Nursing Assessment Mastery Guide: Subjective & Objective Data, Emergency
Assessment, Focused & Comprehensive Evaluation, ABCs, Pain Management,
Vital Signs, Physical Examination, Health History, Patient Interviewing, Open &
Closed Questions, Communication Process, Cultural Competence, Heritage &
Spiritual Assessment, Functional Assessment, COLDSPA Pain Analysis,
Inspection, Palpation, Percussion, Auscultation, Orthostatic Blood Pressure, BMI,
Temperature, Pulse, Respiration, Blood Pressure Interpretation, Skin & Vascular
Lesions, Clubbing, ABCDE Skin Self-Assessment, Clinical Judgment, Nursing
Process ADPIE, Evidence-Based Practice, Patient Safety, Geriatric to Pediatric
Care, Professional Documentation & Critical Thinking Exam Questions Verified
and Provided with Complete A+ Graded Rationales Latest Updated 2026
Subjective Data
what the patient tells you (examples: "I have a fever", "My ankle hurts").
Objective Data
What you can see, hear, or feel (examples: Temperature is 102.1 OR ankle is red and swollen)
Emergency Assessment
This is an urgent, rapid collection of crucial information gathered for treating patients with life
threatening injuries. (ABC's-Airway, Breathing, Circulation)
,Focused Assessment
Detailed nursing assessment of a specific body system, problem, and/or concern of the patient.
(ex. pain in abdomen)
Comprehensive Assesment
This assessment includes a complete patient history, general appearance, physical examination
and vital signs of new patients.
1st Level (Red Light)
emergent, life threatening, & immediate such as establishing an airway or supporting breathing.
2nd Level (Yellow Light)
next in urgency- those requiring prompt intervention to prevent further deterioration (acute
pain, mental status change, abnormal lab values)
3rd Level (Green Light)
Important to the patient's health but can be addressed after more urgent health problems.
Interventions to treat problem are more long term and response to treatment may take more
time (ex. problems with lack of knowledge, rest, family coping..see pg. 5 in textbook).
Describe the purpose of health assessment
Gather information about the patient
Analyze and synthesize data collected
, Make judgements about nursing interventions
Evaluate patient outcomes
Primary Data Source
information that comes from the patient
Secondary Data Source
All other sources of information (ex. spouse, parent, health professional, medical record.)
Complete Total Health Database
Includes complete health history, full physical examination, & describes the current and past
medical history. This is used for new patients.
Problem Centered Database
Limited to short term problems. It includes a mini database, a focus database that consists of
one problem or body system, and it includes a focused assessment based on that problem. (ex.
An urgent care visit for a small burn)
Follow Up Database
Status of all identified problems are evaluated. The nurse notes any changes so they can better
evaluate if problem is getting better or worse. (ex. Follow up appointment a week after surgery)
Assessment, Focused & Comprehensive Evaluation, ABCs, Pain Management,
Vital Signs, Physical Examination, Health History, Patient Interviewing, Open &
Closed Questions, Communication Process, Cultural Competence, Heritage &
Spiritual Assessment, Functional Assessment, COLDSPA Pain Analysis,
Inspection, Palpation, Percussion, Auscultation, Orthostatic Blood Pressure, BMI,
Temperature, Pulse, Respiration, Blood Pressure Interpretation, Skin & Vascular
Lesions, Clubbing, ABCDE Skin Self-Assessment, Clinical Judgment, Nursing
Process ADPIE, Evidence-Based Practice, Patient Safety, Geriatric to Pediatric
Care, Professional Documentation & Critical Thinking Exam Questions Verified
and Provided with Complete A+ Graded Rationales Latest Updated 2026
Subjective Data
what the patient tells you (examples: "I have a fever", "My ankle hurts").
Objective Data
What you can see, hear, or feel (examples: Temperature is 102.1 OR ankle is red and swollen)
Emergency Assessment
This is an urgent, rapid collection of crucial information gathered for treating patients with life
threatening injuries. (ABC's-Airway, Breathing, Circulation)
,Focused Assessment
Detailed nursing assessment of a specific body system, problem, and/or concern of the patient.
(ex. pain in abdomen)
Comprehensive Assesment
This assessment includes a complete patient history, general appearance, physical examination
and vital signs of new patients.
1st Level (Red Light)
emergent, life threatening, & immediate such as establishing an airway or supporting breathing.
2nd Level (Yellow Light)
next in urgency- those requiring prompt intervention to prevent further deterioration (acute
pain, mental status change, abnormal lab values)
3rd Level (Green Light)
Important to the patient's health but can be addressed after more urgent health problems.
Interventions to treat problem are more long term and response to treatment may take more
time (ex. problems with lack of knowledge, rest, family coping..see pg. 5 in textbook).
Describe the purpose of health assessment
Gather information about the patient
Analyze and synthesize data collected
, Make judgements about nursing interventions
Evaluate patient outcomes
Primary Data Source
information that comes from the patient
Secondary Data Source
All other sources of information (ex. spouse, parent, health professional, medical record.)
Complete Total Health Database
Includes complete health history, full physical examination, & describes the current and past
medical history. This is used for new patients.
Problem Centered Database
Limited to short term problems. It includes a mini database, a focus database that consists of
one problem or body system, and it includes a focused assessment based on that problem. (ex.
An urgent care visit for a small burn)
Follow Up Database
Status of all identified problems are evaluated. The nurse notes any changes so they can better
evaluate if problem is getting better or worse. (ex. Follow up appointment a week after surgery)
