nurse leverage clinical judgment to determine if any alterations are needed on the care plan.
More Resources for Nursing Assessments
- Head-to-Toe Nursing Assessments versus Focused Assessments
- Tips for Cardiac Nurse Assessment
- Neuro Assessment: How to Assess An Unconscious Neuro Patient Like a Neuro ICU Nurse
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