Chapter 4

Basic Nursing Assessments

The Patient Interview

Functional Assessment

Interviewing Strategies

Cultural Assessment

Spiritual Assessment

Physical Assessment

Assessment Techniques

Temperature

Thermal Disorders

When to Measure Vital Signs

Pulse

Pulse Points

Respiration

Blood Pressure

For an in-depth study of basic nursing assessments, consult the following publications:

Lewis SM, et al: Medical-surgical nursing, ed 8, St. Louis, 2011, Mosby.

Nugent P, Green J, Hellmer Saul MA, Pelikan P: Mosby’s comprehensive review of nursing for the NCLEX-RN examination, ed 20, St. Louis, 2012, Mosby.

Potter PA, Perry AG, Stockert PA, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby.

Weilitz P, Potter PA: Pocket guide for health assessment, ed 6, St. Louis, 2007, Mosby.

The Patient Interview

Demographics

Includes name, address, sex, age, birth date, marital status or significant other, religion, race, education, occupation, hobbies, significant life events

Health History

Includes history of smoking, heart disease, alcohol or other drug use or abuse, surgeries, injuries, childhood diseases and vaccinations, hypertension, diabetes, arthritis, seizures, cancer, emotional problems, transfusions, drug or food allergies, perception of patient’s health or illness, lifestyle, hygiene and eating habits, health practices

Family Medical History

Includes history of heart disease, alcohol or drug use or abuse, diabetes, arthritis, cancer, emotional problems

Current Situation

Reasons for seeking help or chief complaint; include annual check-up, follow-up care, second opinion, new symptoms, monitoring existing health problem(s)

History of Present Illness

Includes location and quality of symptoms, chronology, aggravating and alleviating factors, associated symptoms, effect on lifestyle, measures used to deal with symptoms, review of body systems

Medications

Prescribed, occasional use (CPRN), over the counter, herbals

Functional Assessment

Health Perceptions

General health (good, fair, poor)

Tobacco or alcohol use (how much, how long)

Recreational or prescribed medications (list)

Hygiene practices

Nutrition

Type of diet (list)

Enjoys snacks (yes/no, what type)

Fluid intake (types of fluids)

Fluid restriction (yes/no)

Skin (normal, dry, rash)

Teeth (own, dentures, bridge)

Weight (recent gain or loss)

Respiration and Circulation

Respiratory problems (shortness of breath)

Smoking history

Circulation problems (chest pain, edema, pacemaker)

Elimination

Upper GI (nausea, vomiting, dysphagia, discomfort)

Bowels (frequency, consistency, last bowel movement, ostomy)

Bladder (incontinence, dysuria, urgency, frequency, nocturia, hematuria)

Activity and Exercise

Energy level (high, normal, low)

Usual exercise and activity patterns (recent changes)

Needs assistance with (eating, bathing, dressing)

Requirements (cane, walker, wheelchair, crutches)

Sleep

Problems (falling asleep, early waking, hours per night, napping)

Methods used to facilitate sleep

Feelings on waking (fatigued, refreshed)

Cognitive

Educational level

Learning needs

Communication barriers (list)

Memory loss (yes/no)

Developmental age

Reads English (yes/no)

Other languages (list)

Sensory

Hearing and vision (no problems, impaired, devices)

Pain (yes/no, how managed)

Coping and Stress

Needs (social services, financial counselor)

May need (home care, nursing home)

Coping mechanisms used by patient

Self-Perception

How illness or wellness is affecting patient

Body image or self-esteem concerns

Roles and Relationships

Significant other or emergency contacts

Primary, secondary, or tertiary roles

Role changes caused by illness or wellness

Role conflicts caused by illness or wellness

Sexuality

Last menstrual period, menopause, breast examination

Testicular examination

How illness may affect sexuality

How hospitalization may affect sexuality

Any questions, needs, or additional concerns

Values and Beliefs

Religious or cultural affiliation

Religious or cultural beliefs concerning health or illness

Holiday or food restrictions while hospitalized

Religious or cultural restrictions on medications or treatments

Religious or cultural rituals needed while hospitalized

Clergy or religious leader requested while hospitalized

Interviewing Strategies

Open-ended questions: “How can I help you?”

Summarizing statements: “Coughing and wheezing seem to be your concerns.”

Reflective statements: “You seem out of breath.”

Leading questions: “Is your sputum green?”

Focused questions: “Are you short of breath now?”

Clarification: “When did you last take you inhaler?”

Restating: “So you said your shortness of breath became worse yesterday?”

Encouraging: “Tell me more about your breathing.”

Cultural Assessment

Include introductory information, such as:

• Patient’s name, unit, or room number

• Admission date, admitting diagnosis

• Proposed length of stay

Information about the country can be important:

• What is the cultural or ethnic affiliation?

• In what country was the patient born?

• How many years has he or she been in the United States?

• What generation American is the patient?

Assess language needs:

• Does the patient need an interpreter (what language)?

• Does the patient need a communication tool (language board)?

• Could the patient use telephone language line (available through most local telephone companies)?

Assess for cultural practices:

• Are there special rituals that may need to be honored?

• Are there special health practices that may need to be honored?

• How will the illness affect cultural practices?

• How will the illness affect cultural rituals?

Assess for cultural supports:

• Which cultural or ethnic supports may help your patient?

• To whom does the patient turn for help?

• How does the patient describe his or her family?

• Who is the patient’s main source of support?

• Who is the patient’s main source of hope?

Spiritual Assessment

Include introductory information, such as:

• Patient’s name, unit, or room number

• Admission date, admitting diagnosis

• Proposed length of stay

• Religious affiliation

• Local clergy and telephone number

Assess for potential religious supports:

• Minister, priest, rabbi, shaman, emmen, other

• The need for church or prayer services

• The need for confession, communion, religious music

• The need for a Bible, Koran, Bhagavad-Gita, prayer books

Assess for religious practices:

• Are there special rituals that may need to be honored?

• Are there special health practices that may need to be honored?

• Are there special religious dietary needs?

• Is there a special prayer schedule that should be followed?

• Are there special fasting rituals that should be followed?

• How will the illness affect religious practices?

• How will the illness affect religious rituals?

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