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How a pyramid helps to unravel the stages of nursing assessment

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David Stanley, BSc, MSc, RN, RM, Dip HS; Helen Jones, BA (Hons), MA, RN, PGDE

David-Senior Lecturer in Nursing and Midwifery; Helen-Senior Lecturer in Nursing and Midwifery, University College Worcester, Worcester

The ability to assess clients and patients appropriately and accurately has always been a key part of nurses’ responsibilities. Nurses now face meeting the requirements of the Making a Difference (DoH, 1999) agenda. They will have to cope with the roles extended to them by the decrease in junior doctors’ hours - one of which is that nurses will be involved in patient assessment to a greater level than in the past.

The Scope of Professional Practice (NMC, 2002) indicated that nurses ‘must be satisfied that each aspect of practice is directed to meeting the needs and serving the interests of the patient or client’.

Confusion over defining health assessment

In terms of ‘health assessment’, this can be a problem, as different stages of the process become muddled together. Terms such as ‘holistic assessment’, ‘physical assessment’, ‘nursing assessment’, ‘health screening’ and so on, are often used interchangeably, to explain a range of approaches. But that can lead to confusion.

Anderson (1998) defines ‘nursing assessment’ as ‘identification by the nurse of the needs, preferences and abilities of a patient’.

‘Assessing’ is seen as a category of nursing behaviour that includes gathering, verifying and communicating information related to the client. Assessment of a patient involves collecting and analysing both subjective and objective data (Jackson, 2002; Bowers and Thompson, 1988).

In assessment the examiner evaluates the disease or condition, based on the patient’s subjective report of the symptoms and course of the illness, together with the objective data obtained through laboratory tests, physical examination and medical history (Anderson, 1998). Health assessment has also been described as the first part of the problem-solving method or ‘nursing process’ (Bowers and Thompson, 1988). As such, it forms a funnel for collecting information, which becomes the foundation for decisions and judgements about the most appropriate care and nursing interventions. Appropriate, safe and relevant patient care depends on skilful and relevant assessment. If you are not assessing you are guessing and, frankly, patient care and nursing interventions are too important to do that.

The health assessment pyramid

This paper’s lead author, David Stanley, a senior lecturer on health assessment to pre- and post-registration nurses at University College Worcester, felt it was necessary to find a way of regrouping and organising the terms around health assessment. He developed the health assessment pyramid (Figure 1) to enable this to happen. A clearer understanding of assessment activities allows for judicious curriculum planning and places the principles of assessment within an appropriate and tiered context. The pyramid graphically displays the inter-relationship between various elements of health assessment.

The pyramid represents the need to have core holistic skills - at the bottom of the figure - before proceeding to others. For example, a nurse assessing a cardiac patient may be concerned with the physical symptoms, but other elements can be just as important - such as finding out that the patient is worried about a pet who has been left at home while they are in hospital. The pre-registration sessions tend to focus more on the holistic side of assessment, while the more advanced students focus more on the physical assessment skills; with even more advanced students going into more depth on specific assessments. But the pyramid is always the starting point.

The pyramid structure:

- Holistic assessment At the pyramid’s base are the factors that contribute towards holistic assessment. Higgleton et al (1999) define holism as a consideration of a whole, taking into account social, physical and psychological factors that impact on and relate to the person’s health and well-being, such as their living environment, family history, general appearance, and psychosocial history. The holistic assessment represents factors that will inform other aspects of the patient’s assessment. It is relevant to all levels of the pyramid.

Interview and communication strategies and a sound knowledge of holism are fundamental to any assessment activity.

A pre-operative assessment, for example, depends on the nurse’s insight into risk-assessment tools and the patient’s medical or surgical condition. But it will also rest on the nurse’s ability to consider the patient as a person and look at their psychosocial history and lifestyle, relying on communication and physical assessment skills.

- Physical assessment The second significant part of the pyramid is the physical assessment skills, covering each body system and various stages of the life span. This includes skills related to observation, inspection, auscultation, percussion, palpation and so on.

Engaging with physical assessment requires the student/clinician to have a firm grasp of the elements of holistic assessment as well as of anatomy, physiology and pathophysiology.

- Special/specific assessment The next part of the pyramid considers specialist or specific assessments, such as deep vein thrombosis (DVT), nutritional or wound assessments.

For this, practitioners need a grasp of holistic assessment as well as pathophysiology and the various body systems.

- Health screening The point of the pyramid relates to the community as a whole rather than the individual. Procedures that assess the state of a community’s health include breast and cervical screening for cancer, or hearing and Guthrie tests in young children and babies. This part of the pyramid may draw on issues of public health, health promotion and disease prevention.


The health assessment pyramid provides a framework for educators and students of health assessment to conceptualise aspects of health assessment relating to individuals and the community. It can highlight the relationships between holistic, physical and specific or specialist types of assessment and draw them together.

The pyramid is helpful in planning the pre- and post-registration curriculum and in allowing students and nursing lecturers to see where the sessions on health assessment are going and where they have been. It provides students with a map as they plot the course of their learning.

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