Patient assessment is the first and most critical step in the nursing process. It provides the foundation for clinical decision-making, ensuring accurate diagnoses and safe, effective patient care.
In addition, nurses perform different types of assessments, from comprehensive health evaluations to emergency rapid assessments, using structured frameworks like the ABCDE approach and the IPPA physical examination method.
Understanding these techniques helps nurses detect early warning signs, prevent complications, and provide high-quality care.
To understand how patient assessment integrates into the nursing process, this guide explores:
The nursing process is a systematic, patient-centered framework for delivering healthcare. It consists of five key steps, each playing a role in assessment and decision-making:
Assessment – Collecting patient history, symptoms, and clinical findings
Diagnosis – Identifying health problems based on data analysis
Planning – Setting goals and developing an intervention strategy
Implementation – Carrying out the nursing interventions
Evaluation – Assessing the effectiveness of care and making adjustments
A structured nursing process ensures that patient assessment is systematic, minimizing errors and improving patient outcomes.
As the first step in the nursing process, the initial nursing assessment is a fundamental component of this framework.
This assessment involves the systematic and continuous collection of data, followed by the sorting, analyzing, and organizing of that data to inform the development of a tailored care plan. (Toney-Butler & Unison-Pace, 2019).
The information is directly reported by the patient and family. For instance:
Chief complaints: “I feel like I can’t breathe properly.” / “I feel dizzy and nauseous.”
Current and past medical history
Elimination, sleep, nutrition, and activity patterns
Patient perception of their health condition
Psychosocial and spiritual factors
May include vital signs, physical appearance, and the presence of any abnormalities or deviations from the normal range.
The following are examples of objective cues:
Vital signs:Blood pressure: 90/60 mmHg
Heart rate: 110 bpm (tachycardia)
Oxygen saturation: SpO₂ 89%
ECG: ST-elevation detected
Level of consciousnessGlasgow Coma Scale – GCS
System-specific examinations
Respiratory, cardiovascular, and neurological assessments
Functional status and independence in ADLsActivities of Daily Living
By integrating subjective and objective data, the nurse can thoroughly understand the patient’s unique circumstances, including their cultural, spiritual, and physical needs.
Lastly, this individualized approach, rather than a one-size-fits-all approach, is crucial in delivering evidence-based, patient-centered care that optimizes health outcomes(Toney-Butler & Unison-Pace, 2019).
Nurses perform different types of assessments depending on the patient’s condition:
Subjective Data
Includes the symptoms, medical history, and patient-reported family.
Objective Data
Focused on vitals, physical exam findings, diagnostic test results
Combining both subjective and objective insights improves clinical decision-making and ensures patient-centered care.
Indonesian nurses use structured forms based on SDKI and focused data, which may include:
All assessment findings must be documented accurately and promptly. Documentation can follow formats like SOAP for effective communication between healthcare providers.
Example:
S: Patient complains of abdominal pain for the past 2 hours
O: BP 140/90 mmHg, pulse 96 bpm, tense abdomen
A: Acute pain
P: Monitor vital signs, collaborate with physician, provide pain education
When rapid decision-making is required, the Primary Survey prioritizes life-threatening conditions using the ABCDE approach:
The ABCDE Nursing Assessment Approach A – Airway: Is the airway open and clear? (Check for obstructions, choking, trauma)
B – Breathing: Is the patient breathing effectively? (Assess respiratory rate, oxygen levels)
C – Circulation: Is there adequate blood flow? (Check pulse, blood pressure, skin color)
D – Disability: Is neurological function intact? (Evaluate Glasgow Coma Scale, pupils)
E – Exposure: Are there hidden injuries or environmental risks? (Check for burns, wounds, temperature)
Additionally, the OLD CART method helps assess symptoms comprehensively:
Here’s a breakdown of what each letter stands for:
O: Onset – When did the symptom start?
L: Location – Where is the symptom located?
D: Duration – How long has the symptom been present?
C: Characteristics – What is the symptom like (e.g., sharp, dull, throbbing)?
A: Aggravating and Alleviating Factors – What makes the symptom worse or better?
R: Radiation – Does the symptom spread to other areas?
T: Timing – Is there a pattern to the symptom (e.g., time of day, after meals)?
S: Severity – How severe is the symptom on a scale of 1 to 10?
This mnemonic helps ensure a comprehensive and systematic approach to patient assessment, which is crucial for accurate diagnosis and treatment planning.
The secondary survey helps detect hidden injuries and conditions that may not be obvious in the primary survey.
Nurses in Indonesia must consider the patient’s cultural values, traditions, and beliefs during the assessment process which includes the following:
Firstly, the beliefs in traditional medicine – Many patients still rely on herbal remedies or traditional practices as part of their healing process.
Secondly, family involvement in decision-making- Families often play a central role in determining medical interventions or care plans.
Lastly. the religious or spiritual preferences in care – Religious beliefs can influence how patients respond to medical procedures and the healing process.
A physical examination follows four key techniques, often abbreviated as IPPA (Inspection, Palpation, Percussion and Auscultation):
The IPPA Method: 4 Steps of Physical Assessment
Inspection – Visually assessing posture, skin color, symmetry
Palpation – Using touch to check for swelling, temperature, tenderness
Auscultation – Listening to heart, lung, and bowel sounds with a stethoscope
Percussion – Tapping the body to detect abnormal air, fluid, or masses
A structured assessment ensures consistency and accuracy in diagnosing patient condition.
Nurses face multiple challenges in performing effective patient assessments, particularly in emergency settings.
Recent advancements have introduced innovative tools that enhance nursing assessments:
Artificial Intelligence in Patient Triage AI-powered triage systems analyze vital signs and symptoms to predict high-risk cases faster. AI chatbots also help assess patient conditions remotely, streamlining hospital workflows.
Point-of-Care Ultrasound (POCUS) Unlike traditional ultrasound, POCUS provides instant bedside imaging, assisting in real-time diagnosis of heart conditions, lung disease, and internal fluid accumulation.
An organized patient assessment is essential for accurate diagnosis, successful treatment, and patient safety.
Nurses can use the nursing process, primary and secondary surveys, and physical examination procedures to enhance patient outcomes and deliver evidence-based care.
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