Nursing Assessment

Core Concepts

Subjective data: the health history

The history is where assessment begins, and it often points the examiner to what to look for. Start with the patient's chief concern in their own words. For chest pain or discomfort, the OPQRST mnemonic structures the questions:

• Onset — when did it start? Sudden or gradual?
• Provocation/palliation — what makes it better or worse? Does activity trigger it?
• Quality — what does it feel like (e.g., pressure, squeezing, sharp)?
• Region/radiation — where is it, and does it spread (e.g., to the jaw, arm, or back)?
• Severity — how bad is it, on a 0–10 scale?
• Timing — how long does it last? Constant, or comes and goes?

Ask about other symptoms that point to heart or vessel problems: shortness of breath at rest, with activity, or when lying flat; palpitations (a feeling of racing or skipped beats); dizziness or fainting; fatigue; swelling of the feet or ankles; leg pain or cramping with walking (claudication); and numbness or tingling in the limbs. Then collect risk factors — age, family history of heart disease, smoking, high blood pressure, diabetes, high cholesterol, inactivity, and stress — plus a complete medication list, including over-the-counter drugs, and whether the patient takes them as prescribed.

Objective data: inspection, palpation, auscultation

Inspection is looking before touching. Observe general appearance and comfort level (is the patient short of breath at rest?), skin color (pallor, duskiness, or a bluish tint in the lips or nail beds), the neck for visible vein distention, and the legs and feet for swelling, color changes, hair loss, shiny skin, or wounds that are slow to heal.

Palpation adds what the hands can feel. Palpate peripheral pulses at common sites — radial, brachial, femoral, popliteal, dorsalis pedis (top of the foot), and posterior tibial (behind the ankle bone) — noting presence, strength, symmetry, and rhythm, and compare the same pulse on both sides. Check capillary refill by pressing a nail bed briefly and releasing; compare with the opposite side, since a delay compared with the unaffected limb suggests reduced blood flow. Feel skin temperature and check for pitting edema — press a finger into swollen tissue and note how deep the indentation is and how slowly it rebounds. Edema is commonly described on an ordinal scale, but grading conventions vary by facility, so learn your institution's scale. Palpate gently and watch the patient's face for pain.

Auscultation is listening with a stethoscope. At the heart, listen for the two normal sounds: S1 ("lub"), the closure of the atrioventricular valves at the start of systole, and S2 ("dub"), the closure of the semilunar valves at the end of systole. Note the rate, rhythm, and any extra sounds. A murmur is a whooshing sound caused by turbulent blood flow; detecting one is a finding to document and report — not a diagnosis. If the radial pulse feels irregular, count the apical pulse at the heart for a full minute rather than relying on a short sample. Blood pressure and pulse are measured per facility policy; when a patient reports dizziness on standing, the provider may order orthostatic (postural) measurements lying, sitting, and standing, performed per the facility's protocol.

The assessment sequence: a process walkthrough

1. Prepare: provide privacy, explain what you will do and why, gather equipment (stethoscope, blood pressure cuff), and perform hand hygiene.
2. Take the history before the exam; let the patient's concerns guide what you inspect closely.
3. Measure vital signs, including blood pressure and pulse.
4. Examine: inspect, then palpate, then auscultate, comparing side to side.
5. Compare with baseline — the patient's prior documented findings, if available.
6. Document promptly: use the patient's own words for symptoms, quantify what you measured, and describe what you observed.
7. Report urgent findings immediately through the facility's chain of command (e.g., new chest pain, an absent pulse, a cold painful limb, new unilateral leg swelling).

From findings to nursing care

Findings rarely stand alone; cluster them into patterns. One swollen, warm, painful calf after a long car trip is a different pattern from two swollen ankles that improve overnight. Unilateral leg swelling with pain and warmth is a pattern that must be reported promptly — and the area should not be massaged, because that could dislodge a clot. Bilateral ankle swelling with shortness of breath when lying flat suggests a different pattern again. The nurse documents the pattern, reports it, and uses it to plan care: how often to reassess, what to teach the patient to watch for, and what safety measures are needed (for example, fall precautions for a person who feels dizzy when standing). Nursing diagnoses and care plans are hypotheses that guide nursing care; they are not medical diagnoses.

Common Confusions