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

Ptosis

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

Edema

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?