Name:

Address:
Gender: Age:
Birthdate: Educational Attainment:
Occupation:
Marital Status:
If Married;
Spouse: Age: Occupation:
If Single;
Mother: Age: Occupation:
Father: Age: Occupation:
Religion:
Dialect/ Language Spoken: Ethnic Group:
Admitting Diagnosis:
Final Diagnosis:
Operation Procedure:

History of Present Illness

History of Past Illness

Family History
 STEPS ADDITIONAL INFORMATION

1. General appearance: Alterations may reflect neurologic impairment, oral injury

or impairment, improperly fitting dentures, differences in
dialect or language, or potential mental illness. Unusual
findings should be followed up with a focused
● Affect/behaviour/anxiety
neurological system assessment.
● Level of hygiene
● Body position
● Patient mobility
● Speech pattern and articulation

Assess general appearance

This is not a specific step. Evaluating the skin, Check for and follow up on the presence of lesions,
hair, and nails is an ongoing element of a full bruising, and rashes.Variations in skin temperature,
body assessment as you work through steps texture, and perspiration or dehydration may indicate
3-9. underlying conditions.

2. Skin, hair, and nails: Redness of the skin at pressure areas such as heels,
elbows, buttocks, and hips indicates the need to reassess
patient’s need for position changes.
● Inspect for lesions, bruising, and
rashes.
● Palpate skin for temperature, Unilateral edema may indicate a local or peripheral cause,
moisture, and texture. whereas bilateral-pitting edema usually indicates cardiac
● Inspect for pressure areas. or kidney failure.
● Inspect skin for edema.
● Inspect scalp for lesions and hair and
scalp for presence of lice and/or nits. Check hair for the presence of lice and/or nits (eggs),

● Inspect nails for consistency, colour, which are oval in shape and adhere to the hair shaft.

and capillary refill.

3. Head and neck: Check eyes for drainage, pupil size, and reaction to light.
Drainage may indicate infection, allergy, or injury.

● Inspect eyes for drainage.

● Inspect eyes for pupillary reaction to Slow pupillary reaction to light or unequal reactions

light. bilaterally may indicate neurological impairment.

● Inspect mouth, tongue, and teeth for

moisture, colour, dentures.
● Inspect for facial symmetry.

Check pupillary reaction to light

Dry mucous membranes indicate decreased hydration.

Facial asymmetry may indicate neurological impairment

or injury. Unusual findings should be followed up with a
focused neurological system assessment.
4. Chest: Chest expansion may be asymmetrical with conditions
such as atelectasis, pneumonia, fractured ribs, or
pneumothorax.
● Inspect:
○ Expansion/retraction of
Use of accessory muscles may indicate acute airway
chest wall/work of
obstruction or massive atelectasis.
breathing and/or accessory
muscle use
○ Jugular distension Jugular distension of more than 3 cm above the sternal
● Auscultate: angle while the patient is at 45º may indicate cardiac
○ For breath sounds anteriorly failure.
and posteriorly
○ Apices and bases for any
adventitious sounds The presence of crackles or wheezing must be further
○ Apical heart rate assessed, documented, and reported. Unusual findings
● Palpate: should be followed up with a focused respiratory
○ For symmetrical lung assessment.
expansion

Auscultate anterior chest; blue dots indicate stethoscope

placement for auscultation
Auscultate posterior chest; blue dots indicate stethoscope
placement for auscultation

Auscultate apical pulse at the fifth intercostal space and

midclavicular line

Note the heart rate and rhythm, identify S1 and S2, and
follow up on any unusual findings with a focused
cardiovascular assessment.
5. Abdomen: Abdominal distension may indicate ascites associated with
conditions such as heart failure, cirrhosis, and pancreatitis.
Markedly visible peristalsis with abdominal distension
may indicate intestinal obstruction.
● Inspect:
○ Abdomen for distension,
asymmetry Hyperactive bowel sounds may indicate bowel
● Auscultate: obstruction, gastroenteritis, or subsiding paralytic ileum.
○ Bowel sounds (RLQ)
● Palpate:
○ Four quadrants for pain and Hypoactive or absent bowel sounds may be present after
bladder/bowel distension abdominal surgery, or with peritonitis or paralytic ileus.
(light palpation only)
● Check urine output for frequency,
colour, odour. Pain and tenderness may indicate underlying inflammatory

● Determine frequency and type of conditions such as peritonitis.

bowel movements.
●
Unusual findings in urine output may indicate
compromised urinary function. Follow up with a focused
gastrointestinal and genitourinary assessment.

Unusual findings with bowel movements should be

followed up with a focused gastrointestinal and
genitourinary assessment.

Auscultate abdomen
6. Extremities: Limitation in range of movement may indicate articular
disease or injury.

● Inspect:
○ Arms and legs for pain, Palpate pulses for symmetry in rate and rhythm.

deformity, edema, pressure Asymmetry may indicate cardiovascular conditions or

areas, bruises post-surgical complications.

○ Compare bilaterally
● Palpate:
Unequal handgrip and/or foot strength may indicate
○ Radial pulses
underlying conditions, injury, or post-surgical
○ Pedal pulses: dorsalis pedis
complications.
and posterior tibial
○ CWMS and capillary refill
(hands and feet)
CWMS: colour, warmth, movement, and sensation of the
● Assess handgrip strength and
hands and feet should be checked and compared to
equality.
determine adequacy of perfusion.
● Assess dorsiflex and plantarflex feet
against resistance (note strength and
equality). Check skin integrity and pressure areas, and ensure
● Check skin integrity and pressure follow-up and in-depth assessment of patient mobility and
areas. need for regular changes in position.

Assess dorsiflexion
Assess plantarflexion

Assess CWMS – colour, warmth, movement, and sensation

Assess bilateral hand strength

Palpate and inspect capillary refill and report if more than

3 seconds.
Assess pedal pulses

Check capillary refill

To check capillary refill, depress the nail edge to cause

blanching and then release. Colour should return to the
nail instantly or in less than 3 seconds. If it takes longer,
this suggests decreased peripheral perfusion and may
indicate cardiovascular or respiratory dysfunction.
Unusual findings should be followed up with a focused
cardiovascular assessment.

Clubbing of nails, in which the nails present as

straightened out to 180 degrees, with the nail base feeling
spongy, occurs with heart disease, emphysema, and
chronic bronchitis.
7. Back area (turn patient to side or ask to sit Check for curvature or abnormalities in the spine.
up or lean forward):

Check skin integrity and pressure areas, and ensure

● Inspect back and spine. follow-up and in-depth assessment of patient mobility and
● Inspect coccyx/buttocks. need for regular changes in position.

8. Tubes, drains, dressings, and IVs: Note amount, colour, and consistency of drainage (e.g.,
Foley catheter), or if infusing as prescribed (e.g.,
intravenous).
● Inspect for drainage, position, and
function.
● Assess wounds for unusual drainage.

Urinary catheter bag

Assess wounds for large amounts of drainage or for

purulent drainage, and provide wound care as indicated.
9. Mobility: Assess patient’s risk for falls. Document and follow up
any indication of falls risk. Note use of mobility aids and
ensure they are available to the patient on ambulation.
● Check if full or partial
weight-bearing.
● Determine gait/balance.
● Determine need for and use of
assistive devices.

Patient position prior to

standing

10. Report and document assessment findings Accurate and timely documentation and reporting promote
and related health problems according to patient safety.
agency policy.

Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Stephen et al., 2012