Nursing Assessment
1.What
are the 12 Areas of your Assessment?
Intro
Gait/Speech
Skin
Vitals
Face
Eyes/Mouth
Back
Chest
Neck/Chest
Genitourinary
Lower Extremities
Closing
2. Introduction Includes
Any allergies
Bed Locked
LOC "Say speech is articulate"
Any health problems?
3. Skin
Adjust Bed Height, PT at edge
Colors, Scars, Lesion, Rashes, Bruising
Temp, Moisture, Texture, Edema, Turgor, Tenderness?
Nails
Cap Refill less than 3 sec
4. Vitals
Radial Pulse
Respirations
BP (clean Steth)
Temperature
Pulse Ox
Pain?
5. Face
Inspect/Palpate Hair
Smile, Frown, Raise Eyebrows, Puff Cheeks
6. Eyes/Mouth
Measure Pupil Size
Confrontation Test
Corneal Light Reflex
6 Cardinal Positions
Inspect Mouth, Color? Uvula?
Lift up tongue
7. Back
Check Oxygen
Inspect
Inspect 1:2 Ratio
Listen 6 Breath Sounds
"I'm checking your rate/rhythmn" (eupnic)
8. Chest
6 Sounds, start above collar bone
"I'm checkin RR" say Eupnic
Work of breathing
9. Arms
Radial Pulse Strength (2+)
Move Wrists down/up
Spread Arms out Wide/over head
10. Chest/Neck (Move to lying down)
JVD
Inspect Precordium
APTM (diaphram)- Reg. Rate/ Rhythm
APTM (Bell) "no sounds"
Listen Lung Rt Side (x3)
Listen Lung Left Side (x2)
11. Abdomen
I'm Inspecting your contour/symmetry
Auscultate Bowl @ RLQ
Auscultate Aorta "No Bruits"
Percuss Clockwise
Palpate Clockwise (any pain?)
12. Genitourinary (Stay Lying Down)
When was your last bowel movement?
How often do you have BM?
Color of your urine?
Any burning/itching when you pee?
13. Lower Extremties (Lying Down)
Inspect Symmetry of Legs
Scars, Lesions, Rashes, Color, bruising?
Tibial Pulse
Dorsal Pedi Pulse
Skin Temp
Push Edema, "no varicose veins" 0 edema
Check Muscle in legs
14. Closing
Bed Rails Up
Bed Lowered
Call Light
Thanks
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