Editing Fundamentals of Nursing (section)

=== Assessment ===

Assessment is the systematic, deliberate collection of data about the patient. It always comes first. When an examination item offers a plausible intervention and a plausible assessment, choose assessment unless the situation is an emergency with an obvious required action, such as an unwitnessed collapse or an airway obstruction.

* '''Subjective data''' are what the patient reports: pain, nausea, dizziness, fatigue, fear. Pain is always subjective and the patient's self-report is the single most reliable indicator.
* '''Objective data''' are what the nurse observes or measures: vital signs, wound appearance, gait, laboratory values, intake and output.
* '''Primary source''' is the patient. '''Secondary sources''' include family, the medical record, and other members of the health care team.
* '''Types of assessment''' include the comprehensive admission assessment, the focused assessment of a specific problem or body system, the ongoing or shift assessment, and the emergency assessment.

Techniques of physical assessment are inspection, palpation, percussion, and auscultation, performed in that order for every region except the abdomen. For the abdomen, auscultate before palpating, because palpation alters bowel sounds.

Scope note: in the registered nurse role, assessment means the comprehensive evaluation and the clinical interpretation of findings. The licensed practical nurse performs focused data collection, contributes findings to the assessment, and reports changes to the registered nurse. The initial and comprehensive assessment is a registered nurse responsibility and cannot be delegated.