In what area do nurses use assessment tools?

Assessment tools cannot substitute for good clinical skills and judgements. As clinicians we need to be aware that assessment tools can tell us more than just a score.

Assessment involves collecting information that gets to know the patient in detail, evaluates their risks and the nature of problems to be identified.

Assessment should integrate all the relevant issues. It should explore the medical, physiological, social and psychological function of the older person.

The assessment process encourages us to be curious and to consider the best possible interventions that we can employ to minimise risks and maximise our patient’s quality of life. This can ultimately involve balancing some risks with some gains and working with our team and the older person and their family to make an informed choice about this.

Assessment supports us to:

• treat the condition that caused the admission (such as shortness of breath)
• detect and quantify additional conditions or psychosocial issues that contribute to or complicate the admission and respond to them as able both during the admission and when planning for discharge. For example
  • depression - consider if the person needs a medical review
  • poor nutrition - consider what can be done to optimise the person’s intake
  • social isolation, or risk of loneliness - consider how you can encourage the person to participate in their care by harnessing their personal and social connections, and consider linking them to supports that are meaningful to them on discharge
• use strategies to prevent conditions that often emerge during hospital stays but can be avoided (such as delirium and falls).

We can gather information as part of the assessment process from multiple sources, and these may vary at the stages of a hospital admission.

The four main sources of information are:

1. Older people themselves - self report.
2. Others who know the older person well - informant report.
3. Observation of the person undertaking various activities - direct observation.
4. Various secondary written or verbal sources - including hospital records, medical reports, investigation results, communication from community care providers.

Unless there are reasons to suspect otherwise the older person is considered the best source of information about their own health1. Direct observation is the best source of information about physical function; however, we should consider how the environment or setting where observations take place may impact on the older person’s performance.

Assessment tools can be focussed on exploring one particular condition such as pain, pressure injury or nutrition. They can also be more comprehensive and encompass a broader focus beyond one particular issue. Examples of these types of tools include:

• InterRAI Comprehensive Assessment Tool: Acute
• Systematic Evaluation and Intervention for Seniors At Risk (SEISAR) - a short, standardised, comprehensive tool for the evaluation of active geriatric problems in seniors in the emergency department.

The assessment tool or scale should enable collection of useful patient data that supports interpretation of the holistic health status, identifies patient needs, and informs care planning and interventions to restore health and wellbeing.

Selecting an assessment tool

Consider the following factors when selecting an assessment tool include:

• A standardised tool can reduce variation in practices and interpretation of findings and allow comparison across assessments.
• A validated assessment tool ensures the right data is captured to evaluate the patient and their progress.
• Is a specific tools mandated for specific circumstances or settings? See the individual topics for examples.
• Does the tool cater for cultural or language differences?
• Is the tool appropriate for the physiology of ageing?

The format used will also depend on the discipline, skill and expertise of the clinician, the context and setting of the assessment, the time available and the number of assessors involved. The assessment can be:

• unstructured – if the professional expertise of the assessor is high
• semi-structured – incorporates specific tools and checklists
• structured and standardised – using global assessment instruments.

Comprehensive Geriatric Assessment

There is no gold standard for assessment of older people; however, a Comprehensive Geriatric Assessment is highly recommended to understand the multidimensional complex care needs of frail older people and to determine both short and long term care needs.

A Comprehensive Geriatric Assessment can be undertaken by any member of the interdisciplinary healthcare team who has the required knowledge and skills. Multiple team members with specific skills may need to be involved depending on the patient’s needs.

Ideally, the assessment should be completed within the patient’s first 24 hours in hospital and communicated to all team members, the patient and informal carers.

Conducting assessments

We also need to be aware of the following when conducting assessments of older people:

• At all times, it is vital that we maintain an understanding the older person’s perspective.
• In acute hospital settings, circumstances may mean older people are not able or willing to be actively involved when health professionals assess them.
• Older people may take more time to complete tools than younger people, so allow for rests during formal assessments.
• Ensure that any needs for communication assistances are met. These may include use of interpreters, ensuring the older person is wearing their glasses and/or hearing aids if they are used routinely.
• Do not assume older people know why they are being assessed. Explain why certain questions or tests are being undertaken.
• Establish cognitive status as early as possible in an assessment. Do not assume older people are able to hear, comprehend what is said or are capable of accurate, intelligible responses (for example if they are acutely unwell).
• Note that appearing ‘flat’, minimal eye contact and being non-committal responses may indicate depressive symptoms are present. Depressed older people can give the appearance of being cognitively impaired.
• Consider the need for an interpreter for those with limited English proficiency. The interpreter can also assist with cultural care delivery.
• Consider specific cultural issues and seek assistance necessary from cultural liaison officers or Indigenous health workers.

Applying clinical skills to assessment

Good clinical skills, observation, listening, interpreting and clinical judgement are all vital in decision-making.

When we assess older patients, we use tools and draw on our clinical reasoning skills. The reasoning cycle2 sets out the elements of effective clinical decision-making:

• Consider the patient situation
• Collect cues and information – through observation, questions
• Process the information – what does it mean?
• Identify problems and issues – what does the information indicate?
• Establish goals – what actions need to be taken?
• Take actions
• Evaluate outcomes
• Reflect on process and new learning.

1. Levett-Jones, T. (2013). Clinical Reasoning: Learning to think like a nurse. Frenchs Forest: Pearson Australia

2. Dorevitch 2004 p 229 in Nay, R., Garratt, S., & Fetherstonhaugh, D. (2013). Older People: Issues and Innovations in Care (4th ed.). Australia: Churchill Livingstone Australia

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. 

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.

More Resources for Nursing Assessments: