What is included in a nursing evaluation?

Nursing assessments are critical to the job of being a nurse, and there are several different types of assessments that nurses need to be able to perform. They may be broad in scope or focused on mental health or a single body system.

The purpose of these assessments is to identify current and potential care needs for your patient by using critical thinking to recognize the normal versus abnormal.

Here’s some background and other information you need about each type.

As a nurse, the types of assessments you perform will change based on the reason for the patient coming in and the information that any previous assessments have presented.

This is one of the most basic, comprehensive nursing assessments to conduct and is usually done when a patient first arrives for care. It’s essentially a thorough review of why the patient is seeking care, a medical history, an exam, etc.

Here’s what you need to look for as a nurse in a head-to-toe nursing assessment in order to understand your patient’s physical, emotional, and mental needs.

First, you’ll need a few equipment items to complete a head-to-toe assessment, including but not limited to:

• Gloves 
• Thermometer
• Blood pressure cuff
• Watch, or clock that’s visible with a second hand
• Penlight
• Stethoscope

The exact order of the assessment is up to the individual nurse, but many nurses prefer go from top to bottom (or, head to toe!).

If your nursing assistant has not taken a set of vitals already, this would be a great time to do so.

Here’s a very basic checklist to check for:

• Vital signs– heart rate, respiration rate, blood pressure, vital signs, temperature, pulse oximetry, pain, etc.
• Neuro – observe their level of consciousness, ask orientation questions, see if they can move all 4 extremities with equal strength and tone (push-pull with hands, dorsi-plantar flex with feet),
• Face – look at the coloration of the face, lips, and mouth, note any visual deficits (field-cuts, nystagmus, etc), and if the face is symmetrical
• Respiratory – listen to lung sounds, note any abnormalities and consider your vital sign findings (pulse ox) with this, note if they require any supplemental oxygen and if that’s changed recently
• Cardiac – listen for abnormal rhythm, check the rate, and check the pulse in arms, legs, and feet.
• Abdomen – inspect and listen for abnormal sounds, distention, firmness, and pain.
• Extremities – check the arms and legs for a range of motion, strength, sensation, and capillary refill.
• Skin – check for coloration, lesions, rashes, abrasions, tenderness, and lumps. Is the skin consistent for their ethnicity? (Meaning, do they look pale, flushed, etc.?)
• Psycho-social – do they feel safe in their living environment? Are there any spiritual or religious beliefs we need to observe? Do they have what they need to take care of their health needs (walker, shower chair, can they afford their meds?), are they using illicit drugs, how much alcohol do they consume regularly?
• Safety – ensure their call light is nearby, they know how to contact a nurse, the bed is in the lowest and locked position, non-skid socks are on or near them, etc.

Upon admission, a very thorough skin assessment is crucial. This is especially true if the patient has decreased mobility and may sit or lay in one position for extended periods. We need to catch if the patient has any pressure ulcers, sores, or breakdown because we don’t want to make it worse and should evaluate if it needs to be seen by the wound team and brought to the attention of the physician.

What you find in your head-to-toe assessment may lead you to performing one or more focused assessments.

Focused Nursing Assessments

Focused assessments are nursing assessments that target the specific body system where the patient demonstrates a problem, disorder, or concern. This can relate to one or multiple body systems. You’ll most often see these performed in emergency departments when a patient presents for a specific issue. Their goal is to identify and address a specific issue, not a comprehensive medical evaluation for all things that could be impacting a person.

Nurses should use their best clinical judgement to determine which focused assessments pertain to their patient based on a previous head-to-toe assessment as well as input from the patient. (Typically in an urgent situation for inpatients and for most emergency department patients).

Nurses can perform focused assessments in any of these areas: 

• Neurological assessment.
• Respiratory assessment.
• Cardiovascular assessment.
• Gastrointestinal assessment.
• Renal assessment.
• Musculoskeletal assessment.
• Skin assessment.
• Eye assessment.
• Ears Nose and Throat (ENT) assessment

While completing a focused assessment, a nurse should ensure the patient remains stable overall and not become overly fixated on that one aspect of the assessment. For example, if a patient complains of eye pain, but shortly thereafter begins complaining of shortness of breath, the nurse should not wait to address the shortness of breath until the eye assessment and interventions are complete. Pivot as the clinical picture evolves and requires it.

Emergency Assessments

Knowing that emergencies can happen at any time, this nursing assessment is continually performed during the course of caring for a patient until the emergency is over. 

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Using the acronym ABCCS, nurses perform emergency assessments when they meet a patient and repeat them anytime they determine that their patient’s condition could be becoming unstable. 

Here’s what the acronym stands for:

• A = airway – ensure the airway is not obstructed or compromised
• B = breathing – ensure patient is breathing, and if it is absent or labored to intervene immediately
• C = circulation – check to ensure the patient has a pulse, and if patient is on cardiac monitoring (which they should be if circulation is a concern!) then check the patients heart rhythm
• C = consciousness – check their level of consciousness and observe for any abrupt changes
• S = safety – ensure that the patient is safe from risk of harm

Once the patient stabilizes, the nurse may discontinue emergency assessments and transition to an initial or focused assessment, depending on the situation.

Med-Surg Nursing Assessments

Patients on the medical surgical unit may be preparing for a surgical procedure or recovering from one. Or they may have an illness that requires close monitoring by a med-surg nurse to watch for any changes in their condition or the need for a higher level of care. 

Every shift, a med-surg nurse must complete a head-to-toe assessment, and also after any changes (like a code or if the patient went to surgery and came back). This head-to-toe nursing assessment aims to alert nurses to anything that may indicate a problem for the patient. It’s imperative to do this regularly (most policies say once per shift and with changes) so the providers and nursing staff know how the patient is doing continuously, and detect changes faster.

It is a bit more abbreviated than an admission head-to-toe assessment, as previously described. While your routine skin assessment does not need to be quite as thorough, you will want to check the following additional items:

• Intake and output
• Assess any lines, tubes, drains, and airways
• Compare current vitals and labs to previous trends
• Ensure anything that can be discontinued is promptly removed
• Any meds continuously infusing into an IV are at the correct rate, dose, and is the correct med
• Any oxygen is hooked up appropriately, flowing, and at the correct level
• Any necessary equipment (like sequential compression devices) are connected

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ICU Assessments

ICU assessments are very similar to but very different from a general head-to-toe assessment because they’re more detailed due to the critical nature of the care the patient needs. You’ll do this type of assessment for each patient when you come on shift, and it begins as soon as you see your patient. 

First, check monitors, drips, ventilator, and medications to verify settings, levels, labels, drawing labs if needed, and ensuring alarms are set appropriately. ICU assessments also include general neural assessments, checking tubes, suction, dressings, heart sounds, lung sounds, bowel sounds, catheters, and extremities.

This type of assessment involves checking much more than a simple head-to-toe assessment because the patient requires a much higher level of care than a general patient or even a med surg patient.

For additional tips on taking care of critically ill patients, check out this post.

Similarities And Differences Between The Different Types Of Nursing Assessments

Performing assessments is a huge part of a nurse’s job, and a single nurse may perform many assessments in the course of one shift. 

All of these nursing assessments involve a head-to-toe examination to varying degrees as well as conducting some version of a patient interview to assess mental status. The degree and depth to which the assessment is performed by the nurse on duty are determined by the patient’s needs and information gleaned from the initial head-to-toe assessment.

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