Comprehensive Nursing Assessment

A comprehensive health assessment builds a clinically useful picture from the client's story, direct observations, measurements, physical examination, functional abilities, psychosocial situation, and relevant environment. It establishes a baseline against which later findings can be compared. It also reveals change: a new symptom, a subtle decline in function, or a trend in vital signs may be more meaningful than any single abnormal value. “Comprehensive” does not mean asking every question before responding to danger. Priority changes with the client's condition. Airway obstruction, severe breathing difficulty, shock, acute neurological change, or altered level of consciousness takes precedence over completing a routine head-to-toe sequence. The nurse stabilizes what can be addressed immediately, obtains help, and returns to the broader assessment when the immediate threat is being managed. In Ontario the designation is registered practical nurse (RPN); in British Columbia it is licensed practical nurse (LPN). In either setting, autonomous assessment depends on the client's health state and the nurse's competence. A stable or predictable client may be assessed autonomously without a client-specific order when the nurse has the required knowledge and skill....