Comprehensive Assessment Techniques: What Are the Important Assessment Skills in Nursing?

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

It all begins with a comprehensive assessment, which is one of the most important aspects of any medical visit or appointment.

“Comprehensive” is certainly the right word to describe initial assessments conducted by nurses — the scope of these can be vast, with assessments revealing (or ruling out) not only a wide range of health concerns but also demonstrating the patient’s mindset.

In-depth training centered around patient assessments can make a world of difference in both nursing performance and patient outcomes. Keep reading to learn why patient assessments are so important and what should happen when assessing a patient with a medical complaint. You will also get a better sense for the training and comprehensive knowledge aspiring nurses need to develop to handle these assessment tasks with ease.

What Is the Importance of an Effective Assessment?

Patient assessment forms the basis of every medical appointment. This is a must 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.”¹

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’ assessment process. This includes a general survey of the patient’s physical status, with special attention paid to any areas highlighted by the patient as problematic.
• Mental assessment. Delving into cognitive concerns and other mental considerations, this portion of the assessment calls for a nuanced understanding of cognitive and emotional health, plus the application of approved testing procedures and surveys to reveal the patient’s current mental status.
• Psychological. Focused on the patient’s mental health and wellbeing, these assessments help to reveal psychological concerns that might call for intervention.
• Patient goals. In the interest of empowering patients, assessments often incorporate personal goals as they relate to treatment plans and long-term health outcomes. As patients share these intentions, their goals can be built into both treatment protocol and educational efforts.

How to Start the Assessment Process

Nurses are responsible for developing a foundation of trust to ensure that patients feel comfortable enough to share important details with medical professionals — and that they 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. After all, the ANA explains that nurses should strive to provide “the safest environment possible for conducting assessments,” adding that there is a strong need to “honor the whole person” and to “recognize the health care consumer…as the decision-maker regarding their own health.”

These intentions should be abundantly clear as soon as the patient medical assessment begins. This means providing a clear and friendly introduction, complete with eye contact and a gentle demeanor. Small talk can cut through the tension and provide a welcome distraction for worried patients that should seamlessly transition into a brief overview of what, exactly, will happen during the assessment.

Clarify Medical History

Once patients feel comfortable enough to discuss their concerns, it’s time to proceed with background information, which could have a huge influence on 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 have significant implications for future diagnoses and treatment plans, so they should be top of mind while conducting patient assessments.
• Medication history. Patients should provide updates on prescriptions or over-the-counter medications they may currently be taking. If they are no longer using drugs mentioned in their medical history, this information should also be updated.
• Family medical conditions. From genetics to environmental factors, family members hold much in common that may enlighten medical professionals on 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 watching for 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 medical appointment should include at least a brief mention of everyday practices such as nutrition, exercise and sleep, plus a chance to convey concerns about drug or alcohol consumption.

These conversations can feel sensitive and, often, patients will be reluctant to share. This is where previous efforts to build rapport will 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 if observed directly. Hence, the need for the physical portion of the assessment, in which nurses observe patients closely to reveal outward signs or symptoms of possible illnesses or conditions — as well as their severity.

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

Any physical, head-to-toe assessment should also include a thorough overview of HEENT: Head, Ears, Eyes, Nose and Throat. 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 “systemically work down through each of the body systems.”²

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 patients’ 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.
• A nasal speculum or otoscope can be used to inspect the nasal passages.
• Assessments of the mouth should reveal inflammation of the salivary glands, ability to swallow, and movement of the uvula.
• Lymph nodes should be palpated for signs of swelling. Note enlargement of the thyroid gland if relevant, along with the presence of any masses.

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

• Skin inspections. The physical assessment should reveal whether the patient’s skin is clammy or if there are any problematic lesions or abrasions. Nurses should also be on the lookout for bruising or swelling. Color variation should be noted during visual inspections, followed by thickness, texture and moisture during skin palpations.
• 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, which experts from the resource Cardiac Exam refer to as the “cornerstone of any physical exam.”³
• Musculoskeletal system. Important for verifying the patient’s functioning (especially as it relates to daily living), 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 will be willing to discuss sensitive details about their cognitive or emotional health, but assessments can provide insight into their current mental state. Known as mental status assessments, these assessments reveal the current functionality of the central nervous system. Concerns to evaluate include:

• Mood and affect. Depending on the situation, the patient’s emotional state may best be discerned by simply inquiring 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. Disturbances such as agitation or rage should be noted.
• Degree of arousal. This term references how attentive or responsive the patient is at the time of the assessment. For example, the patient may appear confused or tired. This may be assessed via the Observational Scale of Level of Arousal (OSLA), which can detect variances in arousal within the context of delirium.⁴
• Mini Mental State Examination (MMSE). Widely recommended as a means of detecting cognitive impairment in older patients, the MMSE relies on a short series of questions to establish the patient’s orientation, short-term memory and language function.⁵

Important Steps to Know About Psychological Assessments

In addition to the mental status basics outlined above, a variety of other tests can be conducted to reveal the 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.⁶
• Suicide risk assessments. Beyond Beck’s, a variety of other tools for assessing suicide 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. 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.

Depending on the indicators revealed during the 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 will be 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 makes them feel empowered and motivated and can also have a positive impact on patient satisfaction and follow-through.
One of the most effective strategies for getting them invested in their health and wellbeing? Giving them plenty of opportunities to set goals for individual medical appointments and for long-term treatment plans.

Nurses should encourage patients to share goals during assessments so that they can get a better idea of what patients need and how this can be facilitated, both in the short-term and far into the future.

What Is the Best Way to Keep Patient Records?

Clear and organized medical files play heavily into 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.⁷ Several of these are highlighted below:

• Documentation characteristics. Ideally, all nursing documentation will be accessible, accurate and concise. It should also be “timely, contemporaneous and sequential.
• Documentation entries. All entries into approved medical records systems should be accurate, truthful, and readable. These should feature standardized terminology (including approved acronyms) and be time-stamped by the nurses who create the entries.
• Education and training. All nurses should demonstrate proficiency with required software systems and the various technical elements of documentation.
• Protection systems. Confidentiality is crucial. To ensure this is achieved, documentation procedures abide by industry standards and government mandates regarding data security and patient identification protection.

Promote Quality Patient Care With Impactful Assessments

Learn how to perform thorough and in-depth patient assessments with SJVC nursing programs from Vocational Nursing or Registered Nursing programs.]

Sources

1. “Nursing: Scope and Standards of Practice.” American Nurses Association. https://www.nursingworld.org/~4af71a/globalassets/catalog/book-toc/nssp3e-sample-chapter.pdf
2. “HEENT Assessment.” Lippincott NursingCenter. https://www.nursingcenter.com/clinical-resources/nursing-pocket-cards/heent-assessment
3. Malik, M. et al. “Cardiac Exam.” National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK553078/
4. Hall, H. et al. “The Observational Scale of Level of Arousal: A brief tool for assessing and monitoring level of arousal in patients with delirium outside the ICU.” International Journal of Geriatric Psychiatry. https://onlinelibrary.wiley.com/doi/full/10.1002/gps.5324#
5. Arevalo-Rodriguez, I. et al. “Mini-Mental State Examination (MMSE) for the early detection of dementia in people with mild cognitive impairment (MCI).” Cochrane Database of Systematic Reviews. https://pubmed.ncbi.nlm.nih.gov/34313331/
6. Lee, A. et al. “Diagnostic Test Accuracy of the Beck Depression Inventory for Detecting Major Depression in Adolescents: A Systematic Review and Meta-Analysis.” Clinical Nursing Research. https://pubmed.ncbi.nlm.nih.gov/34961346/
7. “Principles for Nursing Documentation.” American Nurses Association. https://www.nursingworld.org/~4af4f2/globalassets/docs/ana/ethics/principles-of-nursing-documentation.pdf