Patient assessment is an important part of nursing care. It helps identify changes in a patient's condition and supports safe, appropriate care.
Observe the patient's overall appearance, level of comfort, behavior, and any signs of distress.
Assess the patient's alertness, orientation, and ability to respond appropriately.
Measure and assess temperature, pulse, respiratory rate, blood pressure, and other vital signs as required.
Ask about pain and assess its location, intensity, quality, and factors that make it better or worse.
Observe breathing rate, effort, pattern, and any signs of respiratory distress.
Assess pulse characteristics, circulation, skin color, and other relevant findings within your scope of practice.
Observe skin color, temperature, moisture, and condition. Report any redness, wounds, or other changes.
Assess the patient's ability to move safely and identify potential fall or safety risks.
Compare findings with the patient's baseline when available and promptly communicate significant changes to the appropriate healthcare professional.
💡 Quick Tip
Assess carefully, compare changes, and report concerns promptly.
☐ Did I identify the correct patient?
☐ Did I explain what I am doing?
☐ Did I perform hand hygiene?
☐ Did I assess the patient's overall condition?
☐ Did I obtain the required assessment findings?
☐ Did I compare findings with previous or baseline information when available?
☐ Did I recognize any abnormal or concerning changes?
☐ Did I communicate important findings promptly?
☐ Did I document the assessment appropriately?
⭐ Remember
A careful assessment helps you recognize changes early and support safe patient care.