L'évaluation clinique (assessment) est la première étape de la démarche de soins. Elle permet de collecter des données objectives et subjectives pour identifier les problèmes de santé, établir des priorités et planifier des interventions. Une évaluation précise et systématique est la base de soins infirmiers sûrs.
- Données subjectives (symptômes) : ce que le patient décrit — douleur, fatigue, nausées ; collectées par l'entretien
- Données objectives (signes) : ce que l'infirmière observe et mesure — signes vitaux, résultats biologiques, aspect clinique
- PQRSTU pour la douleur : Provoque/Pallier, Qualité, Région/Irradiation, Sévérité, Timing/Traitement, Understanding (compréhension du patient)
- Signes vitaux : température, pouls, fréquence respiratoire, pression artérielle, SpO₂, douleur (6ème signe vital)
- Évaluation par systèmes : tête aux pieds (head-to-toe) ou par systèmes — systématique pour ne rien oublier
Health Assessment Foundations
Master the foundations of patient assessment including subjective vs objective data collection, IPPA techniques, systematic head-to-toe assessment, vital signs interpretation, documentation methods, and recognition of critical red flags.
Subjective vs Objective Data
Understanding the two pillars of assessment
Every nursing assessment collects two fundamental types of data. Distinguishing between them is essential for accurate documentation, clinical reasoning, and communication with the healthcare team.
Subjective Data (Symptoms)
Information reported by the patient that cannot be independently verified. Includes chief complaint, history of present illness, pain descriptions, emotional state, cultural beliefs, and past medical/surgical history. Use open-ended questions first ('Tell me about your pain'), then focused questions ('Where exactly does it hurt?'). Document using the patient's own words in quotation marks.
Objective Data (Signs)
Observable, measurable findings obtained through physical examination, vital signs, laboratory results, and diagnostic imaging. Examples: heart rate 102 bpm, 2+ pitting edema bilateral ankles, crackles in bilateral lung bases, WBC 14,200/mm³. Objective data is verifiable by any qualified examiner and forms the basis for clinical decision-making.
Subjective vs Objective Distinction
Subjective data is information reported by the patient, symptoms, feelings, perceptions, and history. Only the patient can provide this data (e.g., 'I feel dizzy,' 'My pain is 7/10'). Objective data is observable, measurable information obtained through examination, diagnostic tests, and direct observation (e.g., BP 148/92, temperature 38.5°C, crackles auscultated in lung bases). The distinction matters because nursing diagnoses and clinical decisions require both types of data to form a complete clinical picture.
IPPA Techniques
Inspection, Palpation, Percussion, Auscultation
IPPA represents the four systematic techniques used in physical examination, always performed in this specific order (except for the abdomen, where auscultation precedes palpation and percussion to avoid altering bowel sounds).
The Four Assessment Techniques
Exception: Abdominal Assessment Order
For the abdomen, the order changes to Inspection → Auscultation → Percussion → Palpation. Auscultation must precede palpation and percussion because touching the abdomen can stimulate or diminish bowel sounds, producing inaccurate findings. This is a commonly tested concept on nursing exams.
Vital Signs Interpretation
The foundation of every patient assessment
Vital signs, temperature, pulse, respirations, blood pressure, and oxygen saturation (the 'fifth vital sign'), provide baseline data and indicate physiological status. Trends in vital signs are more clinically significant than single readings.
Normal Adult Vital Sign Ranges
Orthostatic Vital Signs
Measure BP and HR lying, sitting, and standing (wait 1-3 minutes between position changes). Orthostatic hypotension is defined as a drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg, or an increase in HR ≥20 bpm upon standing. Causes include dehydration, blood loss, medication effects (antihypertensives, diuretics), and autonomic dysfunction. Always ensure patient safety during positional changes.
Head-to-Toe Assessment & Documentation
Systematic approach and accurate recording
A systematic head-to-toe assessment ensures no body system is missed. The standard approach moves cephalocaudal (head to toe) and proximal to distal. Document findings accurately using standardized terminology and approved abbreviations.
Head-to-Toe Assessment Order
1. General survey:Overall appearance, body habitus, hygiene, level of consciousness, gait
2. Neurological:LOC (Glasgow Coma Scale), orientation (person/place/time/situation), pupil response (PERRLA), cranial nerves, sensation, motor strength
3. Head/Face:Skull symmetry, facial expression, TMJ, sinuses
4. Eyes/Ears/Nose/Throat:Visual acuity, hearing, nasal patency, oral mucosa, tonsils
5. Neck:Lymph nodes, thyroid, jugular vein distention (JVD), carotid pulses, tracheal midline
6. Chest/Lungs:Respiratory effort, breath sounds all fields, chest expansion symmetry
7. Cardiovascular:Heart sounds (S1/S2), rhythm, PMI, peripheral pulses, capillary refill, edema
8. Abdomen:Inspect → Auscultate → Percuss → Palpate; bowel sounds, distention, tenderness
9. Musculoskeletal:ROM, strength, gait, joint swelling or deformity
10. Integumentary:Skin color, turgor, moisture, lesions, wound assessment, pressure injury risk
11. Extremities:Pulses, edema, sensation, skin integrity, IV sites
Documentation Methods
SOAP notes organize documentation into Subjective (patient's report), Objective (measurable findings), Assessment (clinical judgment/diagnosis), and Plan (interventions). Focus charting uses DAR: Data (subjective + objective), Action (nursing interventions), and Response (patient outcomes). Narrative charting tells the story chronologically but can be disorganized. Exception-based charting documents only deviations from normal, saving time but risking missed documentation. Always document assessment findings promptly, accurately, and objectively, avoid subjective language like 'patient seems fine.'
Red Flags Requiring Immediate Action
Red flags are assessment findings that require immediate intervention or escalation. Key red flags include: sudden change in level of consciousness (stroke, hypoglycemia, increased ICP), new-onset chest pain with diaphoresis (MI), respiratory distress with SpO2 < 90% (respiratory failure), systolic BP < 90 mmHg (shock), unilateral weakness or speech changes (stroke), rigid/board-like abdomen (peritonitis), and asymmetric pupils (increased ICP, herniation). When you identify a red flag, stop the routine assessment and activate the appropriate emergency response.
Match the Assessment Concept
Terms
Definitions
Health Assessment Quiz
1/20A patient states, 'I feel like my heart is racing.' This is an example of:
Nursing Responsibilities
L'infirmière recueille les données de façon structurée, prioritise selon l'urgence, documente avec précision et objectivité, et transmet les anomalies à l'équipe médicale. Elle utilise des outils validés (échelle de douleur, Glasgow, Braden) et répète les évaluations pour suivre l'évolution. Elle prend en compte le contexte culturel et adapte sa communication.
Clinical Pearls
Les valeurs normales varient selon l'âge — la tachycardie chez un nourrisson (< 100/min est normal jusqu'à 160/min) n'est pas la même que chez l'adulte. Une pression artérielle « normale » pour un patient hypertendu chronique peut être hypotensive pour lui. Documentez toujours les tendances, pas seulement les valeurs isolées — une PA qui chute progressivement de 150/90 à 100/60 sur 2 heures est plus alarmante qu'une valeur unique.
Patient Education
Expliquez aux patients comment surveiller leurs propres signes vitaux à domicile si pertinent (tensiomètre, oxymètre de pouls). Enseignez-leur à décrire leurs symptômes avec précision (localisation, intensité, durée, ce qui aggrave ou soulage) pour faciliter les consultations. Encouragez-les à signaler tout changement nouveau ou inhabituel.
Key Takeaways
- L'évaluation systématique (tête aux pieds) prévient les oublis — établissez une routine et suivez-la
- Documentez les tendances et l'évolution dans le temps, pas seulement les valeurs ponctuelles
- Les données subjectives (symptômes) et objectives (signes) se complètent — ne négligez pas ce que le patient ressent
- Les signes vitaux de base incluent maintenant la douleur comme 6ème signe — évaluez-la systématiquement