Introduction to Health Assessments

The assessment you provide as a nurse will vary based on your role and based on the setting in which you practice. A health assessment in general will consist of observations and measurements to identify problems or keep the client safe. This Health Assessment NCLEX^® Review aims to provide readers with an understanding of health assessment to prepare for daily responsibilities as a nurse as well as the NCLEX^® exam.

Importance of Nursing Health Assessment

Health assessments serve the purpose of identifying current problems, identifying problems the client is at risk for, keeping the client alive and/or stable, and treating any current problems. Thorough, accurate health assessments create the pathway for the client’s treatment and care plan. Performing a health assessment requires organization, focus, and competence with each client.

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Prior to Starting a Health Assessment

Before you start a health assessment, be sure the room or area is clear, that there are no safety precautions and that you have necessary equipment for the assessment. Equipment may include gloves, thermometer, blood pressure cuff, watch, scale, tape measure, light, and stethoscope, among other more specialized tools. A health assessment is driven by the needs of the client.

Head-to-Toe Health Assessment

As you may infer from the name, a head-to-toe health assessment is one that encompasses the entire client from head to toe. This includes physical and neurological health. The head-to-toe assessment includes the client’s mental status, head, neck, thorax, abdomen, and extremities. Throughout the exam, observe the skin for color, lesions, temperature, and dryness or moisture2.

Head-to-toe approach for generic physical assessments to remember:

Assessment Area	Data
General safety survey	Assess: Bed position, call bell positioning, emergency equipment, ambulatory devices, fall hazards
Vital Signs	Assess: Temperature, pulse, respirations, BP, oxygen saturation, pain assessment Subjective data: Have you had any pain in the last 12 hours? Are you having any pain now?
Mental Status	Assess: Level of consciousness, orientation to person, place, and time; confusion assessment, if indicated Subjective data: What’s the date today? Where are you?
Psychosocial	Assess: Client behavior and affect Subjective data: How do you feel today? How have you been coping with being in the hospital?
Head, eyes, ears, nose, throat, neck	Assess: Eyes, pupils, mouth, speech, carotid arteries, swallowing; facial color, moisture, lesions Subjective data: Do you wear glasses? Can I get your glasses for you? Do you use a hearing aid? Can I get your hearing aid for you?
Chest anterior/ posterior	Assess: Chest color, moisture, lesions, quality of respirations (depth, effort, symmetry), heart sounds Subjective data: Have you been coughing? If yes: Is it a dry cough or have you been able to cough up sputum?
Abdomen	Assess: Abdomen color, moisture, lesions, bowel sounds. Inspect and lightly palpate for distension and pain/discomfort Subjective data: When was the last time you ate? When was the last time you moved your bowels and/or urinated? What did your bowel movement/urine look like?
Upper and lower extremities	Assess: SCATTERS: Skin, Color, Arteries, Temperature, Tenderness, Edema, Refill, Strength and sensation
Activity	Assess: Client movement and ambulation Subjective data: Have you been out of bed? How much activity have you been able to do? Can you walk to the sink and back? Do you require assistance with toileting at this tiame?
Therapeutic Devices	Assess: Peripheral and central venous access devices. Supplemental oxygen settings, pacemakers, cardiac monitor, urinary catheters, gastric tubes, chest tubes, dressings, braces, slings Subjective data: Are any of these devices giving you pain or concern?

Gather data while moving from head to toe, asking related questions along the way. Though this is a general overview of how to conduct a head-to-toe assessment, each client is unique and may require more investigation into problem areas as the assessment continues.

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Health Assessment Mnemonics

It can be overwhelming to remember all of the details that go into performing a thorough health assessment. Mnemonic tools exist for a variety of health assessment components and can help you perform a thorough assessment.

Level of Consciousness Assessment: AVPU4

This assessment tool helps you determine a client’s level of consciousness by assessing their responsiveness to pain and/or verbal stimulus. The AVPU scale should be used to assess the clients response of their eyes, voice, and motor skills.

A: Alert
V: Response to verbal stimuli
P: Response to pain
U: Unresponsive

Health History Assessment: SAMPLE

A health history is important to obtain after life-threatening injuries have been addressed and when the client has stabilized. SAMPLE can be used to obtain important parts of the client’s history.

S: Symptoms
A: Allergies
M: Medications
P: Past medical history
L: Last oral intake
E: Events leading up to the illness or injury

Rapid Trauma Assessment: DCAP-BTLS

This rapid trauma assessment is useful when assessing a client after a traumatic injury.

D: Deformities
C: Contusions
A: Abrasions
P: Punctures or penetrations
B: Burns
T: Tenderness
L: Lacerations
S: Swelling

Alcoholism Screening: CAGE

CAGE is a questionnaire to determine whether a client may suffer from alcoholism. A “yes” response to 2 or more questions indicate that alcoholism may be present and the client should be further treated.

C: Have you ever felt that you should CUT down on your drinking?
A: Have you ever become ANNOYED by criticisms of your drinking?
G: Have you ever felt GUILTY about your drinking?
E: Have you ever had a morning EYE OPENER to get rid of a hangover?

Emergency Trauma Assessment: ABCDEFGHI

Trauma clients can be complex and require haste when performing an accurate, in-depth health assessment. Each part of the emergency trauma assessment is intended to save the life of the client by taking action where it is appropriate.

A: Airway
- Make sure the airway is open and that the client is able to breathe. Tilt the head back and lift the chin to help open the airway and allow the client to breathe. Remove any obstructions to avoid respiratory or cardiac arrest.
B: Breathing
- Use look, listen, and feel techniques to ensure that the client is breathing. Be sure the chest is rising and falling in a normal respiration rhythm, you can hear air movement, and that you can feel air expelling from the mouth or nose. Initiate CPR if the client is not breathing.
C: Circulation
- If the client is breathing, check for the clients pulse. If the client is not breathing, initiate CPR immediately.
D: Disability
- Check that the client’s neurological status is intact and if there are obvious disabilities and/or deformities.
E: Expose and examine
- The client’s clothing should be removed to allow you to properly assess all parts of the client’s body for injury.
F: Full set of vital signs
- Note pulse (carotid, brachial, radial), pupils, breathing, level of consciousness, blood pressure, and skin color or temperature.
G: Give comfort measures
- Clients may be extremely anxious and/or in pain during a traumatic injury. Keep the client as comfortable as possible so they do not injure themselves further.
H: History and head-to-toe assessment
- SAMPLE is a good pneumonic to insert here in order to get a health history and a head-to-toe assessment.
I: Inspect posterior surface
- Examine the client for any obvious problems such as deformities, discolorations, wounds, or more.

Seven Warning Signs of Cancer: CAUTION

The seven warning signs of cancer help identify certain problems in order to detect cancer as early as possible. The American Cancer society uses “CAUTION” to identify the warning signs of cancer. These signs should not be used to definitively diagnose cancer, but may impose more testing and investigation.

C: Changes in bowel or bladder habits
A: A sore throat that does not heal
U: Unusual bleeding or discharge
T: Thickening or lump in the breast or other parts of the body
I: Indigestion or dysphagia
O: Obvious changes in a wart or mole
N: Nagging cough or hoarseness

Breast Assessment: LMNOP

In addition to the CAUTION warning signs, LMNOP is used to screen for and identify breast cancer, cysts, abscesses, and mastitis. Any changes in breasts or masses warrant a further evaluation.
L: Lump
Palpate the breast for any signs of lumps.
M: Mammary changes
Palpate for any dimpling, tenderness, and abnormalities.
N: Nipple changes
Observe nipple discharge, lesions, or discharges.
O: Other symptoms
Symmetry, skin appearance, point direction, rashes, ulceration etc.
P: Client risk factors
Ask client about any predisposing factors, family history.

Family History Assessment: BALD CHASM

Family history plays a large role in a client’s health. Family history can identify diseases the client is at risk for, chronic illnesses, and diseases that may have been genetically inherited. The following disorders have found to be strongly correlated with a family history of the diseases and should be screened for regularly if a family history is present.

B: Blood pressure
A: Arthritis
L: Lung diseases
D: Diabetes
C: Cancers
H: Heart disease
A: Alcoholism
S: Stroke
M: Mental health disorders

Eye Abbreviations3

Short abbreviations for the eyes can be hard to keep straight. OU stands for both eyes, OD stands for right eye, and OS stands for left eye. The following pneumonic can help you remember which abbreviation stands for which term.

YOU look with BOTH EYES
The RIGHT dose won’t OD (overdose).
The only one LEFT is OS.

Signs vs. Symptoms

Signs and symptoms are both important to identify a client’s problems and the correct treatment path. Distinguishing between signs and symptoms is important.

sIgn: something I can detect even if my client is unconscious
Symptom: something only the client knows about. Cannot be measured directly.

Pain Assessment: OPQRSTU

Assessing pain is very important to ensure that the client is comfortable. Pain can be a traumatic feeling for a client and can lead to further injury, anxiety, and can lengthen the time a client takes to recover. Pain is subjective to each client and a thorough assessment must be done.

O: Onset
- When did the pain start? How long does the pain last? How often does the pain occur? What started the pain?
P: Provoking or palliating factors
- What brings it on? What makes it better or worse?
Q: Quality
- What does the pain feel like? (Throb, stab, dull pain)
R: Region and Radiation
- Does the pain radiate? Where does it spread to?
S: Severity
- What is the intensity on a pain scale of 1-10? (or visual scale).
T: Time and treatment
- When did the pain begin? Do you take any medications for the pain?
U: Understanding and Impact
- What do you think is causing the pain? How is this affecting you?

Health Assessment Nursing Conclusion

Health assessments are critical to providing comprehensive care to clients. Performing a head-to-toe assessment, as well as disease-specific assessments, is a crucial responsibility of a nurse and has a large impact on client care. Health assessments identify injury and disease, prevent disease progression, help curate treatment and therapy plans, and help identify diseases the client may be at risk for.

Health assessments can be overwhelming due to the sheer amount of data that should be recorded with each assessment. This health assessment NCLEX^® review serves as an overview of the importance and how to perform health assessments to aid your understanding and help your future practice as a nurse.

References

Lee N. “How to Conduct a Head-to-Toe Assessment”. Nurse.Org. Accessed: May 12, 2020. https://nurse.org/articles/how-to-conduct-head-to-toe-assessment/
Haugh KH. Head-to-toe: Organizing your baseline client physical assessment. Nursing. 2015;45(12):58‐61.
Vera M. Nursing Health Assessment Pneumonics & Tips. Accessed: May 12, 2020. https://nurseslabs.com/nursing-health-assessment-mnemonics-tips/
Romanelli D, Farrell MW. AVPU (Alert, Voice, Pain, Unresponsive). In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2020.
Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA. 1984;252(14):1905‐1907. doi:10.1001/jama.252.14.1905
Thim T, Krarup NH, Grove EL, Rohde CV, Løfgren B. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. Int J Gen Med. 2012;5:117‐121. doi:10.2147/IJGM.S28478
Bleyer A. CAUTION! Consider cancer: common symptoms and signs for early detection of cancer in young adults. Semin Oncol. 2009;36(3):207‐212. doi:10.1053/j.seminoncol.2009.03.004

Health Assessment Nursing NCLEX^® Review

Overview

Learning Outcomes

Rationales

Test Taking Tips

Introduction to Health Assessments

Importance of Nursing Health Assessment

Prior to Starting a Health Assessment

Head-to-Toe Health Assessment