Conducting Nursing Assessments

Required Source Documents

• Most recent prior nursing assessment (for comparison trending)
• Active physician/APP orders
• Current vital signs (within preceding 4 hours or per unit protocol)
• Relevant laboratory results (BMP, CBC, coagulation studies, lactate as applicable)
• Imaging results if pertinent to current condition
• Pain assessment score from most recent evaluation

Scope Determination

• Determine if this is an admission assessment, shift assessment, focused reassessment, or transfer assessment
• Identify unit-specific required assessment components (e.g., neuro checks q1h for stroke unit, circulatory checks for post-catheterization)
• Confirm documentation system and required flowsheet fields

Step 1 — General Survey and Vital Signs Baseline

Perform the general survey before touching the patient:

1. Observe level of consciousness using the Glasgow Coma Scale (Eye 1–4, Verbal 1–5, Motor 1–6; total 3–15)
2. Assess general appearance: nutritional status, hygiene, affect, posture, gait if ambulatory
3. Record a complete set of vital signs: temperature (route), heart rate, respiratory rate, blood pressure (position and extremity), SpO2 (on room air or specify FiO2), pain score
4. Calculate the Modified Early Warning Score (MEWS) or unit-specific early warning score
5. Compare current vitals against the patient's baseline trend (not just reference ranges)
6. Flag any MEWS ≥ 4 or single-parameter critical value for immediate escalation per rapid response criteria

Document deviations from expected baseline. A blood pressure of 100/60 may be normal for a young athletic patient but critical for a patient whose baseline runs 160/90.

Step 2 — Neurological Assessment

1. Orientation — assess to person, place, time, and situation (A&Ox4)
2. Pupil response — size in millimeters, shape (round, ovoid, irregular), reactivity (brisk, sluggish, fixed), consensual response; compare bilaterally
3. Motor function — grip strength bilateral, dorsiflexion/plantar flexion bilateral; use 0–5 muscle strength scale
4. Sensory — light touch and sharp/dull discrimination in all extremities if indicated
5. Cranial nerves — facial symmetry (CN VII), gag reflex (CN IX/X), tongue midline (CN XII) as appropriate to diagnosis
6. Fall risk — complete the Morse Fall Scale or unit-specific fall risk tool; score ≥ 45 = high risk requiring fall prevention interventions

Document any change from previous assessment. New-onset unilateral weakness, pupil asymmetry > 1 mm, or sudden change in LOC requires immediate provider notification.

Step 3 — Cardiovascular Assessment

1. Auscultate heart sounds in aortic, pulmonic, Erb's point, tricuspid, and mitral areas
2. Identify rhythm (regular vs. irregular), rate, and any murmurs (grade I–VI), gallops (S3/S4), or rubs
3. Assess peripheral pulses: radial, dorsalis pedis, posterior tibial — rate 0 (absent) to 3+ (bounding)
4. Evaluate capillary refill (normal < 3 seconds)
5. Inspect for edema: location, pitting scale (1+ to 4+), and symmetry
6. Check JVD with head of bed at 45 degrees
7. Review telemetry rhythm if monitored (reference managing-telemetry-monitoring skill)

Report new murmurs, absent pulses, capillary refill > 3 seconds, or 3+ pitting edema immediately.

Step 4 — Respiratory Assessment

1. Observe respiratory effort: use of accessory muscles, nasal flaring, retractions, tripod positioning
2. Auscultate all lung fields bilaterally: anterior (6 sites) and posterior (6 sites)
3. Document breath sounds: clear, diminished, crackles (fine/coarse), wheezes (inspiratory/expiratory), rhonchi, stridor, absent
4. Record oxygen delivery method and flow rate or FiO2
5. Note cough characteristics: productive (describe sputum color, consistency, amount) or nonproductive
6. Calculate SpO2/FiO2 ratio if concern for acute respiratory distress (ratio < 315 suggests ALI, < 200 suggests ARDS)

New-onset stridor, SpO2 < 90% on supplemental O2, or acute respiratory distress requires immediate escalation.

Step 5 — Gastrointestinal Assessment

1. Auscultate bowel sounds in all four quadrants before palpation (normoactive, hypoactive, hyperactive, absent)
2. Inspect abdomen: contour (flat, rounded, distended, protuberant), surgical scars, ostomy presence
3. Palpate lightly for tenderness, guarding, rigidity, rebound
4. Document last bowel movement, stool characteristics (Bristol Stool Scale 1–7), and any emesis
5. Assess nutritional intake: percentage of meals consumed, enteral/parenteral nutrition tolerance
6. Evaluate tube placement verification if NG/OG/PEG present (pH testing, external length marking)

Rigid abdomen, absent bowel sounds with distension, or new-onset bloody emesis requires immediate provider notification.

Step 6 — Genitourinary Assessment

1. Document urine output: amount, color, clarity, odor
2. Calculate urine output per kg/hr if critically ill (target ≥ 0.5 mL/kg/hr)
3. Assess Foley catheter if present: insertion date, securement, drainage tubing patency, daily necessity review per CAUTI bundle
4. Evaluate for urinary retention via bladder scan if indicated (> 300 mL post-void residual is significant)
5. Note continence status and any skin breakdown risk from moisture

Step 7 — Musculoskeletal and Integumentary Assessment

1. Perform Braden Scale assessment (sensory perception, moisture, activity, mobility, nutrition, friction/shear; score 6–23; ≤ 18 = at risk, ≤ 12 = high risk)
2. Inspect skin systematically: head, trunk (anterior/posterior), bilateral upper and lower extremities, perineum, under medical devices
3. Document any skin breakdown using NPUAP/EPUAP staging (Stage 1–4, Unstageable, DTPI)
4. Measure wounds per WOCN guidelines: length × width × depth in centimeters, tunneling, undermining
5. Assess mobility and ROM limitations
6. Evaluate assistive device use, orthotics, splints

Refer to managing-skin-integrity and managing-wound-assessment-nursing skills for detailed wound documentation.

Step 8 — Psychosocial and Safety Assessment

1. Screen for depression using PHQ-2 (score ≥ 3 triggers PHQ-9 completion)
2. Assess suicide risk per Columbia Suicide Severity Rating Scale if indicated
3. Evaluate substance use history and withdrawal risk (CIWA-Ar for alcohol, COWS for opioids)
4. Document support system, coping mechanisms, and cultural/spiritual considerations
5. Screen for intimate partner violence per institutional protocol
6. Verify safety measures: call light within reach, bed in low position, brakes locked, environment clear of hazards

Step 9 — Lines, Drains, and Device Inventory

1. Catalogue all invasive lines: type, location, insertion date, dressing status, patency
2. Document all drains: type (JP, Hemovac, chest tube, wound vac), output amount/color/characteristics per shift
3. Verify sequential compression devices, anti-embolic stockings, or other VTE prophylaxis devices
4. Check restraints if applicable (reference managing-restraint-documentation skill)
5. Confirm infusion pump settings match active orders for all running IV fluids and medications

Checkpoint B — Assessment Synthesis and Documentation Review

Completeness Verification

• All body systems assessed and documented (neuro, cardiovascular, respiratory, GI, GU, integumentary, musculoskeletal, psychosocial)
• Vital signs complete with early warning score calculated
• Fall risk score current and interventions match risk level
• Braden Scale score current and prevention plan in place if ≤ 18
• All lines/drains/devices inventoried with dates and status
• Pain assessment completed (reference managing-pain-assessment-nursing skill)
• Abnormal findings clearly described with comparison to prior assessment

Clinical Reasoning Verification

• NANDA-I nursing diagnoses updated based on assessment findings
• Priority problems identified and communicated to care team
• Changes from prior assessment explicitly documented with provider notification if required
• Care plan updated to reflect current assessment (reference creating-nursing-care-plans skill)

Quality Audit

• Assessment completed within required timeframe (admission: per CMS CoP; shift: per institutional policy)
• Documentation uses objective, measurable terms (not "looks good" or "appears fine")
• All abnormal findings include comparison trending (e.g., "crackles bilateral bases, new since 0700 assessment")
• Provider notifications for critical findings documented with time, provider name, and read-back confirmation
• SBAR format used for all provider communications regarding assessment findings
• No use of prohibited abbreviations per Joint Commission "Do Not Use" list
• Assessment supports the current nursing diagnoses and plan of care
• All required screening tools completed (fall risk, Braden, PHQ-2, etc.)
• Meets ANA Standard 1 (Assessment) requirements for systematic, ongoing data collection
• Documentation would withstand medical-legal scrutiny: "If it wasn't documented, it wasn't done"

Guidelines

• ANA Scope and Standards: Standard 1 (Assessment) requires systematic, ongoing collection of relevant data; Standard 4 (Planning) requires the assessment to drive the care plan
• Joint Commission NPSGs: NPSG.01.01.01 (patient identification), NPSG.02.03.01 (critical results reporting), NPSG.06.01.01 (clinical alarm management)
• CMS Conditions of Participation: §482.13 requires assessment by an RN within timeframes specified by state law and hospital policy
• NANDA-I Taxonomy: All nursing diagnoses must be supported by assessment data (defining characteristics and related factors)
• Documentation standard: Objective findings documented with clinical measurements; subjective data attributed to patient in quotes; clinical judgment supported by data
• Frequency: Admission assessment, shift assessment, focused reassessment after interventions, reassessment for change in condition, transfer assessment — per institutional policy and state regulations
• Scope of practice: RN performs comprehensive assessment; LPN/LVN may collect data under RN direction per state Nurse Practice Act; findings requiring clinical judgment must be interpreted by RN
• Escalation: Any assessment finding meeting rapid response activation criteria requires immediate team activation — do not delay to complete remaining assessment components