Comprehensive Nursing Assessment

A comprehensive nursing assessment gives the nurse a current, usable picture of the patient's condition. Begin by confirming identity, immediate safety, reason for care, and baseline status; then obtain subjective history and perform an organized objective assessment. When a threat is present, airway, breathing, circulation, mental status, and major bleeding take precedence over completing a routine head-to-toe assessment. Compare new findings with prior data, interpret clusters and trends, and turn abnormalities into a clear report. Document relevant patient statements, measurable findings, the time of assessment, actions taken, response, and notification. For a US LVN/LPN, state law, facility policy, assignment, and individual competence determine which assessment activities and interventions may be performed.