Overview
Health assessment is how nurses gather objective data about the body. It blends four hands-on examination techniques with the measurement of vital signs and pain. Done well, assessment turns vague impressions into precise findings that guide the entire plan of care and catch deterioration early.
The Four Techniques of Physical Examination
Nurses use four techniques, generally in this order:
- Inspection — looking (and smelling): noting color, symmetry, swelling, movement, and drainage. It begins the moment you meet the patient.
- Palpation — feeling with the hands for temperature, moisture, texture, tenderness, pulses, and masses.
- Percussion — tapping the body surface; the resulting sound reveals whether tissue underneath is air-filled (resonant), fluid-filled (dull), or solid.
- Auscultation — listening with a stethoscope to heart, lung, and bowel sounds.
The usual order is inspection → palpation → percussion → auscultation. The abdomen is the exception: it is auscultated before palpation so that pressing does not alter bowel sounds.
Vital Signs
Vital signs are the core indicators of body function. Memorizing normal adult ranges lets you recognize abnormal values instantly.
| Vital sign | Normal adult range | Notes |
|---|---|---|
| Temperature | ~36.1–37.2 °C (97–99 °F) | Route (oral, tympanic, axillary) affects reading |
| Pulse (heart rate) | 60–100 beats/min | <60 bradycardia; >100 tachycardia |
| Respirations | 12–20 breaths/min | Count without alerting the patient |
| Blood pressure | <120/80 mmHg (normal) | Systolic/diastolic in mmHg |
| Oxygen saturation (SpO2) | 95–100% | Measured by pulse oximeter |
Blood pressure is written as systolic over diastolic. Systolic is the pressure when the heart contracts; diastolic is the pressure between beats. A reading of 118/76 mmHg means 118 systolic and 76 diastolic.
Always interpret a vital sign in context. Fever, anxiety, pain, exercise, and medications all shift the numbers, and trends over time often matter more than a single value.
Assessing Pain
Pain is considered subjective — the patient’s report is the most reliable measure. Nurses commonly use a 0-to-10 numeric rating scale (0 = no pain, 10 = worst imaginable). For patients who cannot self-report, faces scales or behavioral cues (grimacing, guarding, restlessness) are used. A helpful memory aid is OPQRST: Onset, Provocation/palliation, Quality, Region/radiation, Severity, and Timing. Documenting pain before and after an intervention shows whether it worked.
The Head-to-Toe Assessment
A head-to-toe assessment examines every body system in a consistent, downward order so nothing is overlooked. A typical flow:
- General survey — overall appearance, level of consciousness, distress
- Head and neck — eyes, ears, mouth, lymph nodes
- Chest — heart sounds and lung sounds by auscultation
- Abdomen — inspect, auscultate bowel sounds, then palpate
- Extremities — pulses, capillary refill, edema, strength, skin
- Neurological — orientation, movement, sensation
Assessment frequency depends on the setting: a critically ill patient is reassessed far more often than a stable one. A focused assessment zooms in on a specific complaint (for example, a detailed lung exam for shortness of breath), while a comprehensive assessment covers every system, as at admission.
Before the physical exam, nurses also gather a health history — the patient’s chief complaint, past illnesses, medications, allergies, and social context. Combining this subjective history with the objective exam produces a complete database. Throughout, the nurse maintains privacy, explains each step, and positions the patient comfortably, because a cooperative, relaxed patient yields more accurate findings and a better experience of care.
Recognizing Findings to Report
Certain findings need prompt escalation: a marked change from the patient’s baseline, oxygen saturation dropping below the ordered threshold, a systolic blood pressure that is very high or very low, a new irregular pulse, a respiratory rate that is rising, or a sudden change in mental status. Comparing a value against the patient’s own baseline is often more revealing than comparing it against a textbook range, since each person’s normal differs. Recognizing and acting on these changes early is one of the most important skills a nurse develops.
Clinical Relevance
Vital signs and assessment findings are the vocabulary of clinical communication. They populate the chart, trigger rapid-response calls, and tell the team whether a treatment is working. A nurse who takes accurate vital signs, performs a systematic exam, and knows normal ranges can detect subtle deterioration hours before a crisis. This early recognition — turning small changes into timely action — is central to safe, effective nursing care.