Introduction to Patient Assessment
Fundamental concepts, steps, and tools for gathering reliable clinical information.
1. Purpose of Patient Assessment
- Identify health status – baseline and changes over time.
- Detect problems early – prevent complications and guide interventions.
- Prioritize care – determine urgency and allocate resources.
- Document baseline – essential for legal, ethical, and continuity‑of‑care reasons.
- Evaluate outcomes – measure effectiveness of treatment plans.
2. Core Components (The “ABCDE” Framework)
| Component |
What It Covers |
Key Observations |
| A – Airway |
Patency, obstruction risk |
Voice quality, coughing, stridor, gag reflex |
| B – Breathing |
Respiratory rate, effort, oxygenation |
Chest expansion, use of accessory muscles, auscultation findings, SpO₂ |
| C – Circulation |
Heart rate, rhythm, perfusion, blood pressure |
Skin color/temperature, capillary refill, pulses, blood pressure, ECG |
| D – Disability (Neurologic) |
Level of consciousness, neurologic function |
AVPU scale, Glasgow Coma Scale, pupil size/reactivity, motor response |
| E – Exposure/Environment |
Full body inspection, temperature regulation, privacy |
Skin integrity, rashes, wounds, ambient temperature, patient comfort |
Note: In many settings the assessment expands to F – Family/social history, G – Goals of care, etc., but the ABCDE model remains the rapid bedside foundation.
3. Systematic Assessment Process
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Preparation
- Verify patient identity (name, DOB, MRN).
- Review reason for visit, medical record, and any recent labs/imaging.
- Gather necessary equipment (stethoscope, BP cuff, pulse oximeter, thermometer).
- Ensure privacy, introduce yourself, explain the process, obtain consent.
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Data Collection
- Subjective Data – patient’s own report.
- Chief complaint (CC) in the patient’s own words.
- History of present illness (HPI): onset, location, duration, character, aggravating/relieving factors, timing, severity (OLDCART).
- Review of systems (ROS) – pertinent positives/negatives.
- Past medical, surgical, medication, allergy, family, and social histories (PMHx, PSHx, Meds, Allergies, FHx, SHx).
- Objective Data – clinician’s observations and measurements.
- Vital signs (BP, HR, RR, Temp, SpO₂, pain score).
- Physical exam (inspection, palpation, percussion, auscultation) organized by systems.
- Diagnostic results available at the time (labs, imaging, ECG).
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Analysis & Synthesis
- Compare findings to normal values and to the patient’s baseline.
- Identify pertinent positives (abnormal findings that explain the problem) and pertinent negatives (expected findings that are absent).
- Generate a prioritized list of problems/diagnoses (e.g., “1. Acute dyspnea – possible COPD exacerbation; 2. Hypertension – uncontrolled”).
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Planning
- Set SMART goals (Specific, Measurable, Achievable, Relevant, Time‑bound).
- Choose interventions (pharmacologic, non‑pharmacologic, diagnostic, referrals).
- Determine need for immediate actions (e.g., oxygen,