nursing assessment
How nursing assessments connect to admission, ongoing care, care planning, discharge, consultations, and chart review
You're asking how all the medication assessments we've discussed fit into the larger nursing workflow: when a patient is admitted, how nurses identify abnormalities in the chart, how they decide what to monitor during the stay, how they plan care, when they contact a specialist, and how they prepare the patient for discharge.
The key idea is that nursing care is one continuous cycle of collecting information, identifying problems and risks, planning interventions, evaluating the results, and communicating changes. Medication administration is one part of that cycle.
A finding such as low blood pressure, dizziness, an abnormal creatinine result, or repeated headaches can influence several stages of care—not just whether the next dose should be given.
1. The complete nursing workflow
1. Admission assessment
Establish the patient's baseline, medical history, medication list, allergies, current symptoms, vital signs, functional status, and relevant laboratory findings.
2. Chart review and identification of abnormalities
Compare current and historical findings, recognize abnormal trends, identify risks, and determine which findings require immediate action or further assessment.
3. Care planning
Turn the assessment into prioritized nursing problems, measurable goals, monitoring schedules, interventions, and criteria for escalation.
4. Ongoing assessment and intervention
Administer medications when appropriate, monitor response, reassess risks, document findings, and update the plan when the patient's condition changes.
5. Consultation and collaboration
Escalate concerns, communicate with the provider, and help coordinate specialist assessment or other services when the patient's needs warrant them.
6. Discharge planning
Determine what the patient needs to manage safely outside the hospital, including medication instructions, follow-up, equipment, support, and warning signs.
This is not strictly linear. New findings during ongoing care can send the nurse back to assessment, reprioritization, provider notification, or a revised care plan.
2. Admission: establish the baseline before you can recognize a change
At admission, you're trying to answer five questions:
What is happening to the patient right now?
What was their health like before this illness or hospitalization?
What medications are they taking, and are there risks associated with them?
What abnormal findings or potential complications need attention?
What will this patient need during the stay and after discharge?
What the nurse reviews
Assessment area | What you're looking for | How it affects care |
Medical history | Hypertension, kidney disease, liver disease, heart conditions, allergies | Identifies medication risks and monitoring needs |
Medication reconciliation | Home medications, OTC drugs, supplements, last doses, possible duplicates | Identifies interactions, omissions, discrepancies, and potential toxicity |
Vital signs | BP, HR, respiratory rate, temperature, oxygen saturation as appropriate | Establishes a baseline and identifies instability |
Symptoms | Pain, dizziness, headache, shortness of breath, nausea, constipation | Establishes current problems and possible medication effects |
Laboratory results | Renal function, electrolytes, blood counts, liver tests, coagulation tests when relevant | Identifies abnormalities that may affect treatment safety |
Function and safety | Mobility, falls, cognition, ability to take medications, available support | Guides fall prevention, education, and discharge needs |
Patient goals | What matters to the patient, their concerns, and their priorities | Helps shape a realistic, individualized care plan |
Example: a patient admitted with hypertension
Suppose the patient has a history of hypertension, takes lisinopril and furosemide, reports dizziness, and has an elevated creatinine result.
The nurse shouldn't look at each finding in isolation.
Lisinopril: assess BP and review renal function and potassium as relevant.
Furosemide: assess fluid status, BP, renal function, and electrolytes as relevant.
Dizziness: assess symptom timing, positional changes when appropriate, mobility, and fall risk.
Elevated creatinine: compare with previous results, review the clinical context, and report a concerning change.
Combined picture: determine whether the patient may have dehydration, medication-related hypotension, worsening kidney function, or another problem requiring further assessment.
These findings do not prove a particular diagnosis. They tell the nurse what needs investigation, what risks to manage, and what information the care team needs.
3. Chart review: how to look for abnormalities systematically
Chart review is more than looking for values marked in red. You're looking for abnormal values, changes from baseline, patterns over time, inconsistencies, and combinations of findings that may signal a problem.
A practical approach is to review the chart in six passes.
Pass 1 — Vital signs
Look at current and previous BP, HR, respiratory rate, temperature, and oxygen saturation when available. Check trends, symptoms, and patient-specific parameters—not just isolated numbers.
Pass 2 — Laboratory results
Review relevant CBC, electrolytes, creatinine/eGFR, liver tests, glucose, and medication-specific monitoring. Compare with prior values and consider how quickly the result changed.
Pass 3 — Medication orders and administration record
Identify new medications, recently changed doses, PRN medications, missed or held doses, duplicate therapies, potential interactions, and whether required monitoring is in place.
Pass 4 — Symptoms and physical assessment
Review pain scores, neurological changes, respiratory findings, bowel function, urine output, fluid balance, skin findings, and other assessment results relevant to the patient.
Pass 5 — Trends and previous events
Look for recurring dizziness after medication, increasing pain, worsening kidney function, repeated abnormal BP, frequent PRN use, or symptoms that return after treatment.
Pass 6 — Plans and pending actions
Review provider notes, existing care plans, pending tests, consultation recommendations, medication changes, and required follow-up. Confirm who is responsible for unresolved items.
What counts as an abnormality worth investigating?
Chart finding | What the nurse should consider |
BP lower than the patient's usual level with dizziness | Symptomatic hypotension, medication effects, dehydration, bleeding, or another cause |
HR unusually low after a rate-slowing drug | Medication effect, conduction abnormality, or another cause |
Respiratory rate falling after an opioid | Possible respiratory depression; assess and escalate promptly |
Creatinine rising from baseline | Possible acute kidney injury, fluid-related changes, medication effects, or other causes |
Potassium outside the reference range | Potential medication effects, renal dysfunction, or other causes; urgency depends on degree and clinical context |
Increasing frequency of PRN pain medication | Inadequate symptom control, worsening condition, or a need to reassess the treatment plan |
Repeated nausea, vomiting, or constipation | Possible medication adverse effect, dehydration, or another underlying problem |
Missed doses or conflicting medication lists | Reconciliation issue, access barrier, misunderstanding, or potential safety problem |
A flagged result is a prompt to interpret, not a diagnosis. Review the reference range, trends, symptoms, clinical context, and urgency. Follow escalation procedures for critical results and concerning changes.
4. Care planning: turn the abnormalities into a plan
Once you identify a problem or risk, you translate it into a nursing care plan. This is the bridge between noticingsomething and doing something about it.
A useful structure is:
Assessment evidence: What did you observe or find in the chart?
Nursing problem or risk: What patient need does this suggest?
Goal/outcome: What should improve or remain stable?
Interventions: What will nursing do?
Monitoring frequency: When will you reassess?
Escalation criteria: What finding requires the provider or emergency response?
Evaluation: Did the intervention work? Does the plan need revision?
Example care plans
Example 1
Problem: risk of falls associated with dizziness
Evidence: patient reports dizziness after antihypertensive medication.
Goal: Patient remains free from falls and can mobilize as safely as their condition allows.
Interventions: Assess dizziness and BP as indicated; evaluate orthostatic symptoms when appropriate; review medications; assist with mobility; implement fall precautions.
Escalation: New syncope, significant symptomatic hypotension, or concerning deterioration.
Evaluation: Reassess symptoms and mobility; determine whether further review of the treatment plan is needed.
Example 2
Problem: risk of respiratory compromise during opioid treatment
Evidence: opioid prescribed for pain; sedation or respiratory risk factors identified.
Goal: Pain is managed while the patient maintains safe respiratory status and alertness.
Interventions: Assess pain, respiratory status, and sedation; review other sedatives; follow prescribed hold parameters and monitoring protocols.
Escalation: Worsening respiratory status or reduced responsiveness.
Evaluation: Assess both pain relief and medication safety after administration.
Example 3
Problem: risk of worsening renal function
Evidence: rising creatinine in a patient receiving medications that may affect renal function.
Goal: Renal status remains stable or improves, with medication treatment adjusted appropriately by authorized clinicians.
Interventions: Review trends, fluid status, urine output when indicated, relevant electrolytes, and medication exposure; communicate concerning changes.
Escalation: Significant deterioration, reduced urine output, or concerning electrolyte abnormalities.
Evaluation: Review subsequent results and confirm that the treatment and monitoring plan addresses the findings.
These are illustrative templates, not universal prescribed care plans. Actual diagnoses, outcomes, interventions, and monitoring schedules must reflect the patient's assessment and your facility's documentation standards.
5. Ongoing care: repeatedly compare the patient with the plan
Ongoing nursing care is where the workflow repeats throughout the shift and hospitalization.
The nurse is continuously asking:
Is the patient improving, worsening, or unchanged?
Are medications producing the intended effect?
Have any adverse effects or new abnormalities appeared?
Are the interventions working?
Does the provider need to be notified?
Does the care plan still fit the patient's needs?
Example: frequent PRN medication use
Suppose a patient repeatedly requests a PRN migraine medication.
The task isn't simply to administer each dose whenever requested. The nurse should follow the order and reassess:
What is the headache severity and pattern?
Is this consistent with the patient's usual migraine?
What medication was taken, at what time, and with what effect?
Is the medication appropriate to repeat under the current order?
Are there adverse effects or contraindications?
Is the frequency of attacks or acute medication use increasing?
If the treatment isn't controlling symptoms, the pattern should be communicated to the provider. The provider may decide to investigate another cause, change acute treatment, review contraindications, or consider preventive therapy.
The nurse should not independently prescribe a new migraine medication or increase the dose. The nursing contribution is to identify the pattern, assess the patient, administer within the authorized plan, and ensure the unresolved problem reaches the appropriate clinician.
How often should nurses reassess?
There is no single schedule that applies to every medication or every patient. Timing depends on the patient's stability, medication onset and duration, route, potential harm, clinical setting, and prescribed monitoring protocol.
A patient receiving a high-risk IV medication may need close, scheduled monitoring.
A stable patient receiving a routine oral medication may need a different level of monitoring.
A new symptom or deteriorating vital sign can require immediate reassessment regardless of the routine schedule.
6. When does a specialist consultation become appropriate?
A nurse generally does not independently order every specialist consultation. The nurse recognizes a clinical need, escalates it to the responsible provider, and may initiate or coordinate a consultation when authorized by policy or protocol.
A consultation may be warranted when the patient's problem needs expertise beyond the current team's plan, the condition is complex, the response to treatment is inadequate, or specialized testing or treatment may be required.
Pattern identified in the chart | Possible consultation or service | Why it may help |
Persistent or unusual headaches, complex migraine management | Neurology | Further evaluation and treatment planning |
Difficult-to-control hypertension, complex cardiovascular findings | Cardiology or another appropriate medical specialist | Evaluation of cardiac risk and difficult BP management |
Worsening renal function or complex electrolyte abnormalities | Nephrology | Evaluation of kidney dysfunction and specialized management |
Complex medication interactions, adverse effects, or dose adjustments | Clinical pharmacist or pharmacy service | Medication reconciliation, safety review, and dosing recommendations |
Difficult pain control or complex opioid regimen | Pain management service | Review of treatment options and safe pain management |
Recurrent falls, impaired mobility, or difficulty with daily activities | Physical or occupational therapy | Mobility assessment, rehabilitation, and safety recommendations |
Difficulty managing medications at home or obtaining supplies | Case management, social work, or pharmacy | Addressing access, support, education, and discharge barriers |
These are examples, not automatic referral rules. Consultation decisions depend on the findings, urgency, local resources, existing orders, and the responsible provider's assessment.
Urgency matters more than the specialty name. For example, acute chest pain, severe respiratory compromise, or sudden neurological deficits require immediate evaluation through the appropriate emergency pathway—not a routine referral request.
How the nurse helps the consultation succeed
Provide the specialist and referring provider with the relevant clinical story:
What is the concern?
When did it start, and how has it changed?
What objective findings support the concern?
What medications and treatments have been tried?
What was the response?
What laboratory results or imaging are relevant?
What question needs to be answered?
A consultation is most useful when it addresses a clearly described clinical problem rather than simply forwarding an abnormal number without context.
7. Discharge: turn the hospital's findings into a safe plan at home
Discharge planning starts early—often at admission—not just when the provider says the patient can leave.
The nurse considers whether the patient or caregiver can safely manage the treatment plan outside the hospital.
What should be reviewed before discharge?
Medication reconciliation
What medications should continue, stop, start, or change? Are there duplicate ingredients, interactions, or special administration instructions? Confirm that the discharge medication list is consistent with authorized orders.
Patient and caregiver education
Explain medication purpose, schedule, important precautions, relevant monitoring, and what to do if a dose is missed or a problem occurs. Use teach-back to confirm understanding.
Follow-up and outstanding results
Confirm follow-up appointments, required laboratory tests, pending investigations, and who will review results. Make responsibilities clear.
Warning signs and escalation
Explain which symptoms require urgent medical attention and which require contacting the provider. Tailor these instructions to the patient's diagnosis and medications.
Practical ability to manage at home
Consider mobility, cognition, access to prescriptions, ability to obtain food and supplies, transportation, caregiver support, and whether home health or other services are needed.
Example: the patient had dizziness and abnormal renal results during admission
Before discharge, the team should establish the authorized medication plan, clarify whether the renal findings need follow-up, determine which laboratory tests are required and when, and ensure the patient understands medication instructions and warning signs.
The nurse should not assume that the problem is resolved simply because the patient's latest BP is acceptable. Discharge planning must account for the overall clinical picture and any outstanding risks.
8. Put it all together: follow one finding through the entire hospitalization
Here is a worked example of how a chart abnormality can influence every stage of nursing care.
ADMISSION
Finding: Patient taking an antihypertensive reports dizziness; creatinine is higher than a previous result.
Nursing response: Establish baseline, assess current symptoms and vital signs, review medications and relevant labs, evaluate fall risk, and report concerning findings.
CHART REVIEW
Finding: Dizziness has occurred after previous doses, and renal function has changed over time.
Nursing response: Compare the trend with medication timing, fluid status, other symptoms, and the patient's history. Avoid assuming that the medication is the cause without further evaluation.
CARE PLAN
Priority: Reduce fall risk and identify the cause of the symptoms and laboratory changes.
Nursing response: Set appropriate monitoring, mobility precautions, reassessment criteria, and escalation parameters.
ONGOING CARE
Finding: The patient becomes more dizzy, or a new abnormality develops.
Nursing response: Reassess promptly, follow the medication order and relevant hold parameters, communicate the change, and implement authorized interventions.
CONSULTATION
Finding: The renal abnormality persists or the cause remains unclear.
Nursing response: Communicate the trend and relevant clinical context to the responsible provider, who can determine whether additional investigation or specialist input is needed.
DISCHARGE
Goal: The patient has a safe, understandable plan for continued care.
Nursing response: Confirm medication instructions, follow-up testing, appointments, support needs, and warning signs, with clear responsibility for outstanding results.
Notice that the same original finding can lead to several different actions depending on what happens next. Nursing care is not just identifying abnormalities; it is tracking their significance and ensuring they are addressed.
9. Your master mental model for nursing practice
When reviewing a patient's chart, ask these questions in order:
What is abnormal? Identify unusual symptoms, vital signs, examination findings, laboratory results, or medication-related events.
How important is it right now? Determine whether it signals immediate danger, needs prompt notification, or can be addressed through routine monitoring.
What might explain it? Consider the illness, medications, recent interventions, baseline findings, and other possible causes.
What must I assess next? Choose focused assessments that help clarify the concern.
What action is authorized and appropriate? Follow orders, protocols, scope of practice, and escalation requirements.
What is the desired outcome? Establish what improvement or stability should look like.
Did the intervention work? Reassess and compare with baseline.
Does the plan need to change? Communicate recurring or unresolved concerns and update the care plan through the appropriate process.
What must be handed off or completed at discharge? Make sure the next clinician or the patient has the information and follow-up needed to continue safe care.
The central principle is: assessment tells you what is happening; clinical judgment helps you decide what it means; the care plan organizes what to do; ongoing reassessment tells you whether it worked; consultation brings in additional expertise when needed; and discharge planning ensures the care continues safely.
That is how medication knowledge, chart review, nursing responsibilities, and the larger care process all fit together.
introduce self
hi my name is X, ill be your nurse today
safety measures
wash hands
gloves on
identify patient
call for assistance
call provider
contact 12-lead ECG
Contact labs
Contact ultrasound
educate patient
activities, safety, fall risk
assessment steps
coughing
diagnostics
diet
improving venous return
incentive spirometry
intake and output
pain management
plan of care
ROM exercises
pain assessment
can you describe the pain
do you have any pain
do you have chest pain
do you need something for the pain
does anything make the pain better
does anything make the pain worse
how would you rate your pain, on a scale of 0-10?
when did the pain start
where does it hurt
current illness
are you dizzy
are upiu gettign the meals you need on a daily basis
can i get you some water
can you describe the diarrhea
can you feel your toes
do you binge on large amounts of food in a short period
do you do any breathing exercises
do you feel better now
do you feel nauseated
do you follow a special diet prescribed to you by a doctor
do you have trouble breathing
do you need something for nausea
do you use any vitamins or food supplements
do you view yourself as overweight
do you weigh yourself frequently throughout the week
has there been a normal amount of feces in the pouch today
has there been any pain, swelling, or discoloration around the colostomy pouch
has there been any smell, secretions, or discharge from the wound
have the urine volume, and color been normal
have you had any pain or itching from the wound
have you had any signs of dehydration such as leg cramps, palpitations, weakness, fatigue, dizziness
have you had any signs of urinary tract infections like fever, urge, or pain
have you had anything to eat or drink today
have you had increased swelling of legs in the past week
how are you feeling
how long have you had diarrhea
how many bowel movements do you have everyday
what is the consistency
how would you describe your coughing
is it dry, wet, productive
what did the vomit look like
what do you need
what happened
what other symptoms do you have
what were you doing when the symptoms started
when did the symptoms start
when did you have your last menstruation
when did you last have something to eat
when did you last urinate
when was your last bowel movement
past medical history
are you a smoker?
how many packs a day
do you have any allergies
what kind of reactions do you have
do you take any medication
have you taken your medication
orientation
are you awake
can you tell me todays date
can you tell me where you are
what year is it
vital signs
respirations
temperature
pulse
blood pressure
oxymeter
skin, hair, nails
dressing inspection
hair and scalp
perineal incision
nails on hands and feet
skin on abdomen
skin and hair on arms
skin and hair on back, sacral, and pelvis
skin and hair on chest
skin and hair on legs
inspect skin on feet
neurological system
sensation on abdomen
sensation on arms
sensation on back
sensation on chest
sensation on feet
sensation on hands
sensation on legs
check eye opening
check motor responses
responses to commands
verbal responses
pupil response
tracking finger with eyes
head and neck
inspect eyes
inspect ears
inspect mouth
inspect nose
heart and neck vessels
auscultate heart
check carotid pulse
inspect neck vessels
thorax and lungs
auscultate lungs
abdomen
auscultate abdomen
inspect abdomen
palpate abdomen
musculoskeletal
mobility of arms
mobility of legs
strength of arms and hands
strength of feet
strength in legs
elbow
hips
knees
shoulders
ankles
wrist
intervention
call provider
check emesis basin
check oxygen device
contact 12 lead ECG
contact labs
contact ultrasound
encourage coughing
give water
high sitting position
sitting position
supine position
incentive spirometry
drug and IV management
assess IV access
You should have asked the patient about allergies.
You should have asked the patient when she had her last menstruation.
You should have asked the patient when she last urinated.
You should have assessed the pain level.
You should have asked the patient if she could describe the pain.
You should have asked the patient about the duration of the pain.
You should have asked the patient where the pain was located.
You should have asked the patient if anything makes the pain better.
You should have asked the patient if anything makes the pain worse.
ou should have asked the patient if he could tell where he was.
You should have asked the patient about today's date.
You should have assessed how the patient was feeling.
You should have auscultated the patient's heart.
You should have palpated the skin on the patient's thorax.
You should have inspected the skin and hair on the patient's arms.
You should have palpated the skin on the patient's arms.
You should have inspected the skin and hair on the patient's legs.
You should have palpated the skin on the patient's legs.
You should have inspected the patient's eyes.
You should have inspected the patient's ears.
You should have inspected the patient's nose.
You should have assessed the range of motion of the patient's arms.
You should have measured the capillary refill time on the patient's hands.
You should have measured the capillary refill time on the patient's feet.
You should have assessed the pedal pulses.
You should have educated about intake and output.
abdominal pain
You introduced yourself. Always remember to tell the patient who you are.
00:22You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room.
00:25You put on gloves.
00:36You identified the patient. To maintain patient safety, it is important that you quickly identify the patient.
00:53You educated the patient about pain management.
You asked the patient if she could describe her pain. She replied: 'It's like a sharp, stabbing pain.'
01:54You asked the patient if anything made the pain better. She replied: 'The pain medications helps, and if I lay perfectly still, it is better.'
You asked the patient if anything made the pain worse. She replied: 'Yes, it gets worse when I move around.'
02:10You asked: How would you rate your pain? She replied: 'Not too bad; it's about a 3.
02:17You asked the patient when the pain started. She replied: 'It started yesterday and only got worse.'
02:24You asked the patient: Where does it hurt? She replied: 'Just my stomach, to the lower right.'
You asked the patient: When did you have your last menstruation? She replied: 'Two weeks ago.'
You asked the patient: When did you last have something to eat? She replied: 'I had something around 2 this morning.'
04:28You asked the patient: When did you last urinate? She replied: 'At the emergency room.'
04:33You asked the patient: When was your last bowel movement? She replied: 'Yesterday.'
04:44You asked the patient: Do you have any allergies? If so, what kind of reaction did you have? She replied: 'No, I am not allergic to anything.'
You checked the temperature at the ear. The temperature was 100 °F (37.8 °C). It is reasonable to check the temperature here.
05:47You measured the blood pressure at 118/70 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure.
You attached the pulse oximeter. It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously.
You auscultated the lungs. This was reasonable. Auscultation of lungs revealed normal lung sounds without added sound.
08:43You inspected the patient's abdomen. The abdominal contour is slightly distended.
08:50You auscultated the abdomen. This was reasonable. The abdomen sounded hypoactive.
08:58You palpated the abdomen. This was reasonable.
A patient handoff was performed.
Situation
The patient is being prepped for an appendectomy
Background
Blood work was drawn and the patient has been diagnosed with appendicitis
Sara was healthy prior to this event and has no history of surgeries
Assessment
The pain is localized to her right lower quadrant and is described as a sharp, stabbing pain
Her pain increases with movement
Recommendation
Continue to be monitored for any increase or change in pain prior to surgery
focused assessment
assessed for
she reported
she rated
she stated
it began
progressively worsened
X provides relief
X decreases pain
She stated
she was educated on X regarding
she reported
last menstrual period/meal/urination/BM was
she reported no X
Absominal assessment documentation
X assessment was performed
X appeared slightly distended
Bowel sounds were hypoactive
abdomen was auscultated and palpated
she reported tenderness pain in RLQ
Pain increased with movemnt
Temp was
BP was
Lung sounds were clear without adventitious sounds
Pulse oxymetry was applied for ongoing monitoring
Nursing care provided and patient response
introducing self to patient
performed hand hygiene upon entering room
patient was identified using appropriate identifiers
gloves were applied as indiated
focused pain and abdominal assessments were completed
vital signs and oxygen saturation were monitored
patient was educated about pain management and encouraged to communicate changes in pain or other symptoms
she reported that pain management helped relieve her pain with movement
Patient remained able to communicate her symptoims and participated in the assessment and care provided
patient teaching and response
patient was educated regarding the importance of reporting changes in abdominal pain, including increased severity, changes in location or character or pain that is not adequately relieved by prescribed interventions
she was instructed to communicate any new or worsening symptoms to the nursing staff
pain management measures and the importance of communicating her pain level were discussed
safety measures and the need for continued monitoring while preparing for surgery were reinforced
she participated in the taching and was able to describe her current plan and factors that make the pain feel better or worse
Evidence Based Practice
pain assessment
location, intensity, quality, onset, duration, aggrevating factors, and relieving factors
abdominal assessment
contour, distention, bowel sounds, tenderness, changes in abdominal findings
vital signs
particularly temperature because she has appendicitis and a temperature of 100 'F
GI assessment
last bowel movement, nausea vomiting if present, ability to tolerate oral intake, and changes in abdominal symptoms
GU assessment
last urination, and continued monitoring for urine output
reproductive assessment
last menstrual period, particularly because patient is female, with abdominal pain and is preparing for surgery
allergy assessment
medication/food/environmental allergies adn the type of reaction
Preoperative assessment
last oral intake, current medications, medical/surgical history, and other information needed before appendectomy
ongoing reassessment
monitoring for increasing pain, worsening tenderness, increased temeprature, changes in vital signs, and other changes that could indicate deterioration
PCC - additional nonpharmacolgical action for pain
positioning for comfort
reduce unnecessary movemnt
calm environment
relaxation techiques
distraction
provides explanations before care
frequent reassessments
nurse needs to ask about these symptoms
if they are having any of them
Assessing your voiding patterns, habits, and medical history helps identify the root cause of urinary symptoms like frequency, urgency, or retention
Assess for nonverbal signs of weakness or illness
questions to ask if some has
trouble sleeping
Description of sleeping problems
• Usual sleep pattern
• Physical and psychological illness
• Current life events
• Emotional and mental status
• Bedtime routines
• Bedtime environment
• Behaviors of sleep deprivation
religious
FICA©
SPIRITUAL ASSESSMENT TOOL
Faith or Beliefs:
What is your faith or belief?
Do you consider yourself spiritual or religious?
What things do you believe in that give meaning to your life?
Importance and Influence:
Is it important in your life?
What influence does it have on how you take care of yourself?
How have your beliefs influenced your behavior during this illness or situation?
What role do your beliefs play in regaining your health?
Community:
Are you part of a spiritual or religious community?
Is this of support to you and how?
Is there a person or group of people you really love or who are really important to you?
How would you like me, your healthcare provider, to address these issues in your healthcare?
s your nurse, is there
something I can do to provide spiritual sup-
port for you?
How about people or
a group—is there someone that provides
spiritual support?
Normal white blood cell count
Negative bacteria and viral cultures
Non-tender soft lymph nodes
Recognition of self
Tissue integrity
Cellular regulation
Comfort
Coping
Nutrition
Mobility
Functional ability
Thermoregulation
Cancer
Immune suppression
Immune deficiency
Chronic inflammatory response
Exaggerated immune response
Allergic cytotoxic autoimmune reaction
Infection localized or systemic
Intact nonspecific defense barriers
Functional lymphatic system
Optimal innate immune response
Functional inflammatory response
Appropriate adaptice acquired immunity
Musculoskeletal Assessment
A musculoskeletal assessment evaluates the patient's bones, joints, muscles, movement, strength, and mobility.
Assess:
Muscle strength
Range of motion
Joint movement
Gait
Balance
Posture
Pain
Swelling
Deformities
Ability to perform activities of daily living
Ability to transfer and ambulate
Skin Assessment
A skin assessment evaluates the condition and integrity of the patient's skin.
Assess:
Color
Temperature
Moisture
Texture
Turgor
Lesions
Bruising
Rashes
Wounds
Pressure injuries
Edema
Signs of infection
For older adults, pay particular attention to fragile skin and pressure-injury risk.
Sleep Assessment
A sleep assessment evaluates a person's sleep habits, quality, quantity, and factors that interfere with sleep.
Ask about:
Hours of sleep
Bedtime and wake time
Difficulty falling asleep
Waking during the night
Early-morning awakening
Daytime sleepiness
Snoring
Nightmares
Medications
Caffeine/alcohol use
Pain
Anxiety/stress
Sleep environment
Older Adult Assessment
An older adult assessment is a comprehensive evaluation of an older person's physical, psychological, cognitive, functional, social, and environmental health.
Important areas include:
Physical health
Medication use
Nutrition/hydration
Mobility
Fall risk
Vision and hearing
Cognitive function
Mood
Sleep
Skin integrity
Pain
Elimination
Activities of daily living
Social support
Living environment
Safety
Abuse/neglect
delirium
Acute onset
Develops over hours or days
Symptoms can fluctuate
Difficulty paying attention
Confusion
Disorganized thinking
Changes in level of consciousness
Possible hallucinations
unfamiliar surroundings, unfamiliar staff, bed rest, separation from support systems, and stress
malnutrition
identifying treatable sleep-deprivation problems
as a nurse do you know what to look for
Nature of the problem
• Describe the type of sleep problem you’re having.
• Why do you think you are not getting enough sleep?
• Describe a recent night’s sleep. Is this similar to your usual sleep? How is this sleep different from your usual sleep?
Signs and symptoms
• Tell me how difficult it is to fall or stay asleep, or to wake up
• Have you been told that you snore loudly?
• Do you have headaches when awakening?
Onset and duration of signs and symptoms
• When did you notice the problem?
• What do you do to relieve the symptom(s)?
• How long has your sleep problem lasted?
Severity
• On average, how long does it take you to fall asleep?
• How often during the week do you have trouble falling asleep?
• On average, how many hours of sleep a night did you get this week?
• How does this compare to your usual amount of sleep?
• What do you do when you awaken during the night or too early in the morning?
Predisposing factors
• What do you do just before you go to bed?
• Have you recently had any changes at work or at home?
• How is your mood? Have you noticed any changes recently?
• Which medications or recreational drugs do you take on a regular basis?
• Are you taking any new prescriptions or over-the-counter medications?
• Do you eat food (spicy or greasy foods) or drink substances (alcohol or caffeinated beverages) that affect your sleep?
• Do you have a physical illness that affects your sleep?
• Does anyone in your family have a history of sleep problems?
Effect on patient
• How has the loss of sleep affected you?
• Do you feel excessively sleepy or irritable or have trouble concentrating?
• Do you have trouble staying awake? Have you fallen asleep at the wrong times (e.g., while driving, sitting quietly in a meeting)?
Impaired sleep
• How easily do you fall asleep?
• Do you fall asleep and have difficulty staying asleep? How many times do you wake up? Do you wake up at the same time?
• What time do you wake up in the morning? What causes you to wake up early?
• What do you do to prepare for sleep? To improve your sleep?
• What do you think about as you try to fall asleep?
• How often do you have trouble sleeping?
Sleep apnea
• Do you snore loudly? Does anyone else in your family snore loudly?
• Has anyone ever told you that you often stop breathing for short periods during sleep? (Spouse or bed partner/roommate may report this.)
• Do you experience headaches after awakening?
• Do you have difficulty staying awake during the day?
Narcolepsy
• Do you fall asleep at the wrong times? (Friends or relatives may report this.)
• Do you have episodes of losing muscle control or falling to the floor?
• Have you ever had the feeling of being unable to move or talk just before waking or falling asleep?
• Do you have vivid, lifelike dreams when going to sleep or awakening?
Which prescription and nonprescription medications do you take? What herbal and nutritional supplements do you take? When do you take them? How do you take them? Do you have a list of medications from your pharmacy or health care provider’s office?
Why do you take these medications?
Which side effects do you experience? Which of the side effects bother you or affect you negatively?
What have you been told to do if a side effect develops?
Have you ever stopped taking your medications? If so, why?
What do you do to help remember to take your medications?
Do you have any allergies to medications or foods? If so, which ones? Describe what happens when you take the medication or eat the food.
Describe your normal eating patterns. Which foods and at what times do you normally eat?
How do you pay for your medications? Do you sometimes have to stretch your budget to afford them or space them out to save money?
What questions do you have about your medications?
Assessing Pain in the Dying Patient
Verbal Patients: Using a 0–10 scale or descriptive terms (sharp, dull, aching, burning) helps track changes over time
Nonverbal Patients: When a patient can no longer speak, caregivers and clinicians must watch for physical and behavioral indicators:
Strained or sad facial expressions
Tense body language, restlessness, or pulling away
Changes in breathing patterns or increased respiratory rate
Rhythmic rubbing or massaging of a specific area
Increased agitation or resistance to movemen
When did this happen
Where were you going
Primary
best practice
arrival info
arrival documentation
travel screening
LWBS or to L+D - left without being seen
chief complaint
vitals
triage comp/ac
secondary
complaint details
allergies
gender identity
Home medications
History
ED Triage notes
Assessment
primary assessment
tetanus immunization
immun rpt
call in referral
call in
Comments