April 14, 2019

Sample Nursing Assessment

Each floor is different, with each patient population requiring varying assessments. Below is a general assessment within the adult patient population. This list is for nurses who seek an assessment example, a roadmap of what to look for and evaluate. I used this list when I was an ICU nurse and it really helped me to hit each and every body system in great detail. This list also helped me to effectively communicate my concerns to providers. I never simply stated altered mental status, I went through my focused assessment in order to paint the full picture of this patient's clinical presentation. The goal is for you to get the pertinent information to the providers promptly so you can move on to the other 2,590 things you have to do.

The red text is a reminder to dig deeper if abnormalities are found.

Neurological Assessment

Sedation Level (RASS)
Best Eyes Response
Best Verbal Response
Best Motor Response
Glasgow Contributing Factors
Glasgow Coma Scale Total

Level of Consciousness
Speech Description
Stimulus For Response
Communication Style

Left Eye: Position / Size / Shape / Reaction / Visual Fields / Corneal Reflex
Right Eye: Position / Size / Shape / Reaction / Visual Fields / Corneal Reflex

Extra-Ocular Movements
Consensual Response
Palmer Drift
Tongue Deviation
Facial Droop
Babinski Reflex
Gag Reflex
Cough Reflex

Recent Imaging? Medications? PMHx?

Limb Strength / Movement Assessment

LUE Limb Strength
RUE Limb Strength
LLE Limb Strength
RLE Limb Strength

LUE Limb Movement
RUE Limb Movement
LLE Limb Movement
RLE Limb Movement

Amputations? Paralytics? Medications? PMHx?

Respiratory Assessment

Respiratory Effort
Chest Excursion
Respiratory Pattern
Oxygen Device

Anterior: RUL / RML / RLL / LUL / LLL Breath Sounds
Posterior: RUL / RLL / LUE / LLL Breath Sounds 

Cough Description
Pulmonary Secretions Color
Pulmonary Secretions Amount
Pulmonary Secretions Consistency

Tracheostomy Tube Activity
Tracheostomy Stoma Condition
Tracheostomy Size / Equipment

Incentive Spirometry Use
Incentive Spirometry Measurement
Cough & Deep Breathe Effort

Oxygen Demands? Recent Changes? CXR? PMHx?

Cardiovascular Assessment

Heart Rhythm
Heart Sounds
Skin Color
Skin Temperature
Skin Turgor
Capillary Refill

Pulse Description:
Left Carotid / Radial / Brachial / Femoral / Popliteal / PT / DP
Right Carotid / Radial / Brachial / Femoral / Popliteal / PT / DP

Asymptomatic? Symptomatic? EKG? PMHx?

Gastrointestinal Assessment

Lips / Tongue / Teeth
Buccal / Saliva
Bowel Sounds
Abdomen Description

Feeding Devices / Tubes
Ileostomy / Colostomy

Nutrition / Diet
Passing Flatus
Last Bowel Movement

Recent Imaging? N/V/D? Recent Surgery? PMHx?

Genitourinary Assessment

Voiding Status
Voiding Devices

Bladder Distention
Voiding Difficulties
Urine Color / Characteristics

Bladder Scan Volume? PMHx?

Skin Assessment

Braden Scale / Bed Type
Location / Wound Status
Dressing Change Schedule
Wound Vac Settings

Most Recent Photo? Progression?

Pumps / Drips

Drugs / Indications / Parameters

Compatibility? Side Effects?

Tubes / Drains

Type / Location
Device Assessment
Drainage Description
Drainage Output

Complications? Concerns?

Peripheral / Central Lines

Location / Assessment
Dressing Description
Blood Return / Flushes
Infiltration / Phelbitis

Complications? Concerns?

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