Nursing assessment is an important step of the whole nursing process. Assessment can be called the “base or foundation” of the nursing process. With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. To prevent those kind of scenarios, we have created a cheat sheet that you can print and use to guide you throughout the first step of the nursing process.
||When skin is pinched it goes to previous state immediately (2 seconds).
With fair complexion.
With dry skin
||Evenly distributed hair.
With short, black and shiny hair.
With presence of pediculosis Capitis.
||Smooth and has intact epidermis
With short and clean fingernails and toenails.
Convex and with good capillary refill time of 2 seconds.
|Skull||Rounded, normocephalic and symmetrical, smooth and has uniform consistency.Absence of nodules or masses.|
|Face||Symmetrical facial movement, palpebral fissures equal in size, symmetric nasolabial folds.|
|Eyes and Vision|
||Hair evenly distributed with skin intact.
Eyebrows are symmetrically aligned and have equal movement.
||Equally distributed and curled slightly outward.|
||Skin intact with no discharges and no discoloration.
Lids close symmetrically and blinks involuntary.
||Transparent with capillaries slightly visible|
||Shiny, smooth, pink|
||No edema or tenderness over the lacrimal gland and no tearing.|
||Transparent, smooth and shiny upon inspection by the use of a penlight which is held in an oblique angle of the eye and moving the light slowly across the eye.
Has [brown] eyes.
||Blinks when the cornea is touched through a cotton wisp from the back of the client.|
|Pupils||Black, equal in size with consensual and direct reaction, pupils equally rounded and reactive to light and accommodation, pupils constrict when looking at near objects, dilates at far objects, converge when object is moved toward the nose at four inches distance and by using penlight.|
|Visual Fields||When looking straight ahead, the client can see objects at the periphery which is done by having the client sit directly facing the nurse at a distance of 2-3 feet.
The right eye is covered with a card and asked to look directly at the student nurse’s nose. Hold penlight in the periphery and ask the client when the moving object is spotted.
|Visual Acuity||Able to identify letter/read in the newsprints at a distance of fourteen inches.
Patient was able to read the newsprint at a distance of 8 inches.
|Ear and Hearing|
||Color of the auricles is same as facial skin, symmetrical, auricle is aligned with the outer canthus of the eye, mobile, firm, non-tender, and pinna recoils after it is being folded.|
||Without impacted cerumen.|
||Voice sound audible.|
||Able to hear ticking on right ear at a distance of one inch and was able to hear the ticking on the left ear at the same distance|
|Nose and sinuses|
||Symmetric and straight, no flaring, uniform in color, air moves freely as the clients breathes through the nares.|
|Mucosa is pink, no lesions and nasal septum intact and in middle with no tenderness.|
|Mouth and Oropharynx||Symmetrical, pale lips, brown gums and able to purse lips.|
||With dental caries and decayed lower molars|
||Central position, pink but with whitish coating which is normal, with veins prominent in the floor of the mouth.|
||Moves when asked to move without difficulty and without tenderness upon palpation.|
|Uvula||Positioned midline of soft palate.|
|Gag Reflex||Present which is elicited through the use of a tongue depressor.|
|Neck||Positioned at the midline without tenderness and flexes easily. No masses palpated.|
|Head movement||Coordinated, smooth movement with no discomfort, head laterally flexes, head laterally rotates and hyperextends.|
|Muscle strength||With equal strength|
|Lymph Nodes||Non-palpable, non tender|
||Not visible on inspection, glands ascend but not visible in female during swallowing and visible in males.|
|Thorax and lungs|
|Posterior thorax||Chest symmetrical|
||Spine vertically aligned, spinal column is straight, left and right shoulders and hips are at the same height.|
|Breath Sounds||With normal breath sounds without dyspnea.|
||Quiet, rhythmic and effortless respiration|
|Abdomen||Unblemished skin, uniform in color, symmetric contour, not distended.|
|Abdominal movements||Symmetrical movements cause by respirations.|
||With audible sounds of 23 bowel sounds/minute.|
|Upper Extremities||Without scars and lesions on both extremities.|
|Lower Extremities||With minimal scars on lower extremities|
|Muscles||Equal in size both sides of the body, smooth coordinated movements, 100% of normal full movement against gravity and full resistance.|
|Bones and Joints||No deformities or swelling, joints move smoothly.|
|Language||Can express oneself by speech or sign.|
|Orientation||Oriented to a person, place, date or time.|
|Attention span||Able to concentrate as evidence by answering the questions appropriately.|
|Level of Consciousness||A total of 15 points indicative of complete orientation and alertness.|
|Gross Motor and Balance|
||Has upright posture and steady gait with opposing arm swing unaided and maintaining balance.|
|Standing on one foot with eyes closed||Maintained stance for at least five (5) seconds.|
|Heel toe walking||Maintains a heel toe walking along a straight line|
|Toe or heel walking||Able to walk several steps in toes/heels.|
|Fine motor test for Upper Extremities|
|Finger to nose test||Repeatedly and rhythmically touches the nose.|
|Alternating supination and pronation of hands on knees||Can alternately supinate and pronate hands at rapid pace.|
|Finger to nose and to the nurse’s finger||Perform with coordinating and rapidity.|
|Fingers to fingers||Perform with accuracy and rapidity.|
|Fingers to thumb||Rapidly touches each finger to thumb with each hand.|
|Fine motor test for the Lower Extremities|
|Pain sensation||Able to discriminate between sharp and dull sensation when touched with needle and cotton.|