Nursing Assessment Script

First steps before beginning a nursing assessment?

Knock • Walk in • Provide privacy • Perform hand hygiene • Introduce yourself • Explain why you are there

What patient identifiers should you verify?

Name • Date of Birth (DOB)

What orientation questions assess mental status (AAO ×4)?

Do you know where you are today? • Do you know the month and day today? • Person = Name • Situation = Why they are here

What additional questions should you ask before the assessment?

Do you have any allergies? • Do you have any cultural considerations I should know about? • What brought you in today? (Chief complaint)

What should you tell the patient before starting the physical exam?

Inform them the assessment is beginning • Ask permission to touch them • Ask if they have any questions • Tell them to let you know if they become uncomfortable or have concerns

How do you document a normal General Survey?

AAO ×4 • GCS 15 • Appears healthy for age • Face symmetrical • Eyebrows evenly distributed • Skin color appropriate for ethnicity • Weight appropriate for height/frame • Normal gait • Dressed appropriately for season • No cardiac or respiratory distress • Moves freely in bed • Allergies: ____ • Cultural considerations: ____ • Chief complaint: ____

What do you inspect and palpate during the head assessment?

Hair distribution • Lumps • Bumps • Lesions • Scarring • Flaking • Dryness

What is the normal documentation for the head assessment?

Head is normocephalic • Hair evenly distributed • No lumps, bumps, lesions, or scarring • No flaking or dryness

What are the four skin assessment techniques?

Inspect skin • Assess temperature (dorsal side of hands) • Capillary refill • Skin turgor

How is capillary refill assessed?

Press on the nail bed until it blanches and release • Normal: <2 seconds

How is skin turgor assessed?

Pinch the skin and release • Normal: Returns in <2 seconds • No tenting

What is normal skin documentation?

Warm, dry, clean, intact • No cyanosis, pallor, or jaundice • No lumps, bumps, lesions, or scarring • Capillary refill <2 sec bilaterally • Nail angle <160° • No clubbing • Skin returns to normal in <2 sec • No tenting

What does PERRLA stand for?

Pupils • Equal • Round • Reactive to Light • Accommodation

What eye assessments are performed?

PERRLA • Six cardinal fields of gaze ("H") • Look up and down • Inspect conjunctiva (pull lower eyelid down)

What is normal documentation for the eyes?

PERRLA • Pupils 3 mm • Brown irises • Pink, moist conjunctiva • White sclera • Clear cornea • No lacrimal drainage • No lid lag • No nystagmus • Eyelids/lashes evenly distributed

What are the steps of the mouth assessment?

Inspect with tongue depressor & penlight • Tongue to roof of mouth • Stick tongue out • Say "Ah" • Cough • Swallow • Ask about changes in taste

What is normal documentation for the mouth assessment?

Lips moist, clean, intact • Oral mucosa pink and moist • Buccal mucosa pink • Gums healthy • Roof of mouth pink • Tongue midline • Pharynx pink • No swelling or exudate • Teeth white and present • No lesions or ulcers • Speech clear • Able to cough and swallow • Taste unchanged

What should you ask before the respiratory assessment?

Do you have chest pain? • Do you have shortness of breath?

What do you inspect during the respiratory assessment?

Chest symmetry • Chest expansion • Retractions • Accessory muscle use • Respiratory effort • Rate • Rhythm • Depth

What is normal respiratory inspection documentation?

Thorax symmetric • Good expansion • No retractions • No accessory muscle use • Regular rate, rhythm, depth • No shortness of breath • Skin clean, dry, intact

How do you auscultate the lungs?

Ask patient to take deep breaths • 12 points anterior • 14 points posterior

What is normal lung auscultation documentation?

Lungs clear anteriorly & posteriorly • No adventitious sounds • No wheezing • No coughing • No respiratory distress

How should the patient be positioned for the cardiac assessment?

Head of bed at 30° • Patient supine

What is inspected before auscultating the heart?

Inspect the precordium with a penlight • Normal: No visible pulsations

What are the five cardiac auscultation sites? (APE To Man)

Aortic • Pulmonic • Erb's Point • Tricuspid • Mitral (Apical)

How should heart sounds be auscultated?

Diaphragm first • Then bell • Listen at all five valve areas

What is normal cardiac documentation?

No precordial pulsations • S1 & S2 present • Regular rate and rhythm • HR: ____ bpm • No murmurs • No extra heart sounds • If murmur suspected → assess in supine and left lateral positions

What is the overall order of the nursing health assessment?

1. Before Exam • 2. General Survey • 3. Hair/Head • 4. Skin • 5. Eyes • 6. Mouth • 7. Respiratory • 8. Cardiac • Mnemonic: "Be Good, Happy, Safe Every Morning—Rest Calmly."