Essential Nursing Assessment Skills Every Future Nurse Should Know

The modern nurse’s role is far-reaching, with registered nurses (RNs) in particular holding a wide range of responsibilities and significant autonomy. These trusted medical professionals set the tone for positive healthcare experiences from the get-go.

It all begins with a comprehensive nursing assessment, one of the most important aspects of any medical visit or appointment. Assessments reveal (or rule out) a wide range of health concerns while also evaluating the patient’s mindset.

At Carrington College, nursing students learn assessment skills through classroom instruction, simulation labs, and hands-on clinical experiences. Keep reading to learn why health assessment in nursing matters and the steps taken to assess a patient. You will also gain a better sense of the training and comprehensive knowledge aspiring nurses learn to handle assessment tasks with ease.

What Is a Health Assessment in Nursing?

A nursing assessment describes the careful, systematic collection, organization, validation, and documentation of a patient’s health data. An assessment helps nurses evaluate a patient’s physical, mental, and emotional state, tailoring care to the patient’s unique needs. (1)

What Are the 5 Types of Nursing Assessments?

• Initial Assessment: Performed when the patient first enters a healthcare facility, and includes documentation of a full health history and the collection of baseline data.
• Focused Assessment: Targets specific problems and gathers information on symptoms.
• Emergency Assessment: A fast check of a patient’s condition during a life-threatening crisis, with a focus on the ABCs (Airway, Breathing, and Circulation).
• Ongoing Assessment: Performed during daily rounds and shift changes, tracking changes in a patient’s baseline data.
• Time-Lapsed Assessment: Compares current health data to past data to evaluate the effectiveness of long-term care goals. (2)

Why Are Nursing Assessments Important?

Nursing assessment forms the basis of any medical appointment. It is essential for verifying the patient’s condition or symptoms, gaining insight into potential treatment options, and, just as importantly, establishing rapport with the patient.

Speaking to the far-reaching importance of the assessment process, the American Nurses Association (ANA) explains, “The registered nurse collects pertinent data to the health care and information relative to the health care consumer’s health or the situation.”(3)

This process encompasses several components, such as:

• Physical assessment. Also known as the head-to-toe assessment, this is what most patients picture when they imagine a ‘typical’ nursing assessment. Nurses document the patient’s physical status, paying special attention to any areas the patient identifies as problematic.
• Mental assessment. This portion of a nursing assessment addresses cognitive concerns and other mental considerations. It requires a nuanced understanding of cognitive and emotional health, as well as the use of approved testing procedures and surveys to reveal the patient’s current mental status.
• Psychological. Focuses on the patient’s mental health and well-being; these assessments help to reveal psychological concerns that might call for intervention.
• Patient goals. To empower patients, assessments often incorporate personal goals related to treatment plans and long-term health outcomes. As patients share these intentions, nurses can build them into both treatment protocols and educational efforts.

How to Start the Assessment Process

Nurses must build a foundation of trust so patients feel comfortable sharing important details with medical professionals and feel respected and confident enough to follow through on treatment plans. Small efforts to build rapport can make a huge difference, so this should be a priority as assessments begin.

Build Rapport With the Patient

Nurses should express kindness and empathy from the outset of an assessment. These intentions should be abundantly clear as soon as the patient’s medical assessment begins. Offer a clear, friendly introduction with eye contact and a gentle demeanor. Small talk can ease tension and give worried patients a welcome distraction, then transition smoothly into a brief overview of what will happen during the assessment.

Clarify Medical History

Once patients feel comfortable enough to discuss their concerns, nurses collect background information, which can strongly influence everything from diagnoses to treatment recommendations. Concerns to discuss and update in the medical history records include:

• Past conditions and surgeries. Confirm any medical issues or procedures already listed in the patient’s record before inquiring about anything that has occurred since the last visit. These concerns may significantly affect future diagnoses and treatment plans, so they should be top of mind during patient assessments.
• Medication history. Patients should update you on any prescriptions or over-the-counter medications they are currently taking. If they no longer use the drugs mentioned in their medical history, they should update that information as well.
• Family medical conditions. From genetics to environmental factors, family history shares much that may help medical professionals understand chronic conditions or other concerns. By collecting and tracking family health histories, medical professionals can better understand which preventative measures may be worth implementing while also identifying early signs of high-risk illnesses. Assessments may incorporate a thorough overview of the family’s health background, plus updates if any new conditions or concerns have recently emerged.

Lifestyle Habits

Because lifestyle plays such a significant role in chronic conditions, any nursing assessment should include at least a brief overview of everyday practices such as nutrition, exercise, and sleep, plus a chance to convey concerns about drug or alcohol consumption.

These conversations can be sensitive, and patients are often reluctant to share. This is where previous efforts to build rapport can pay off. If patients genuinely believe that nurses are empathetic and non-judgmental, they are more likely to be open and honest about their lifestyle.

Physical Assessment Process

Background information is vital, but some concerns can only be understood through direct observation. During the physical portion of the assessment, nurses observe patients closely to identify signs or symptoms of possible illnesses or conditions, as well as their severity.

One of the first steps is to collect vitals: commonly tracked, easily obtainable metrics that provide instant insight into the patient’s health status. Examples include pulse, temperature, and breathing rate. Healthcare professionals differ in their willingness to define blood pressure as a vital sign, but it is standard practice to track it during patient assessments.

Any physical, head-to-toe assessment should also include a thorough HEENT (Head, Ears, Eyes, Nose, and Throat) assessment. Critical for detecting a variety of illnesses, HEENT assessments typically occur as the patient is sitting upright so that, as Lippincott NursingCenter explains, the nurse can “systematically work down through each body system.” (4)

Essentials to watch for and note include:

• Alignment of the eyes or drooping of the eyelids.
• Pupil reflex tests, known as PERRLA: Pupils Equal, Round, and Reactive to Light and Accommodation.
• Gaze, including the eyes’ ability to move at the same time in the same direction. The assessment should also verify the patient’s ability to gaze in the cardinal directions: right, right up, right down, left, left up, left down.
• Use an otoscope to inspect for tenderness, elasticity, or drainage.
• Use a nasal speculum or otoscope to inspect the nasal passages.
• Assess the mouth for salivary gland inflammation, swallowing ability, and uvular movement.
• Palpate lymph nodes for swelling. Note enlargement of the thyroid gland if relevant, along with the presence of any masses.

In addition to HEENT overviews and vitals, physical assessments may encompass the following key areas:

• Skin inspections. A physical assessment can reveal whether the patient’s skin is clammy or has problematic lesions or abrasions. Nurses should also watch for bruising or swelling. Note color variation during visual inspection, then assess thickness, texture, and moisture during palpation.
• Cardiac system. In addition to taking a cardiac-focused medical history, nurses should palpate patients with cardiac concerns to detect vibratory sensations known as thrills. A stethoscope can be used for auscultation of heart sounds. (7)
• Musculoskeletal system. Assessments of the musculoskeletal system should include careful observations of the patient’s gait and may also encompass a thorough search for postural abnormalities. This assessment may also reveal muscle strength, with the patient ideally capable of resisting an opposing force.

How to Perform a Mental Assessment on a Patient

Not all patients are willing to discuss sensitive details about their cognitive or emotional health, but nurse assessments can still provide insight into their current mental state. Mental status assessments can reveal the current functionality of the central nervous system. Concerns to evaluate include:

• Mood and affect. Depending on the situation, you may best discern the patient’s emotional state by asking about current and recent moods. This can be as straightforward as asking, “How are you feeling?” Verbal and non-verbal behaviors can also provide valuable insight. Note disturbances such as agitation or rage.
• Degree of arousal. This term refers to how attentive or responsive the patient is during the assessment. For example, the patient may appear confused or tired. This may be assessed using the Observational Scale of Level of Arousal (OSLA), which can detect arousal variations in the context of delirium. (5)
• Mini-Mental State Examination (MMSE). Widely recommended for detecting cognitive impairment in older patients, the MMSE relies on a short series of questions to assess the patient’s orientation, short-term memory, and language function. (6)

What Is an Example of a Nursing Health Assessment?

A patient shows up at the ER complaining of shortness of breath. As part of a comprehensive nursing assessment, a nurse would take the following steps:

• Gather the patient’s health history and take vital signs, including heart rate, respiratory rate, blood pressure, and temperature.
• Use a pulse oximeter on the finger to measure blood oxygen levels.
• Perform a lung auscultation, using a stethoscope to listen for wheezes or crackles from the front and back of the chest.
• Confirm whether chest pain or pressure is present during the breathing problem.
• Document current prescriptions, inhalers, or recent changes in medication.
• Document all findings and observations on the patient’s chart.
• Provide the doctor with the exact vital signs, oxygen levels, and symptoms.

What Are the Four Physical Examination Techniques Used During a Nursing Assessment?

Inspection

Nurses observe overall appearance, posture, movement, symmetry, skin color, and any potential abnormalities, including odors and wounds.

Palpation

The nurse uses their hands and fingers to feel for abnormalities, assessing texture, temperature, moisture, masses, and areas of tenderness. Light palpation assesses the skin surface, while deeper palpation evaluates underlying structures.

Percussion

Percussion involves tapping the body to produce sound waves that help determine the state of the underlying tissue, which produces different sounds if it is solid, filled with air, or filled with fluid.

Auscultation

Usually performed with a stethoscope, auscultation describes listening to sounds within the body, including those produced by the heart, lungs, and intestines. (7)

Important Steps to Know About Psychological Assessments

Beyond the mental status basics outlined above, nurses use other tests to assess a patient’s psychological state. Examples include:

• Beck’s Depression Inventory. Widely recognized as a reliable system for measuring depression, this survey includes 21 questions that delve into concerns such as guilt, hopelessness, disinterest in activities, diminished concentration, and suicidal ideation. Responses are tallied to generate a score, which can then be classified as indicative of mild, moderate, or severe depression. (8)
• Suicide risk assessments. Beyond Beck’s, a variety of other tools for assessing suicidal ideation are currently available. The Harkavy Asnis Suicide Scale (HASS), for example, aims to gather important details about young patients’ current or past suicidal behavior. (9) When working with at-risk adults, strategies such as the Nurses’ Global Assessment of Suicide Risk (NGASR) are preferred for healthcare staff members with limited experience in suicide assessment. (10)

Depending on the indicators revealed during psychological assessment, it may be necessary to refer the patient to mental health professionals. This is particularly important if the patient reveals signs of suicidal ideation or dangerous behaviors. While not all nurses are equipped to give patients in distress the targeted care they need, most have the capacity to perform some sort of suicidal or mental health screening.

How to Support Patient Goals

Patients prefer to have a say in their care. This empowers them and can improve patient satisfaction and follow-through. One of the most effective strategies for getting them invested in their health and well-being is to give them opportunities to set goals for individual medical appointments and for long-term treatment plans.

Nurses should encourage patients to share goals during assessments so they can better understand what patients need and how to meet those needs, both in the short term and long term.

Technology Used During Modern Nursing Assessments & How to Keep Patient Records

Clear, organized medical files support everything from communicating with the healthcare team to facilitating payments and reimbursements. In the Principles for Nursing Documentation, the ANA details several key principles for handling the administrative components of nursing. (11) Several of these are highlighted below:

• Documentation Characteristics: Documents should be accessible, accurate, and concise. They should also be timely, contemporaneous, and sequential.
• Education and Training: Nurses must demonstrate proficiency with electronic documentation software.
• Policies and Procedures: Nurses must understand the healthcare facility’s documentation policies, including what to do if electronic medical records are unavailable.
• Protection Systems: Confidentiality is crucial. To ensure this, documentation procedures follow industry standards and government mandates for data security and patient identification protection.
• Documentation Entries: All entries must be accurate, truthful, and readable. They should use standardized terminology (including approved acronyms) and be time-stamped by the nurses who create them.

Begin Developing Nursing Assessment Skills at Carrington College

Formal training is necessary to understand nursing assessment skills fully. The Carrington College School of Nursing offers a range of nursing certificates and degrees for anyone interested in pursuing a healthcare career.

Resources

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