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 and print and use to guide you throughout the first step of the nursing process.
- Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor. He has a good skin turgor and skin’s temperature is within normal limit.
- Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. There are also no signs of infection and infestation observed.
- Nails: The client has a light brown nails and has the shape of convex curve. It is smooth and is intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds.
- Head: The head of the client is rounded; normocephalic and symmetrical.
- Skull: There are no nodules or masses and depressions when palpated.
- Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses.
Eyes and Vision
- Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned and showed equal movement when asked to raise and lower eyebrows.
- Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.
- Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks approximately 15-20 times per minute.
- The Bulbar conjunctiva appeared transparent with few capillaries evident.
- The sclera appeared white.
- The palpebral conjunctiva appeared shiny, smooth and pink.
- There is no edema or tearing of the lacrimal gland.
- Cornea is transparent, smooth and shiny and the details of the iris are visible. The client blinks when the cornea was touched.
- The pupils of the eyes are black and equal in size. The iris is flat and round. PERRLA (pupils equally round respond to light accommodation), illuminated and non-illuminated pupils constricts. Pupils constrict when looking at near object and dilate at far object. Pupils converge when object is moved towards the nose.
- When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead.
- When testing for the Extraocular Muscle, both eyes of the client coordinately moved in unison with parallel alignment.
- The client was able to read the newsprint held at a distance of 14 inches.
Ears and Hearing
- Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles are aligned with the outer canthus of eye. When palpating for the texture, the auricles are mobile, firm and not tender. The pinna recoils when folded. During the assessment of Watch tick test, the client was able to hear ticking in both ears.
Nose and Sinus
- Nose: The nose appeared symmetric, straight and uniform in color. There was no presence of discharge or flaring. When lightly palpated, there were no tenderness and lesions
- The lips of the client are uniformly pink; moist, symmetric and have a smooth texture. The client was able to purse his lips when asked to whistle.
- Teeth and Gums: There are no discoloration of the enamels, no retraction of gums, pinkish in color of gums
- The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening and with elastic texture.
- The tongue of the client is centrally positioned. It is pink in color, moist and slightly rough. There is a presence of thin whitish coating.
- The smooth palates are light pink and smooth while the hard palate has a more irregular texture.
- The uvula of the client is positioned in the midline of the soft palate.
- The neck muscles are equal in size. The client showed coordinated, smooth head movement with no discomfort.
- The lymph nodes of the client are not palpable.
- The trachea is placed in the midline of the neck.
- The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible.
Thorax, Lungs, and Abdomen
- Lungs / Chest: The chest wall is intact with no tenderness and masses. There’s a full and symmetric expansion and the thumbs separate 2-3 cm during deep inspiration when assessing for the respiratory excursion. The client manifested quiet, rhythmic and effortless respirations.
- The spine is vertically aligned. The right and left shoulders and hips are of the same height.
- Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no presence of heaves or lifts.
- Abdomen: The abdomen of the client has an unblemished skin and is uniform in color. The abdomen has a symmetric contour. There were symmetric movements caused associated with client’s respiration.
- The jugular veins are not visible.
- When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds.
- The extremities are symmetrical in size and length.
- Muscles: The muscles are not palpable with the absence of tremors. They are normally firm and showed smooth, coordinated movements.
- Bones: There were no presence of bone deformities, tenderness and swelling.
- Joints: There were no swelling, tenderness and joints move smoothly.
Nursing Assessment in Tabular Form
||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.|