Thirteen Areas of Assessment
I. PSYCHOSOCIAL STATUS. This area deals with the
person's roles in relationship to others- family, work
group, health professionals. If the nurse is attempting
to diagnose the problems of a group of persons, this
area would include the social relationships within that
group - patterns of leadership, methods of resolving
conflict. However, beginning practice generally
deals primarily with individuals, and the outline of
data needed will focus only on that need for an
individual.
A. General Social Status
1. Ethnic background
2. Occupation - status or position in that
occupation
3. Economic Status
4. Religious Practices
a. Religious Affiliation
b. Practices of beliefs which might affect
reaction to health care (prescriptions
against immunization or blood transfusion,
dietary laws, beliefs about the cause of
disease)
5. Type of housing accommodation
6. Contacts or previous referrals to social
agencies
B. Family or Peer Group Social Status
1. Position in the family (father, mother, etc.)
2. Others in the family
3. With whom the person lives; whom he or she
considers close if he/she lives alone
4. Marital Status
5. Role in the family (e.g. source of support
during crisis, "black sheep", etc.)
C. Social Development Status
1. Age
2. Sex
3. Marital Status
4. Degree of dependence and independence
(prior to and during health deviation)
5. Diversional and recreational interests
6. Sexuality
a. Level of Sexual Development
b. Attitudes towards own sexuality
c. Reproductive data (Male and Female)
i. Number of children, number of
pregnancies, number of live births (self,
spouse or significant sexual partner)
ii. Attitudes toward contraception;
contraceptive methods if used
iii. Difficulties related to menopause or male
climacterium
d. Reproductive Organs
i. Appearance of genitalia; presence or
absence of lesions; abnormal innervations
ii. Unusual genital discharge
iii. Menstrual pattern, age of menarche
iv. History of disease or surgery affecting
reproductive organs
II. MENTAL AND EMOTIONAL STATUS. These are
considered as one category since one's intellectual
growth bears on reactions to self and others, and
vice versa. There is overlap between the
psychosocial area and the mental-emotional area,
but the student need not waste energy trying to fit a
piece of data precisely into one category. The
important thing is to note the information somewhere.
A. Mental Status
1. Level of consciousness (response to verbal
stimuli, response to noise and light, response
to touch and painful stimuli, spontaneous
activity)
2. Orientation to time, place and person
3. Intellectual development relative to age
4. Mental skills (level of education, ability to
read and write, vocabulary, ability to
comprehend and follow directions, attention
span, memory span, ability to understand
abstraction)
5. Perception and understanding of health
problems and goals of medical and nursing
therapy
6. Beliefs and attitudes about disease
7. Previous experience with and reaction to
illness and hospitalization
B. Emotional Status
1. Affect (general mood and emotional
response)
2. Reactions to stressful situations (includes kinds
of situations persons consider stressful)
3. Patterns of relating to others
4. Special concerns of fear
5. Concept of self -- self-esteem (prior to and in
relation to current health problem, body
image)
6. Substances taken to alter emotional
response (includes prescribed medications ---
tranquilizers, sedatives, mood-elevating
drugs; alcohol; mind expanding drugs,
amphetamines)
III. ENVIRONMENTAL STATUS. Factors in the patient
client’s home, work, or institutional environment are
assessed in several other areas. However, some
factors related to safety, control of infection and
environmental effects upon illness, need to be
assessed in their own right.
A. Safety Factors
1. Age
2. State of mobility
3. Arrangement of objects in physical
environment, other potential safety hazards
4. Sensory deficits
5. Orientation-disorientation to environment
6. Use of restraining devices: bed rails, restraints
7. Use of prosthetic and other supportive
devices: crutches, artificial limbs, mechanical
lifting devices
B. Infection Control
1. Presence of infectious disease or infected
wounds in patient, family, of others proximity
2. Barriers to cross infection (isolation
techniques, hand washing facilities,
distance from infected persons or infectious
persons)
3. Patient and family understanding and
beliefs about transfer of pathogens
4. Equipment potentially harboring pathogens
(isolettes, humidifiers, pulmonary therapy
equipment)
C. Environmental Effects on Illness
1. Patterns of activity, light, noise, color
(varied, steady, excessive, absent)
2. Arrangement of environment in relation to
functional abilities or disabilities (are pictures
and reading materials placed where
bedfast person can see them? Are
implements placed where handicapped
person can reach them?)
IV. SENSORY STATUS. This are refers to the state of
perceiving senses – vision, hearing, smell, taste, touch.
Language perception and information are
categorized here although they are dependent
upon both sensory and motor function.
A. Visual Status
1. Visual acuity (able to distinguish objects at a
specified distance), papillary responses
2. Field of vision (lateral, horizontal, vertical),
extra ocular movements
3. Known deficits (myopia, presbyopia,
astigmatism, color blindness, blindness)
4. Corrective devices
5. Unusual sensations (rainbows around lights,
blind spots, flashing lights)
 B. Auditory Meatus
1. Ability to distinguish voice (distance,
loudness)
2. Known deficits (extent i.e. ear, both ears,
complete, partial)
3. Corrective devices
4. Unusual sensations (ringing, buzzing,
dizziness)
C. Olfactory Status
1. Ability to discriminate odors
2. Unusual sensations (lack of smell,
heightened sensitivity to smell, smelling
odors with no stimulus present)
D. Gustatory Status
1. Ability to discriminate sweet, sour, salt, bitter
2. Unusual sensations (lack of taste, alter taste,
substances taste alike)
E. Tactile Status
1. Ability to discriminate sharp and dull, light
and firm touch
2. Ability to perceive heat, cold, and pain in
proportion to stimulus
3. Ability to differentiate common objects by
touch (stereognosis)
4. Intactness of body image.
5. Aberrant sensation (lack of pain, touch,
heat, cold sensation; increased or
decreased pain in proportion to stimulus; dill
use burning, pricking or pain.
F. Language perception and Formation
1. Intactness of speech organs (mouth, teeth,
tongue, palate, larynx)
2. Deficits in phonation (stammering, lisping,
repetition, jargons, mutism, staccato
speech)
3. Ability to understand, initiate, and imitate
speech
4. Ability to read, write, and copy figures
G. Sensory Environment
1. Intensity
2. Pattern
3. Variety
4. Appropriateness to development level
V. MOTOR STATUS. This area evaluates the ability of the
person’s nervous system to initiate action in relation
to:
A. Medical restrictions on Activity (physician’s
prescription for bed rest, bed rest with restroom
privileges, etc.)
B. Musculoskeletal Status
1. General movement (coordination, ease,
stability)
2. Muscle strength, tone, and mass (all
extremities, trunk and abdomen; symmetry;
prior to and during health problem)
3. Range of motion (all joints, active and
passive motion)
4. Posture
5. Handedness
6. Deformities (intactness of extremities,
prosthetic devices)
7. Abnormal innervations to muscle (paralysis,
weakness)
C. Mobility
1. Method of ambulation (unassisted, with
supportive aids such as cane, crutch,
wheelchair)
2. Gait (mode of walking, coordination,
stability)
3. Endurance (amount of activity tolerated)
VI. NUTRITIONAL STATUS. This area deals not only with
obvious data intake of foods but also with attitudes
towards eating and toward special diets.
A. Dietary Habits
1. Usual eating habits (number and timing of
meals, inclusion of “basic four” categories
of food, preferred foods, excesses)
2. Appetite
3. Changes related to health problem
(appetite changes, special diet prescribed
by physician or by patient client)
4. Person responsible for preparing food at
home
B. Adequacy of diet
1. Height, weight; gain – loss pattern
2. General appearance (obese, normal, thin,
appearance of skin, hair, nails)
C. Attitudes Toward Eating
1. Importance of food to feeling of well-being
2. Religious dietary restrictions
3. Symbolic meaning of food – reward, love,
punishment
D. Factors in Food Ingestion
1. State of teeth (dentures, partially or
complete dentures; disease of teeth and
gums; oral hygiene habits)
2. State of mouth (intactness of mucous
membranes; disorders of salivary glands;
moistness; odor; presence of debris)
3. State of consciousness
4. Ability to swallow
5. Gastrointestinal motility, bowel sounds
E. Digestion
1. Phase of digestion
2. Nausea, vomiting, retching
3. Eructation (belching)
4. Medications affecting digestion and
metabolism of foods
F. Non- oral means of Feeding
1. Parental fluids; hyper alimentation
2. Nasogastric tube, gastronomy
VII. ELIMINATION. This category includes elimination via
the urinary and gastrointestinal tracts.
A. Normal patterns (frequency, amount, color,
consistency of stool)
B. Aids to elimination Normally Used (beverages,
laxatives, position)
C. Changes due to Health Problem
1. Character of urine (color, odor, specific
gravity, unusual constituents)
2. Character of stool (color, odor, specific
gravity, presence of unusual constituents)
D. Method of Eliminating (toilet, commode,
bedpan)
1. Artificial orifices (ileac conduit-urine;
colostomy, ileostomy- bowel)
2. Method of care for excretions from artificial
orifices
E. Special Problems
1. Incontinence (urine, stool; ways of coping)
2. Urinary retention
3. Constipation
4. Diarrhea
5. Abnormal bowel sounds
VIII. FLUIDS AND ELECTROLYTES STATUS. Maintenance of a
balance of body fluids and electrolytes is essential to
homeostasis and to life. Although the physician has
primary responsibility in restoring this balance, nurses’
observations often provide key data for the medical
management. In addition, the nurse may play as
important role in helping to maintain this balance.
A. Normal Patterns of Fluid Intake and Output
1. Ingestion of food fluids (amounts in 24hours,
type preferred)
2. Output (urine, stool, perspiration)
 B. Changes Due to Health Problems (increase or
decrease intake or output)
C. Measurements
1. Oral and parenteral intake (includes type of
solid foods)
2. Output (urine, liquid stool, number of
formed stools, drainage from wounds,
occasionally perspiration and respiratory
loss)
D. Indirect Data
1. State of Fluid Balance
a. Weight
b. Thirst
c. Skin Turgor, dryness
d. Condition of mouth, mucous membranes
(dry, moist, coated, presence of crusts)
e. Edema
f. Blood pressure, lying and standing
2. Venous state (distended, flattened, filling
time)
3. Level of consciousness
4. Depression or elevation of fontanels in
infants
5. Neuromuscular flaccidity or irritability
6. Laboratory values of electrolytes, pH
7. Medical therapy (drugs, parental fluids,
blood)
IX. CIRCULATORY STATUS. These observations give
indirect data about the state of the heart and blood
vessels.
A. Pulse
1. Rate
2. Quality (thread, weak, bounding, strong)
3. Rhythm (regular, irregular, paired beats)
4. Apical-radial differences
5. Response to activity, emotional stress
6. Medications which alter heart rate or
rhythm
B. Heart Sounds
C. Blood Pressure
1. Systolic, diastolic
2. Lying and standing
3. Discrepancies between arms
4. Factors altering accuracy of reading
(obesity, cuff size)
D. General Appearance
1. Color (skin, lips, nails)
2. Evidence of volume depletion or edema
3. Urine output, fluid intake
4. Warmth and color of extremities
5. Undue fatigue after exertion
6. Pains in legs after walking
7. Chest or epigastric pain, precipitating
factors
E. Special Observations. If the patient has acute
cardiac disease and his or her condition is being
specially monitored, the list may also include
data from monitoring devices such as the
character of the electrocardiogram, central
venous pressure, arterial pressure.
X. RESPIRATORY STATUS. The state of the respiratory
function may be assessed both directly and indirectly.
The indirect measurements give some clues to the state
of cellular respiration.
A. Direct Measurements
1. Patency of the airway
2. Respirations
a. Rate, rhythm, depth, ease, use of
accessory muscles
b. Factors altering characters (position,
emotion, cough, humidity, air pollution)
c. Breath sounds
3. Cough
a. Patterns (upon rising, continuous,
random, after smoking)
b. Productive of sputum
c. Character of sputum (color, viscosity,
odor, hemoptysis)
B. Indirect Measurements
1. Smoking History
2. Medications affecting respiratory rate,
patency of bronchial tree
3. Color (skin, lips, nails)
4. Clubbing of nails
5. Posture skeletal defects such as kyphosis
6. Level of consciousness (increase or
decrease)
7. Anxiety or apprehension (diffuse or specific
regarding breathing)
8. Laboratory values (Pao2 Paco2 pH)
C. Supportive Devices
1. Nebulizers, aerosols (patterns of use,
effectiveness)
2. Positive-pressure breathing
3. Tracheotomy
4. Assisted or controlled ventilation with
respiration
XI. TEMPERATURE STATUS
A. Subjective feeling of Warmth and Cold
B. Usual Measure for Temperature Comfort
C. Body Temperature
1. Oral
2. Rectal
3. Axillary
D. Perspiration
1. Presence or absence
2. Pattern (night, day, intermittent)
XII. INTEGUMENTARY STATUS. This area refers to the
condition of the skin and underlying tissues, nails and
hair.
A. Skin Condition
1. Color, turgor
2. Intactness (presence of wounds, incisions,
ulcers, pressure sores, diaper rash)
3. Character of any lesions present (dry,
draining, infected)
4. Areas if ischemia
5. Factors predisposing to skin breakdown
(prolonged pressure, lack of position
change, unprotected bony prominences,
incontinence, age, hyperactivity, self-
destructive tendencies)
B. Condition of Nails and Hair
C. Habits of Personal Hygiene
D.Odors and Excretions (oily, perspiration, abnormal)
XIII. COMFORT AND REST STATUS
A. Sleep
1. Normal sleep patterns (number of hours,
time, feeling of being rested)
2. Alterations due to health problem
3. Aids used for sleep (beverages, warm bath,
medications)
B. Comfort
1. Presence of pain or discomfort (location,
duration, degree, extent, character,
precipitating factors)
2. Use of aids to relieve pain or discomfort
(prior to and during current health problem)
3. Changes in pain or discomfort with current
health problem