Assess and Evaluate · 3 min read
Physical and Psychosocial Assessment
Focused Assessment in Brief Encounters
Ambulatory assessment is targeted to the presenting concern and the patient's known conditions. A complete head-to-toe examination is rarely needed; instead, the nurse gathers a focused history, measures vital signs, examines the relevant systems, and screens for risks the visit type calls for. Pertinent negatives are documented as carefully as abnormal findings.
Vital Sign Standards
| Category | Systolic (mm Hg) | Diastolic (mm Hg) | |
|---|---|---|---|
| Normal | <120 | and | <80 |
| Elevated | 120–129 | and | <80 |
| Stage 1 hypertension | 130–139 | or | 80–89 |
| Stage 2 hypertension | ≥140 | or | ≥90 |
| Severe hypertension | >180 | and/or | >120 |
Severe hypertension with new or worsening target-organ damage (chest pain, dyspnea, neurologic deficit, vision change) is a hypertensive emergency requiring immediate emergency care. Accurate measurement requires the patient seated with back supported, feet flat, arm supported at heart level, the correct cuff size (bladder encircling 80% of the arm), no talking, and 5 minutes of rest. A cuff that is too small produces a falsely high reading.
| Measure | Typical adult reference |
|---|---|
| Heart rate | 60–100 beats/min |
| Respiratory rate | 12–20 breaths/min |
| Oxygen saturation (SpO2) | ≥95% in most adults; many patients with COPD have a prescribed target of 88–92% |
| Temperature | Fever generally ≥100.4°F (38°C) |
| Body mass index | Overweight 25–29.9; obesity ≥30 kg/m² |
Validated Screening Tools
| Tool | Purpose | Key interpretation |
|---|---|---|
| PHQ-2 / PHQ-9 | Depression screening and severity | PHQ-2 ≥3 prompts a PHQ-9; PHQ-9 scores 5, 10, 15, 20 = mild, moderate, moderately severe, severe. Any positive answer on item 9 (self-harm thoughts) requires same-day safety assessment |
| GAD-7 | Anxiety screening | Scores 5, 10, 15 = mild, moderate, severe; ≥10 warrants further evaluation |
| AUDIT-C | Unhealthy alcohol use | Positive at ≥4 for men and ≥3 for women |
| Mini-Cog | Cognitive impairment screening | Three-word recall plus clock draw; a low score prompts full evaluation |
| Timed Up and Go (TUG) | Fall risk (CDC STEADI) | ≥12 seconds indicates increased fall risk |
| Katz ADL / Lawton IADL | Functional status | Identify needs for assistance, home services, or caregiver support |
| Social needs screening | Food, housing, transportation, utilities, safety | Positive screens prompt referral to community resources |
Psychosocial Assessment
Psychosocial assessment explores mood, anxiety, substance use, cognition, coping, social support, caregiver strain, safety at home, health literacy, and the social determinants of health. Intimate partner violence and elder mistreatment screening is conducted privately, without partners or family members present. Suspected abuse of a child or vulnerable adult triggers the mandatory reporting duties described in Chapter 14.
When a patient discloses suicidal thoughts, the nurse stays with the patient (or keeps a telephone caller on the line), asks directly about plan, intent, and access to means, and escalates immediately according to protocol. Asking directly about suicide does not increase risk.
Pain Assessment
Pain is assessed for location, quality, intensity, onset, duration, aggravating and relieving factors, and effect on function. Use a numeric scale for most adults, a faces scale for children and some adults with limited literacy, and behavioral tools for patients with advanced dementia. Reassess after interventions to evaluate response.
- Use the correct cuff size and technique; errors in measurement drive treatment errors.
- Severe hypertension plus new symptoms of organ damage is an emergency.
- A positive PHQ-9 item 9 requires same-day safety assessment.
- Screen for violence privately, with the patient alone.
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