BNS Section 1: Health Assessment

Section Overview

Health assessment is the cornerstone of nursing practice. Every clinical decision — from care planning to medication administration to patient education — depends on an accurate and thorough collection of both subjective and objective data. This section introduces the systematic processes and clinical techniques that BSN nurses use to gather, interpret, and document assessment information across the lifespan, with specific attention to the unique considerations required when caring for older adults.

Competency in health assessment directly supports the nursing process (ADPIE) and the NCSBN Clinical Judgment Measurement Model (CJMM): you cannot recognize cues, analyze cues, or prioritize hypotheses without first having gathered reliable assessment data. This section is foundational to every subsequent module in the Basic Nursing Skills course.

Learning Objectives

By the end of this section, students will be able to:

Perform a systematic head-to-toe physical assessment using the four techniques of inspection, palpation, auscultation, and percussion. (Bloom’s: Apply)
Collect a complete health history using open-ended and focused interview techniques to obtain accurate subjective data. (Bloom’s: Apply)
Identify normal versus abnormal assessment findings and determine which require immediate reporting. (Bloom’s: Analyze)
Apply age-appropriate assessment modifications when performing a physical examination of the older adult patient. (Bloom’s: Apply)
Measure and correctly interpret the six vital signs — including pain as the fifth vital sign — using accurate technique. (Bloom’s: Apply)
Document assessment findings accurately, objectively, and in real time in the electronic health record. (Bloom’s: Apply)

Health Assessment: Core Concepts

Types of Assessment

Nurses conduct several distinct categories of assessment based on clinical context:

Initial/Admission Assessment — A comprehensive head-to-toe assessment completed upon patient admission to establish a baseline.
Focused Assessment — A problem-centered evaluation of a specific body system or clinical concern (e.g., respiratory assessment for a patient reporting dyspnea).
Ongoing/Shift Assessment — A structured re-evaluation conducted at defined intervals to monitor changes in patient status.
Emergency Assessment — A rapid, prioritized evaluation of airway, breathing, circulation, and level of consciousness in an unstable patient.

Assessment Techniques

Four standard physical assessment techniques are applied in every system evaluation. The order of techniques changes specifically for the abdomen:

Technique	Description	Abdominal Exception
Inspection	Visual examination for color, contour, symmetry, movement, and skin changes	Performed first for all systems
Auscultation	Listening with a stethoscope for bowel sounds, breath sounds, and heart sounds	Performed before palpation/percussion for abdomen to avoid altering bowel sounds
Palpation	Light and deep touch to assess texture, temperature, moisture, tenderness, organ borders	Performed third for the abdomen
Percussion	Tapping over body surfaces to assess underlying tissue density (tympany, dullness, resonance)	Performed after palpation for the abdomen

Health History and General Physical Examination

Components of a Complete Health History

The health history is the primary vehicle for collecting subjective data — information the patient reports. A complete health history includes the following components:

Biographical data: Name, age, gender, occupation, primary language
Chief complaint (CC): The patient’s stated reason for seeking care, in their own words, with onset and duration
History of present illness (HPI): A detailed account of the CC using the OLDCARTS or PQRSTU mnemonic
Past medical/surgical history (PMH/PSH): Diagnoses, hospitalizations, surgeries, obstetric history
Medications: Prescription, over-the-counter, supplements, herbal remedies, including dose and frequency
Allergies: Medication, food, and environmental; include type of reaction
Family history (FH): First-degree relative conditions relevant to hereditary risk (e.g., cardiovascular disease, diabetes, cancer)
Social history (SH): Tobacco, alcohol, substance use; occupation; living situation; support systems; cultural and spiritual preferences
Review of systems (ROS): A systematic inquiry through each body system to identify additional concerns not yet disclosed

OLDCARTS — Symptom Analysis Mnemonic

When a patient reports a symptom, use OLDCARTS to fully characterize it:

Letter	Component	Example Question
O	Onset	”When did it start?”
L	Location	”Where exactly does it hurt?”
D	Duration	”Is it constant or does it come and go?”
C	Character	”Describe the pain — sharp, dull, burning, pressure?”
A	Aggravating/Alleviating factors	”What makes it worse or better?”
R	Radiation	”Does it travel anywhere?”
T	Timing	”Does it happen at a specific time of day?”
S	Severity	”On a scale of 0–10, how severe is it?”

Head-to-Toe Assessment Sequence

A systematic head-to-toe assessment proceeds through the following body regions in order:

General appearance — level of consciousness, grooming, hygiene, posture, nutritional status, apparent distress
Neurological — orientation (person, place, time, event), Glasgow Coma Scale, cranial nerve screening, motor strength, sensory function
Head, Eyes, Ears, Nose, Throat (HEENT) — pupils (PERRLA), sclera, mucous membranes, lymph nodes, tracheal position
Neck — thyroid palpation, carotid pulses, jugular venous distension (JVD)
Respiratory — respiratory rate, depth, pattern, breath sounds bilaterally (anterior and posterior), use of accessory muscles, SpO₂
Cardiovascular — heart rate, rhythm, S1/S2, murmurs, peripheral pulses, capillary refill, edema
Abdomen — contour, bowel sounds (all four quadrants), tenderness, organomegaly
Genitourinary — urine color, output, continence status (as appropriate and per patient consent)
Musculoskeletal — muscle strength (5-point scale), joint range of motion, gait, balance
Skin and Integument — color, temperature, turgor, moisture, integrity, lesions, pressure injury risk

NCLEX-Style Practice Questions:

The nurse is performing an abdominal assessment on a patient who reports new-onset cramping. In which sequence should the nurse apply assessment techniques?
- A) Inspection, palpation, percussion, auscultation
- B) Inspection, auscultation, percussion, palpation ✓
- C) Auscultation, inspection, palpation, percussion
- D) Palpation, inspection, auscultation, percussion
A patient describes chest discomfort as “a pressure that spreads to my left arm and started 30 minutes ago.” This information is best classified as:
- A) Objective data
- B) Subjective data ✓
- C) A nursing diagnosis
- D) An inference requiring no further assessment

Older Adult Assessment: Geriatric Considerations

Older adults undergo predictable physiological changes that alter normal assessment findings and create specific vulnerabilities. BSN nurses must distinguish expected age-related changes from pathological findings to avoid both under-treating disease and over-investigating normal aging.

System	Expected Age-Related Change	Clinical Implication
Cardiovascular	Decreased cardiac reserve; arterial stiffening	Resting BP may be elevated; S4 gallop may be a normal variant
Respiratory	Decreased lung elasticity, vital capacity, and cough reflex	Atypical presentation of pneumonia (confusion, not fever)
Neurological	Decreased reaction time; mild short-term memory decline	Do not confuse with dementia; assess baseline from family
Musculoskeletal	Loss of bone density (osteoporosis); kyphosis; decreased muscle mass	Fall risk increases significantly
Skin	Thinning, reduced elasticity, decreased subcutaneous fat	Skin tears easily; poor turgor is not a reliable dehydration indicator
Renal	Decreased GFR; reduced ability to concentrate urine	Medications may accumulate; polyuria and nocturia more common
Sensory	Presbyopia, presbycusis	Increase font size on materials; face patient directly; reduce ambient noise
Thermoregulation	Decreased ability to sense and generate heat	Baseline temperature may be lower; fever threshold may be 37.2°C (99°F)

The Atypical Presentation Principle

Older adults frequently present with atypical signs and symptoms when acutely ill. The classic triad of fever, pain, and focal signs may be absent or muted. Common atypical presentations include:

Infection (including UTI or pneumonia): New onset confusion or delirium, functional decline, or anorexia rather than fever or localized pain
Myocardial infarction: Shortness of breath, fatigue, or nausea rather than classic crushing chest pain
Abdominal pathology: Mild or absent pain despite serious pathology due to reduced pain sensitivity

Geriatric Assessment Tools

Several validated tools support standardized older adult evaluation:

Mini-Cog™ — Brief 3-item recall + clock drawing for cognitive screening
Get Up and Go Test — Observational fall-risk screening (time to rise, walk 10 feet, return to chair)
Braden Scale — Pressure injury risk (see Personal Hygiene & Skin Integrity module)
SPMSQ (Short Portable Mental Status Questionnaire) — 10-item cognition screen for community-dwelling older adults

NCLEX-Style Practice Question:

A nurse is assessing an 82-year-old patient admitted from a long-term care facility. The patient’s daughter reports that her mother “just isn’t herself” and has been refusing meals for two days. The patient has no complaint of pain or fever. Vital signs: T 37.1°C, HR 96, BP 108/68, RR 18, SpO₂ 94%. Which action should the nurse take first?

A) Reassure the family that confusion is expected in older adults
B) Obtain a urine specimen for urinalysis and culture ✓
C) Administer acetaminophen 650 mg per the PRN order
D) Apply restraints to prevent falls associated with confusion

Vital Signs and Pain Assessment

The Six Vital Signs

Vital signs provide a quantifiable window into physiological stability. Any single vital sign must always be interpreted within the context of the patient’s clinical picture, baseline values, trend over time, and concurrent assessment findings.

Vital Sign	Normal Adult Range	Critical Value (Notify Provider)
Temperature (oral)	36.0–37.5°C (96.8–99.5°F)	> 40°C (104°F) or < 35°C (95°F)
Heart Rate (Pulse)	60–100 bpm	< 40 or > 150 bpm
Blood Pressure	< 120/< 80 mmHg (normal)	SBP < 90 or > 180 mmHg; DBP > 120 mmHg
Respirations	12–20 breaths/min	< 8 or > 30 breaths/min
SpO₂ (Oxygen Saturation)	95–100%	< 90% (or per facility policy)
Pain	0 (no pain) goal	≥ 7/10 unmanaged; sudden change in character

Vital Signs: Measurement Technique

Temperature:

Document the route (oral, axillary, rectal, tympanic, temporal); normal ranges differ by route
Oral: wait 15–30 minutes after hot or cold intake; do not use in patients with oral surgery or altered consciousness
Rectal: most accurate core temperature; contraindicated after rectal surgery or in immunocompromised patients
Tympanic: rapid; may be inaccurate with cerumen impaction or improper probe positioning

Pulse:

Palpate the radial artery using 2–3 fingertips (not the thumb); count for a full 60 seconds if irregular
Assess rate, rhythm (regular vs. irregular), and volume (bounding, weak, thready)
Apical pulse preferred for patients receiving cardiac medications; auscultate at the 5th intercostal space, midclavicular line

Blood Pressure:

Select correct cuff size (bladder length = 80% of upper arm circumference; width = 40%)
Position arm at heart level; patient seated or supine, feet flat, not talking
Inflate 30 mmHg above estimated systolic; deflate at 2 mmHg/second
Orthostatic BP: measure supine then standing; a drop of ≥ 20 mmHg systolic or ≥ 10 mmHg diastolic indicates orthostatic hypotension

Respirations:

Count without patient awareness (patient may consciously alter rate if aware)
Observe for rate, depth (shallow vs. deep), symmetry, and pattern (Cheyne-Stokes, Kussmaul, Biot’s)

SpO₂:

Place probe on a well-perfused finger (or earlobe/forehead as alternate sites)
Remove nail polish or acrylic nails; assess for peripheral vasoconstriction or hypothermia affecting accuracy
Always correlate with clinical assessment — SpO₂ may appear normal in carbon monoxide poisoning

Pain Assessment — The Fifth Vital Sign

Pain is a subjective experience and must be assessed, documented, and managed as a vital sign at every patient encounter. The nurse’s role is to assess pain comprehensively, intervene appropriately, and evaluate the effectiveness of interventions.

Pain Assessment Mnemonics:

PQRSTU:

P — Provokes/Palliates: What makes it worse or better?
Q — Quality: Sharp, dull, burning, aching, stabbing?
R — Region/Radiation: Location and whether it spreads?
S — Severity: 0–10 numeric rating scale
T — Timing: Constant or intermittent? When does it occur?
U — Understanding: What does the patient think is causing it?

Age-Appropriate Pain Scales:

Numeric Rating Scale (NRS) 0–10: Adults who can self-report
FACES Pain Scale (Wong-Baker): Children ≥ 3 years; cognitively impaired adults
FLACC Scale (Face, Legs, Activity, Cry, Consolability): Nonverbal patients, infants, patients under anesthesia
CPOT (Critical-Care Pain Observation Tool): Mechanically ventilated patients