Saturday, March 22, 2008

My nursing assessment Part I

As I've written about before, patient assessment is a major part of being a nurse. Here's Part I of what I do within 30 minutes of getting a patient either when I'm coming on shift or they roll out from surgery. I was going to type up the whole thing in one post and then I realized how long it takes to write it all out versus just doing it. It's organized by body system and yes, we have a form to remind the nurse of all the things to check.


Shine a flashlight in their eyes and watch for pupil constriction. Grade the size of the pupil (esitmated in centimeters) and the speed of constriction (brisk or sluggish). Grade their level of consciousness (alert, lethargic, obtunded, stuporous, or comatose). Grade their behavior (sedated, inappropriate, confused, agitated, or combative). Ask them their name, the day/date, where they are, and why they are there to judge how oriented they are. People who only know they're name are Ox1, if they know they're in a hospital and why and at least can get the month then they're Ox4. While they're speaking, grade their speech (clear, slurred, incomprehensible, or they have a breathing tube in and cannot speak). If they are aphasic, note whther they are having difficulty speaking (expressive aphasia), understanding what I'm saying (receptive aphasia), or both (global aphasia). Put two fingers in their hands and ask them to squeeze and release. Have them push against my hands with their feet and pull back their feet toward their knees. Grade their strength in these movements. Note if they have a drain or pressure monitor to their cerebral spinal fluid and if so the condition of the dressing over it, the level it's at, and the type of drainage (clear, serosanguinous, sanguinous).


Listen for heart sounds, note presence of S1 & S2 (the lub-dub sound) and any extra sounds. Check capillary refill at fingers and toes, grade brisk or sluggish (<>3 seconds). Note nailbed color (pink, pale, dusky, cyanotic). Grade the temporal, brachial, radial, dorsalis pedial, and posterior tibialis pulses (palpable, heard with Doppler, absent). Note chest tubes, their placement (pleural, mediastinal), suction applied if any, and what they're draining (clear, serosanguinous, sanguinous). Note pacemaker and/or internal cardiac debrillator and whether it is on. Note whether unused transcutaneous pacemaker wires are wrapped. Print a EKG strip and analyze it for the heart rhythm. Note or adjust the alarm settings for heart rate, blood pressure, and ST segment elevation or depression.

Note all IVs, their size and placement, when they were inserted, how the insertion sites look, and if the dressings over them are intact or due to be changed. If A-line (arterial line used for continuous blood pressure monitoring) and/or CVP (central venous pressure line used for monitoring that pressure as a measurement of right-side heart function and fluid status) present, calibrate the transducers and note how the monitor waveform looks and that the dressings over them are intact and up-to-date.

That's enough for now. I'll get to pulmonary, renal, etc. later. Is this boring? Should I spice it up with stories of things gone wrong?


  1. Thanks for posting this. It was useful to me, a first year nursing student ;)

  2. Good post! It was useful for student nurse, who want to learn Nursing assessment

  3. Good job I will use this as a tool for my LPN Nursing Students
    Everest Instructor