Assessment

Definition

Assessment is the systematic and continuous collection, organization, validation, and documentation of patient data. It is the first step of the nursing process (ADPIE; assessment, Diagnosis, Planning, Implementation, Evaluation).

Types of Data

• Subjective: What the patient says (symptoms, feelings, perceptions).
• Objective: Measurable, observable data (vital signs, lab results, physical findings).
• Primary source: The patient.
• Secondary sources: Family, medical records, other health professionals.

Assessment Techniques

Inspection, palpation, percussion, auscultation. Performed in this order except for the abdominal exam (inspect, auscultate, percuss, palpate).

Nursing Considerations

Collect comprehensive baseline data on admission; perform focused assessments when new symptoms arise and shift assessments per facility policy, always validate abnormal findings. Assessment is the non-delegable step of the nursing process, an RN responsibility.

NCLEX Relevance

When a question asks what to do first for a new complaint, 'assess' is almost always the correct answer. Delegation questions: do not delegate assessment, teaching, evaluation, or planning.