Clinical exam · History taking and the interview
Nursing assessment: head-to-toe and focused assessment !
- Topic
Nursing assessment is the first stage of the nursing process: gathering data about the patient to plan their care.
Updated 2026-11-01
What it is
Assessment is the first phase of the nursing process (assessment, diagnosis, planning, implementation and evaluation). It may be initial or comprehensive, head to toe on admission; focused on one problem; emergency, centred on airway, breathing and circulation; or time-lapsed, repeated over time. It combines subjective data, which the patient reports, and objective data, which the nurse measures or observes.
Key facts
- Focused assessment: directed at the current problem, for example chest pain or the post-operative period.
- Emergency assessment: airway, breathing and circulation first; then a secondary survey.
- Common scales: pain, Glasgow, fall risk and pressure-injury risk.
- Assessment is continuous: it is repeated according to the patient's condition and the care plan.
Step by step
- Hand hygiene, introduce yourself, verify identity with two identifiers and explain the procedure.
- General impression: level of consciousness, appearance, breathing difficulty, pain.
- Vital signs and pain score: 'From 0 to 10, how much pain do you have now?'
- Head and neck, chest (respiratory and cardiovascular), abdomen, genitourinary and limbs, in head-to-toe order.
- Skin throughout: integrity, pressure areas, wounds, lines and tubes.
- Risks: falls, pressure injuries, nutrition, elimination, sleep and self-care.
- Record the findings and compare them with the previous assessment.
- Report changes: situation, background, assessment and recommendation (SBAR).
Test yourself
Think of the answer, then tap the question to see it.
What are the stages of the nursing process?
Assessment, nursing diagnosis, planning, implementation and evaluation.
In what order is the abdomen examined, and why?
Inspection, auscultation, percussion and palpation: listening before touching avoids changing the bowel sounds.
How does a comprehensive assessment differ from a focused one?
The comprehensive assessment covers the whole body and sets a baseline on admission; the focused one targets a specific problem, such as pain or a wound.
What does SBAR stand for when reporting a finding?
Situation, background, assessment and recommendation: a fixed order for reporting to the team without leaving out data.
Related
- Vital signs: what they are and how to record them
- Pain assessment and pain scales
- Level of consciousness and the Glasgow Coma Scale
- Abdominal auscultation: bowel sounds and bruits
- Early warning scores: NEWS2 and qSOFA
- Comprehensive geriatric assessment: function, cognition, falls
Related conditions
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: 12.2 Types of Assessment - Fundamentals of Nursing | OpenStax (OpenStax, Rice University, 2024); 12.3 Collection of Assessment Data - Fundamentals of Nursing | OpenStax (OpenStax, Rice University, 2024); 2.4 Therapeutic Communication - Fundamentals of Nursing | OpenStax (OpenStax, Rice University, 2024).
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Representative model, for educational purposes only.