Chapter 1

• An ongoing or partial assessment of the client consists of data collection that occurs after the comprehensive database is established. This consists of a mini overview of the client’s body systems and holistic health patterns as a follow-up on health status. Any problems that were initially detected in the client’s body system or holistic health patterns are reassessed to determine any changes
• The purpose of an ongoing assessment is to monitor the effectiveness of interventions, identify new problems, evaluate progress toward goals, and assess overall wellness.
• 4 types of health assessment

  1. Initial comprehensive assessment
  2. Ongoing or partial assessment
  3. Focused or problem-oriented assessment
  4. Emergency assessment
• An initial comprehensive assessment involves collection of subjective data about the client’s perception of their health of all body parts or systems, past health history, family history, and lifestyle and health practices (which include information related to the client’s overall functioning) as well as objective data gathered during a stepby-step physical examination.
• A focused or problem-oriented assessment does not replace the comprehensive health assessment. It is performed when a comprehensive database exists for a client who comes to the health care agency with a specific health concern
• An emergency assessment is a very rapid assessment performed in life-threatening situations . In such situations (choking, cardiac arrest, drowning), an immediate assessment is needed to provide prompt treatment.
• Steps of health assessment

  Collection of subjective data

  Collection of objective data

  Validation of data

  Documentation of data
• Subjective Data Collection - The nurse gathers information from the patient through interview questions that are open ended and allow the patient to express his/her feelings and thoughts regarding his/her health status.
• Objective Data Collection - The nurse collects information by observing and measuring the patient's responses to stimuli using standardized tools and techniques.
• Data Validation - The nurse compares the collected data against other sources of information to ensure accuracy and completeness.
• Objective Data Collection - The nurse collects information by observing the patient's behavior, appearance, and responses to stimuli; performing tests on bodily fluids, tissues, and organs; and reviewing medical records.
• Data Validation - The nurse checks the accuracy of the collected data against other sources of information, including previous assessments, laboratory results, and reports from other members of the healthcare team.
• process of data analysis

  Identify abnormal cues and supportive cues.

  Cluster cues.

  Draw inferences and identify and prioritize client concerns.

  Propose possible collaborative problems to notify primary care provider. Identify need for referral to primary care provider.

  Document conclusions.
• C- Character

  O- Onset

  L- Location

  D- Duration

  S- Severity

  P- Pattern

  A- Associated pattern
• Skin, hair, and nails


  • Skin color
  • Skin temperature
  • Skin condition
  • Excessive sweating
  • Rashes
  • Lesions
  • Balding
  • Dandruff
  • Nail condition
• Head and neck


  • Headache
  • Swelling
  • Stiffness of neck
  • Difficulty swallowing
  • Sore throat
  • Enlarged lymph nodes
• Eyes


  • Vision
  • Eye infections
  • Redness
  • Excessive tearing
  • Halos around lights
  • Blurring
  • Loss of side vision
  • Moving black spots/specks in visual fields
  • Flashing lights
  • Double vision
  • Eye pain
• Ears


  • Hearing
  • Ringing or buzzing
  • Earaches
  • Drainage from ears
  • Dizziness
  • Exposure to loud noises
• Mouth, throat, nose, and sinuses


  • Condition of teeth and gums
  • Sore throats
  • Mouth lesions
  • Hoarseness
  • Rhinorrhea
  • Nasal obstruction
  • Frequent colds
  • Sneezing or itching of eyes, ears, nose, or throat
  • Nose bleeds
  • Snoring
• Thorax and lungs


  • Difficulty breathing
  • Wheezing
  • Pain
  • Shortness of breath during routine activity
  • Orthopnea
  • Cough or sputum
  • Hemoptysis
  • Respiratory infections
• Breasts and regional lymphatics


  • Lumps or discharge from nipples
  • Dimpling or changes in breast size
  • Swollen or tender lymph nodes in axilla
• Heart and neck vessels


  • Last blood pressure
  • ECG tracing or findings
  • Chest pain or pressure
  • Palpitations
  • Edema
• Peripheral vascular


  • Swelling, or edema, of legs and feet
  • Pain
  • Cramping
  • Sores on legs
  • Color or texture changes on the legs or feet
• Abdomen


  • Indigestion
  • Difficulty swallowing
  • Nausea
  • Vomiting
  • Abdominal pain
  • Gas
  • Jaundice
  • Hernias
• Male genitalia


  • Excessive or painful urination
  • Frequency or difficulty starting and maintaining urinary stream
  • Leaking of urine
  • Blood noted in urine
  • Sexual problems
  • Perineal lesions
  • Penile drainage
  • Pain or swelling in scrotum
  • Difficulty achieving an erection and/or difficulty ejaculating
  • Exposure to STIs
• Female genitalia


  • Sexual problems
  • STIs
  • Voiding problems (e.g., dribbling, incontinence)
  • Reproductive data such as age at menarche, menstruation (length and regularity of cycle), pregnancies, and type of or problems with delivery
  • abortions, pelvic pain, contraception, menopause (date or year of last menstrual period), and use of HRT
• Anus, rectum, and prostate: bowel habits, pain with defecation, hemorrhoids, blood in stool, constipation, diarrhea
• Musculoskeletal: swelling, redness, pain, stiffness of joints, ability to perform ADLs, muscle strength
• Neurologic: general mood, behavior, depression, anger, concussions, headaches, loss of strength or sensation, coordination, difficulty speaking, memory problems, strange thoughts and/or actions, difficulty learning
• P- Provocative

  Q- Quality

  R- Radiation

  S- Severity

  T- Timing
• I- Inspection

  P- Palpation

  P- Percussion

  A-Auscultation
• Inspection involves using the senses of vision, smell, and hearing to observe and detect any normal or abnormal findings. This technique is used from the moment that you meet the client and continues throughout the examinatio
• Palpation consists of using parts of the hand to touch and feel for the following characteristics:

  Texture (rough/smooth)

  Temperature (warm/cold)

  Moisture (dry/wet)

  Mobility (fixed/movable/still/vibrating)

  Consistency (soft/hard/fluid filled)

  Strength of pulses (strong/weak/thready/bounding)

  Size (small/medium/large Shape (well defined/irregular)

  Degree of tenderness
• Fingerpads Fine discriminations: pulses, texture, size, consistency, shape, crepitus

  Ulnar or palmar surface Vibrations, thrills, fremitus

  Dorsal (back) surface Temperature
• 4 TYPES OF PALPATION

  Light palpation

  Moderate Palpation

  Deep Palpation

  Bimanual Palpation
• Light palpation


  1. Place your dominant hand lightly on the surface of the structure

  2. There should be very little or no depression (<1 cm)

  3. Feel the surface structure using a circular motion

  4. Use this technique to feel for pulses, tenderness, surface skin texture, temperature, and moisture
• Moderate palpation


  1. Depress the skin surface 1 to 2 cm (0.5–0.75 in.) with your dominant hand

  2. Use a circular motion to feel for easily palpable body organs and masses

  3. Note the size, consistency, and mobility of structures you palpate
• Deep palpation


  1. Place your dominant hand on the skin surface and your nondominant hand on top of your dominant hand to apply pressure

  2. This should result in a surface depression between 2.5 and 5 cm (1 and 2 in.)

  3. This allows you to feel very deep organs or structures that are covered by thick muscle
• Bimanual palpation


  1. Use two hands, placing one on each side of the body part (e.g., uterus, breasts, spleen) being palpated

  2. Use one hand to apply pressure and the other hand to feel the structure

  3. Note the size, shape, consistency, and mobility of the structures you palpate
• Percussion


  Tapping body parts to produce sound waves