Pathophysiology
Clinical meaning
Comprehensive nursing assessment is the systematic, evidence-based process of collecting subjective and objective data about a patient's health status to identify actual and potential problems, establish baselines, and guide clinical decision-making. For the registered nurse, assessment is the first step of the nursing process and represents the foundation upon which all subsequent planning, implementation, and evaluation of care is built. Unlike task-focused vital sign collection, RN-level assessment requires integration of anatomical knowledge, pathophysiology, pharmacology, and clinical reasoning to detect subtle changes that may signal clinical deterioration. The health history (subjective data) begins with the chief complaint documented in the patient's own words and explored using a standardized framework such as OLDCARTS (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity) or PQRSTU (Provocation, Quality, Region/Radiation, Severity, Timing, Understanding). The history must capture past medical history, surgical history, medications (including over-the-counter and herbal supplements), allergies (with specific reaction type documented, distinguishing true allergy from intolerance), family history (first-degree relatives for genetic risk), social history (tobacco, alcohol, substance use quantified in pack-years and drinks per week; living situation, support systems, occupation,...