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Assessment guide N44 Page 1 of 3 C. O’Leary-Kelley Revision 01/08 SYSTEMS ASSESSMENT GUIDE NURS 44 School of Nursing Present situation: State the age and gender of the patient. Why admitted to the hospital and on what date? Any surgery done during this admission? If so, state what and how many days ago (i.e. POD #). What was their state of health prior to admission? List pertinent, chronic conditions like diabetes, CHF, COPD, HTN, etc. List any allergies, and include code status. Pain Status: State client’s current pain status. Include any pertinent past pain responses/treatment. Neurological System Status: Level of consciousness (LOC) includes level of arousal and orientation. Level of arousal: note whether alert, attentive to their environment or drowsy, with little motor activity Orientation : has 3 spheres—Person, Place, Time (may also include orientation to situation as 4 th sphere) Communication: coherent, clear, logical or slurred speech? Verbal responsiveness: able to express themselves clearly? What languages do they speak? Able to follow and understand simple commands? Motor function : examine muscle strength; moves all extremities? Steady gait? Any weakness or paralysis? Sensory function : numbness, tingling? Any lack of sensation to any area? Do they have headaches, history of seizures or stroke, memory loss, or mood changes? Mental status : Depressed? Anxious? Grieving a loss? Speech and mannerisms match mood state? Gives eye contact? Asks lots of questions? Makes jokes? Sexually inappropriate? Cardiovascular: Heart tones—“S 1 and S 2 ” is the normal assessment; any murmurs? Heart rate—What is the rate? (give a number) Heart rhythm—regular/irregular? Blood pressure—state the blood pressure readings. Does the patient take antihypertensive medication? Edema—note where it is if present; 1+ (barely detectable) to 4+ (leaves a persistent pit about 1” deep); may also have non-pitting edema or no edema at all. Edema in the extremities is often bilateral, if not state whether it is unilateral. Skin vitals—warm, dry, cool or moist? Nail beds pink, cyanotic, pale? Capillary refill is < 3
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This note was uploaded on 09/08/2010 for the course NURS 148 at San Jose State University .

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