Assessment, the first step in the nursing process, includes systematic collection, verification, organization, interpretation, and documentation of data for use by health care professionals. The purpose of assessment is to establish a database about a client’s physical and emotional well-being, intellectual functioning, social relationships, and spiritual condition.

A comprehensive assessment of the client is the most desirable. A comprehensive assessment is completed upon admission to a health care agency and includes a complete health history. However, time constraints or the clinical situation may necessitate a more focused assessment, concentrated upon the present problem of the client. The assessment can be updated later on, through an ongoing assessment process, with systematic monitoring and observation related to specific problems. An emergency assessment involves a rapid assessment of clients experiencing life-threatening problems or crises.

During the process of assessment, the nurse probes for information on the client’s functional abilities, normal routine for activities of daily living, lifestyle patterns, strengths, family support, coping skills, health care concerns, and health care goals. Assessment is also an excellent opportunity to form a therapeutic relationship with the client.

Client information consists of both subjective and objective data. Subjective data are data from the client’s point of view (“symptoms”), including feelings, perceptions, and concerns obtained through interviews. Objective data are observable and measurable data (“signs”) obtained through observation, physical examination, and laboratory and diagnostic testing. The client should be the primary source of data. However, secondary sources, such as family, other health care professionals, and the medical record, should also be consulted.

The methods of data collection are observation, interview, the health history, the physical examination, and laboratory and diagnostic testing. Observations occur any time the nurse has contact with a client. The nurse should observe both verbal and nonverbal cues. An interview is a therapeutic interaction that has a specific purpose. The stages of an interview are the introduction, working, and closure stages. The nurse (1) establishes rapport with the client during the introduction stage, listening attentively throughout the interview; (2) gathers information and makes observations during the working stage; and (3) summarizes, asks for validation, offers resources, and ends with a positive statement during the closure stage.

Open-ended questions are used to explore problems and concerns; whereas closed-ended questions are questions that can be answered with one word, used most commonly in emergencies. Focused questions are questions used to obtain information that is more specific about a problem or condition, allowing the client to provide a response that is more than a yes or no response.

The health history is a review of the client’s functional health patterns and medical history. Several types of information are part of the health history: Demographic information; reason for seeking health care; perception of health status; previous illnesses, hospitalizations, and surgeries; the client/family medical history; immunizations/exposure to communicable disease; allergies; current medications; developmental level; psychosocial history; sociocultural history; activities of daily living; review of the systems (ROS); and health promotion activities. The psychosocial history includes self-concept, self-esteem, sources of stress, coping abilities, and value/belief system. Activities of daily living consist of nutrition, elimination, rest/sleep, and activity/exercise. When discussing symptoms during the ROS, the nurse should obtain relevant data about the symptom: Location, character, intensity, timing, and aggravating/alleviating factors.

The purpose of the physical examination is to make direct observations of any deviations from normal and to validate subjective data gathered through the interview. The physical examination begins with collection of baseline data, such as height, weight, temperature, pulse, respirations, and blood pressure, for comparison with future measurements. The four assessment techniques used in physical examination are inspection, palpation, percussion, and auscultation. Inspection involves careful observation, from the general to the specific. Inspection requires the nurse to be mindful of the client’s right to privacy. Palpation uses the sense of touch to assess texture, temperature, moisture, organ location and size, vibrations and pulsations, swelling, masses, and tenderness. Percussion uses short, tapping strokes on the surface of the skin to create vibrations of underlying organs. Auscultation involves listening to sounds in the body that are created by movement of air or fluid, such as the lungs, heart, abdomen, and blood vessels. In addition to the history and physical examination, laboratory and diagnostic data can confirm or rule out suspected problems and can be used to monitor the progress of the client.

Data verification is the process through which data are validated as being complete and accurate. The data are reviewed for inconsistencies or omissions. Nonverbal behavior may either confirm or contradict a client’s perceptions. Data should be compared with norms and grossly abnormal findings should be rechecked and confirmed.

Once data collection is completed, it is organized into categories in order to identify areas of strengths and weaknesses (data clustering). How data are organized depends on the assessment model used. Assessment models are frameworks that provide a systematic method for organizing data. Several models are available. Nursing models include Marjory Gordon’s Human Functional Health Patterns, the North American Nursing Diagnosis Association (NANDA) taxonomy of nursing diagnoses, Orem’s Self-Care Theory, the Roy Adaptation Model, and the Leininger Sunrise Model. Nonnursing models include the Body Systems Model (the “medical model”) and Abraham Maslow’s Hierarchy of Needs model. Gordon’s Functional Health Patterns are used because they provide a comprehensive framework. The 11 health patterns in Gordon’s model are the health perception-health management, nutritional-metabolic, elimination, activity-exercise, cognitive-perceptual, sleep-rest, self-perception–self-concept, role-relationship, sexuality-reproductive, coping-stress-tolerance, and value-belief patterns.

Four types of formats are used for documentation of assessment data: open-ended, checklist, combination, and specialty. Open-ended formats allow the nurse to write a narrative description of observations, a time-consuming activity that allows for flexibility in recording findings. Checklists provide consistency in the recording of information and reduce the likelihood of omitting relevant information. However, they discourage recording observations that require further explanation. Combination formats provide both the consistency and flexibility for recording observations. Specialty formats are focused on a particular clinical area, such as outpatient surgery or labor and delivery. The Minimum Data Set (MDS) used by the Centers for Medicare and Medicaid Services (CMS) is a form used to perform assessments in Medicare/Medicaid certified nursing homes.