Nursing Assessment Checklist PDF

Preview

Summary

A nursing head to toe assessment checklist to use on clinical patients when doing a nursing assessment, to make sure you are not missing anything important! Perfect for beginners learning to master a head to toe....

Description

Marissa Bruchmann

Nursing Assessment – Head to Toe 1) Patient Safety Check - Airway, Breathing, Circulation (ABC) - Dressing - Catheter & output - Level of Consciousness

- Correct IV solution & rate - Correct PCA/Epidural medication & rate - Tubes & drains patent - ID & allergy bands on

2) Equipment Safety Check - O2, air, suction flower meter present and functioning - Suction canister, lining, tubing, yankeur, nasal prongs, mask present - Call bell in reach, bed brakes on, bed in lowest position - Signs for precautions visible (NPO, AVB) 3) Neurovascular - orientation x 3? (person, place, time) - pain (rate 1-10, where) - LOC, alertness, pupils equally reactive - upper hand grip, lower foot push/pull strengths & symmetry - ask for two thumbs up - dizzy or lightheaded? - temperature 4) Cardiovascular - BP, pulses/HR, O2 Sats, heart sounds (ir/regular? normal/ bounding/thready) - cap refill - edema (non/pitting) - CWMS (colour, warmth, movement, sensation) 5) Respiratory - RR, O2 sats, depth, ease, laboured? - SOB, accessory muscles - auscultate lung sounds - cough? Sputum? On O2 or RA? 6) Gastrointestinal - Look (abd. Distended?) - Listen bowel sounds x 4 quadrants begin lower right (hypo/eractive) - Feel (palpate) - LBM, last meal, diet, passing gas, IV or NG, blood glucose

- any nausea/vomiting

Marissa Bruchmann

7) Genitourinary - catheter check, & output - continence, burning, frequency, colour, odour, blood? - pain on voiding 8) Integumentary - surgical site/wound check (for bleeding, pus, dressing dry/intact) - colour, circulation, skin turgor - any breakdown (ulcer) - nails/hair check - moist mucous membranes 9) Musculoskeletal - motor control and strengths - weight bearing? ROM? - gait, balance, stamina - joints, posture

Lab Value Normal Ranges Na K RBC Hct Gluc Creat INR Cl WBC Hgb Plate BUN EGFR

= 135 – 145mmoL/L = 3.5 – 5mmoL/L = 3.5 – 5 = (M) 0.42 – 0.5 (F) 0.4 – 0.48 = 3.6 – 7.8 = 45 – 110 = 0.8 – 1.2 = 98 – 108mmoL/L = 4 – 11 = (M) 135 – 180 (F) 115 – 160 = 150 – 400 =2–9 = >60...