, Jensen’s Nursing Health Assessment:
Complete 30-Chapter Summaries & Quick
Revision Guide
Based on Jensen 4th Edition - A Clinical Judgment Approach
This guide provides comprehensive chapter summaries, key definitions,
clinical tips, assessment tables, and memory shortcuts for all 30 chapters of
Nursing Health Assessment: A Clinical Judgment Approach, 4th Edition by
Sharon Jensen.
Unit 1: Foundations of Nursing Health Assessment
Chapter 1: The Nurse’s Role in Health Assessment
Key Definitions
• Health Assessment: A systematic method of collecting and analyzing
data for the purpose of planning patient-centered care.
• Clinical Judgment: The outcome of critical thinking and decision-making
in nursing practice.
Clinical Tips
• Always introduce yourself and explain the purpose of the assessment to
the patient.
• Maintain a professional yet empathetic demeanor to build trust.
,Key Points
• The nursing process (ADPIE) is the foundation of health assessment.
• Assessment is an ongoing, dynamic process.
Chapter 2: Health History and Interview
Key Definitions
• Subjective Data: Information provided by the patient (e.g., symptoms,
feelings).
• Objective Data: Observable and measurable data obtained through
physical examination and testing.
Clinical Tips
• Use open-ended questions to encourage the patient to share more
information.
• Pay attention to non-verbal cues, such as body language and eye contact.
Key Points
• The health history provides the context for the physical examination.
• Effective communication is key to a successful interview.
Chapter 3: Assessment Techniques, Safety, and Infection Control
Key Definitions
• Inspection: The process of performing deliberate, purposeful
observations in a systematic manner.
• Palpation: The use of the sense of touch to assess skin temperature,
turgor, texture, and moisture, as well as vibrations within the body.
,Clinical Tips
• Always perform hand hygiene before and after patient contact.
• Use the correct sequence of assessment: Inspection, Palpation, Percussion,
Auscultation (except for the abdomen).
Key Points
• Standard precautions apply to all patients.
• Proper technique is essential for accurate assessment.
Chapter 4: Documentation and Interprofessional Communication
Key Definitions
• Electronic Health Record (EHR): A digital version of a patient’s paper
chart.
• SBAR: A structured communication technique (Situation, Background,
Assessment, Recommendation).
Clinical Tips
• Document assessment findings promptly and accurately.
• Use objective language and avoid personal opinions in documentation.
Key Points
• Documentation is a legal record of care.
• Effective communication among the healthcare team is vital for patient
safety.
Assessment Tables
Normal vs. Abnormal Findings: General Survey
,Finding Normal Abnormal
Appearance Well-groomed, appropriate Disheveled, inappropriate for
for age/weather age/weather
Behavior Cooperative, appropriate for Agitated, lethargic,
situation inappropriate for situation
Mobility Steady gait, smooth Unsteady gait, tremors, limited
movements range of motion
Memory Shortcuts
• ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation
• PQRSTU: Provocative/Palliative, Quality, Region/Radiation, Severity,
Timing, Understanding
• SBAR: Situation, Background, Assessment, Recommendation
Unit 2: General Examinations
Chapter 5: Vital Signs and General Survey
Key Definitions
• General Survey: An initial observation of the patient’s overall
appearance, behavior, and mobility.
• Vital Signs: Measurements of temperature, pulse, respiration, and blood
pressure.
Clinical Tips
• Ensure the patient is at rest before taking vital signs.
,• Use the correct cuff size for blood pressure measurement to avoid
inaccurate readings.
Key Points
• Vital signs are critical indicators of a patient’s physiological status.
• The general survey provides a ‘first impression’ of the patient’s health.
Chapter 6: Pain Assessment
Key Definitions
• Acute Pain: Pain that is sudden in onset and usually subsides when
treated.
• Chronic Pain: Pain that lasts for 6 months or longer and may be
intermittent or continuous.
Clinical Tips
• Pain is whatever the patient says it is.
• Use a standardized pain scale appropriate for the patient’s age and
cognitive status.
Key Points
• Pain is the ‘fifth vital sign’.
• A comprehensive pain assessment includes location, intensity, quality, and
duration.
Chapter 7: Nutrition Assessment
Key Definitions
• Body Mass Index (BMI): A measure of body fat based on height and
weight.
,• Nutritional Screening: A process to identify individuals who are
malnourished or at risk for malnutrition.
Clinical Tips
• Assess for signs of nutritional deficiencies, such as brittle hair or dry skin.
• Incorporate cultural preferences into nutritional counseling.
Key Points
• Nutrition is essential for health and healing.
• A thorough nutrition assessment includes dietary history and physical
examination.
Chapter 8: Assessment of Developmental Stages
Key Definitions
• Development: The process of growth and change that occurs throughout
the lifespan.
• Developmental Milestones: Key skills or behaviors that most children
can do by a certain age.
Clinical Tips
• Use age-appropriate communication and assessment techniques.
• Involve parents or caregivers in the assessment of children.
Key Points
• Developmental assessment is crucial for identifying delays or issues.
• Nurses must understand the normal stages of development across the
lifespan.
,Chapter 9: Mental Health, Violence, and Substance Use Disorder
Key Definitions
• Mental Status Examination: A systematic assessment of a patient’s
cognitive and emotional functioning.
• Substance Use Disorder: A disease that affects a person’s brain and
behavior and leads to an inability to control the use of a legal or illegal
drug or medication.
Clinical Tips
• Screen all patients for signs of violence or abuse.
• Approach mental health assessments with sensitivity and without
judgment.
Key Points
• Mental health is an integral part of overall health.
• Early identification of substance use or violence can lead to life-saving
interventions.
Chapter 10: Cultural Assessment
Key Definitions
• Culture: The shared beliefs, values, and practices of a group of people.
• Cultural Competence: The ability of healthcare providers to deliver
services that are respectful of and responsive to the health beliefs,
practices, and cultural and linguistic needs of diverse patients.
Clinical Tips
• Avoid making assumptions based on a patient’s cultural background.
,• Use a professional interpreter when a language barrier exists.
Key Points
• Cultural assessment is essential for providing patient-centered care.
• Nurses must be aware of their own cultural biases.
Assessment Tables
Normal vs. Abnormal Findings: Vital Signs
Vital Sign Normal Range Abnormal Findings
Temperature 36.5°C - 37.5°C Fever (>38°C), Hypothermia (<35°C)
(97.7°F - 99.5°F)
Pulse 60 - 100 bpm Tachycardia (>100 bpm), Bradycardia
(<60 bpm)
Respiration 12 - 20 breaths/min Tachypnea (>20 breaths/min),
Bradypnea (<12 breaths/min)
Blood 120/80 mmHg Hypertension (>140/90 mmHg),
Pressure Hypotension (<90/60 mmHg)
Memory Shortcuts
• SAMPLE: Signs/Symptoms, Allergies, Medications, Past Medical History,
Last Oral Intake, Events Leading Up To
• BMI: Body Mass Index (Weight in kg / Height in m^2)
, Unit 3: Regional Examinations
Chapter 11: Skin, Hair, and Nails
Key Definitions
• Cyanosis: A bluish discoloration of the skin resulting from poor
circulation or inadequate oxygenation of the blood.
• Jaundice: A yellowing of the skin and the whites of the eyes caused by an
accumulation of bile pigment (bilirubin) in the blood.
Clinical Tips
• Assess skin turgor over the clavicle in older adults.
• Use the ABCDE rule for assessing moles (Asymmetry, Border, Color,
Diameter, Evolving).
Key Points
• The skin is the body’s largest organ and a key indicator of overall health.
• Assessment includes inspection and palpation of skin, hair, and nails.
Chapter 12: Head and Neck, with Vision and Hearing Basics
Key Definitions
• Lymphadenopathy: Enlargement of the lymph nodes.
• Visual Acuity: The sharpness of vision, measured by the ability to discern
letters or numbers at a given distance according to a fixed standard.
Clinical Tips
• Palpate lymph nodes using a gentle, circular motion with the finger pads.
• Assess for tracheal deviation, which can indicate a serious underlying
condition.
Complete 30-Chapter Summaries & Quick
Revision Guide
Based on Jensen 4th Edition - A Clinical Judgment Approach
This guide provides comprehensive chapter summaries, key definitions,
clinical tips, assessment tables, and memory shortcuts for all 30 chapters of
Nursing Health Assessment: A Clinical Judgment Approach, 4th Edition by
Sharon Jensen.
Unit 1: Foundations of Nursing Health Assessment
Chapter 1: The Nurse’s Role in Health Assessment
Key Definitions
• Health Assessment: A systematic method of collecting and analyzing
data for the purpose of planning patient-centered care.
• Clinical Judgment: The outcome of critical thinking and decision-making
in nursing practice.
Clinical Tips
• Always introduce yourself and explain the purpose of the assessment to
the patient.
• Maintain a professional yet empathetic demeanor to build trust.
,Key Points
• The nursing process (ADPIE) is the foundation of health assessment.
• Assessment is an ongoing, dynamic process.
Chapter 2: Health History and Interview
Key Definitions
• Subjective Data: Information provided by the patient (e.g., symptoms,
feelings).
• Objective Data: Observable and measurable data obtained through
physical examination and testing.
Clinical Tips
• Use open-ended questions to encourage the patient to share more
information.
• Pay attention to non-verbal cues, such as body language and eye contact.
Key Points
• The health history provides the context for the physical examination.
• Effective communication is key to a successful interview.
Chapter 3: Assessment Techniques, Safety, and Infection Control
Key Definitions
• Inspection: The process of performing deliberate, purposeful
observations in a systematic manner.
• Palpation: The use of the sense of touch to assess skin temperature,
turgor, texture, and moisture, as well as vibrations within the body.
,Clinical Tips
• Always perform hand hygiene before and after patient contact.
• Use the correct sequence of assessment: Inspection, Palpation, Percussion,
Auscultation (except for the abdomen).
Key Points
• Standard precautions apply to all patients.
• Proper technique is essential for accurate assessment.
Chapter 4: Documentation and Interprofessional Communication
Key Definitions
• Electronic Health Record (EHR): A digital version of a patient’s paper
chart.
• SBAR: A structured communication technique (Situation, Background,
Assessment, Recommendation).
Clinical Tips
• Document assessment findings promptly and accurately.
• Use objective language and avoid personal opinions in documentation.
Key Points
• Documentation is a legal record of care.
• Effective communication among the healthcare team is vital for patient
safety.
Assessment Tables
Normal vs. Abnormal Findings: General Survey
,Finding Normal Abnormal
Appearance Well-groomed, appropriate Disheveled, inappropriate for
for age/weather age/weather
Behavior Cooperative, appropriate for Agitated, lethargic,
situation inappropriate for situation
Mobility Steady gait, smooth Unsteady gait, tremors, limited
movements range of motion
Memory Shortcuts
• ADPIE: Assessment, Diagnosis, Planning, Implementation, Evaluation
• PQRSTU: Provocative/Palliative, Quality, Region/Radiation, Severity,
Timing, Understanding
• SBAR: Situation, Background, Assessment, Recommendation
Unit 2: General Examinations
Chapter 5: Vital Signs and General Survey
Key Definitions
• General Survey: An initial observation of the patient’s overall
appearance, behavior, and mobility.
• Vital Signs: Measurements of temperature, pulse, respiration, and blood
pressure.
Clinical Tips
• Ensure the patient is at rest before taking vital signs.
,• Use the correct cuff size for blood pressure measurement to avoid
inaccurate readings.
Key Points
• Vital signs are critical indicators of a patient’s physiological status.
• The general survey provides a ‘first impression’ of the patient’s health.
Chapter 6: Pain Assessment
Key Definitions
• Acute Pain: Pain that is sudden in onset and usually subsides when
treated.
• Chronic Pain: Pain that lasts for 6 months or longer and may be
intermittent or continuous.
Clinical Tips
• Pain is whatever the patient says it is.
• Use a standardized pain scale appropriate for the patient’s age and
cognitive status.
Key Points
• Pain is the ‘fifth vital sign’.
• A comprehensive pain assessment includes location, intensity, quality, and
duration.
Chapter 7: Nutrition Assessment
Key Definitions
• Body Mass Index (BMI): A measure of body fat based on height and
weight.
,• Nutritional Screening: A process to identify individuals who are
malnourished or at risk for malnutrition.
Clinical Tips
• Assess for signs of nutritional deficiencies, such as brittle hair or dry skin.
• Incorporate cultural preferences into nutritional counseling.
Key Points
• Nutrition is essential for health and healing.
• A thorough nutrition assessment includes dietary history and physical
examination.
Chapter 8: Assessment of Developmental Stages
Key Definitions
• Development: The process of growth and change that occurs throughout
the lifespan.
• Developmental Milestones: Key skills or behaviors that most children
can do by a certain age.
Clinical Tips
• Use age-appropriate communication and assessment techniques.
• Involve parents or caregivers in the assessment of children.
Key Points
• Developmental assessment is crucial for identifying delays or issues.
• Nurses must understand the normal stages of development across the
lifespan.
,Chapter 9: Mental Health, Violence, and Substance Use Disorder
Key Definitions
• Mental Status Examination: A systematic assessment of a patient’s
cognitive and emotional functioning.
• Substance Use Disorder: A disease that affects a person’s brain and
behavior and leads to an inability to control the use of a legal or illegal
drug or medication.
Clinical Tips
• Screen all patients for signs of violence or abuse.
• Approach mental health assessments with sensitivity and without
judgment.
Key Points
• Mental health is an integral part of overall health.
• Early identification of substance use or violence can lead to life-saving
interventions.
Chapter 10: Cultural Assessment
Key Definitions
• Culture: The shared beliefs, values, and practices of a group of people.
• Cultural Competence: The ability of healthcare providers to deliver
services that are respectful of and responsive to the health beliefs,
practices, and cultural and linguistic needs of diverse patients.
Clinical Tips
• Avoid making assumptions based on a patient’s cultural background.
,• Use a professional interpreter when a language barrier exists.
Key Points
• Cultural assessment is essential for providing patient-centered care.
• Nurses must be aware of their own cultural biases.
Assessment Tables
Normal vs. Abnormal Findings: Vital Signs
Vital Sign Normal Range Abnormal Findings
Temperature 36.5°C - 37.5°C Fever (>38°C), Hypothermia (<35°C)
(97.7°F - 99.5°F)
Pulse 60 - 100 bpm Tachycardia (>100 bpm), Bradycardia
(<60 bpm)
Respiration 12 - 20 breaths/min Tachypnea (>20 breaths/min),
Bradypnea (<12 breaths/min)
Blood 120/80 mmHg Hypertension (>140/90 mmHg),
Pressure Hypotension (<90/60 mmHg)
Memory Shortcuts
• SAMPLE: Signs/Symptoms, Allergies, Medications, Past Medical History,
Last Oral Intake, Events Leading Up To
• BMI: Body Mass Index (Weight in kg / Height in m^2)
, Unit 3: Regional Examinations
Chapter 11: Skin, Hair, and Nails
Key Definitions
• Cyanosis: A bluish discoloration of the skin resulting from poor
circulation or inadequate oxygenation of the blood.
• Jaundice: A yellowing of the skin and the whites of the eyes caused by an
accumulation of bile pigment (bilirubin) in the blood.
Clinical Tips
• Assess skin turgor over the clavicle in older adults.
• Use the ABCDE rule for assessing moles (Asymmetry, Border, Color,
Diameter, Evolving).
Key Points
• The skin is the body’s largest organ and a key indicator of overall health.
• Assessment includes inspection and palpation of skin, hair, and nails.
Chapter 12: Head and Neck, with Vision and Hearing Basics
Key Definitions
• Lymphadenopathy: Enlargement of the lymph nodes.
• Visual Acuity: The sharpness of vision, measured by the ability to discern
letters or numbers at a given distance according to a fixed standard.
Clinical Tips
• Palpate lymph nodes using a gentle, circular motion with the finger pads.
• Assess for tracheal deviation, which can indicate a serious underlying
condition.
