Medical-Surgical Nursing I Assessment
Study Guide/Response Examples
General Survey
 This involves “looking at the client”. Describe how they appear. Comment on:
o Physical Appearance:
 Age: Does the client appear as stated age?
 LOC: alert, confused, lethargic, unresponsive.
 Skin color: Pink, pale, flushed, jaundice, etc
 Any signs of distress? If yes, explain.
 Examples: SOB, guarded movements
o Body Structure:
 Nutrition: Does weight appear normal for height?
 Examples: Wt. appropriate for ht.; overweight; underweight, etc.
 Position: Describe: sitting upright; in tripod position; in fetal position, etc.
 Mobility: Describe: full ROM, paralysis; jerky movements, etc.
o Mood: Describe: cooperative; agitated; crying; withdrawn; non-communicative, etc.
1. Vital Signs – record data in each section
2. Comfort: Pain
 Location: State location of pain. If no pain is present, write “none” or “Ø”
o Examples: Rt. Knee; RLQ (Right Lower Quadrant); Lt knee, etc.
 Intensity: State on a range from 0 (no pain) to 10 (unbearable pain). Document number value
stated by client.
 Character: Ask client “What does the pain feel like?”
o Examples: “throbbing”;” stabbing”;” knife-like”; “dull; aching”, etc.
 Onset & Duration: Ask client “When did the pain begin?”, “How long does it last?”
o Examples: “4 months ago”, “after breakfast”, “upon arising”, etc
 Aggravation & Alleviation:
o What makes the pain worse?
 Examples: Movement, bending, lying down, walking, standing, etc.
o What makes the pain better?
 Examples: Medications, massage, heat/cold, changing position, etc.
 PCA Pump: state if present or not. If client is using the PCA pump, how often?
3. HEENT
 Head: Note size, shape, any lesions, or tenderness, hair distribution
o Examples: symmetrical, nontender, hair thinned over crown, etc
 Eyes: Note color, discharge
o Examples: yellow tinge bilateral sclera, no discharge, etc
 Ears: Note any drainage, lesions, hearing issues
o Examples: clear, no drainage, hearing intact, no hearing aids, etc
 Nose: Note color, presence of exudate, patency
o Examples: left nostril limited airflow, pink, no drainage, minimal yellow exudate right
nostril, etc.
 Throat & Mouth: Note color, moisture, lesions, dentation.
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o Examples: pink, pale, moist, dry, no lesions, white coating tongue, several missing
teeth, dentation intact, several missing teeth, etc.
4. Oxygenation
 Skin/Mucus Membranes/Nail Bed Color:
 Lung Sounds:
o Describe what you hear.
 Crackles: Crackling sound caused by air entering bronchioles/alveoli containing
serous secretions.
 Rhonchi: abnormal coarse sound heard especially over trachea
 Wheezing: breathing with a whistling sound
 Examples: clear and equal bilaterally; no adventitious breath sounds;
expansion symmetrical
o Describe where the sound is heard.
 State side: right (R), left (L), bilateral (B)
 State area: upper lobes (UL), lower lobes (LL), bases
 State when: on inspiration, on expiration, on inspiration and expiration
 Examples: RUL (right upper lobe), BLL (bilateral lower lobe); bibasilar (both
bases), etc
 Respiratory depth & effort: Describe work of breathing.
o Examples: deep; shallow; regular depth and pattern, eupneic (eupnea is regular, quiet,
effortless respirations, unlabored breath sounds); dyspneic (dyspnea is labored or
difficult breathing); tachypneic (tachypnea is a fast respiratory rate >24/min for adult),
bradypneic (bradypnea is a slow respiratory rate <12/min for adult), etc.
 Oxygen: State is patient is on oxygen, flow rate, and delivery method
o Examples: no oxygen, on 3 L O2 via NC (nasal cannula)
 Pulse Ox: State if is on room air or oxygen.
o Examples: 93% on 2 L of O2
 Cough: Write what you observe or patient states
o Examples: non-productive; productive; tight; loose, etc
 Sputum/color: Describe color and amount.
o Examples: clear; white; yellow; green; blood tinged, scant, moderate, large, etc
 Dyspnea: If yes, when?
o Examples: constantly, with ambulation/activity, when speaking, etc.
 Trach: If present, describe site
 Chest Tubes: If present, state location, describe site
o Examples:
5. Perfusion: Cardiovascular
 Apical Rhythm: Describeo Examples: regular; irregular, etc.
 Peripheral Pulses: Assess bilaterally at same time. Objective is to identify the presence and
the strength of the pulse. Document pulses using the following four-point scale:
o 4+ bounding
o 3+ increased
o 2+ normal
o 1+ weak
o 0 absent
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o Examples: strong; weak; thread; bounding, etc
Capillary Refill: Record for UEs and Les
o Examples: immediate; <3 sec; delayed; > 3 sec, etc
Edema: If no edema present, write “none” or Ø. If present, rate the degree of edema present on
the following scale:
 1+ mild pitting, slight indentation, no perceptible swelling of leg
 2+ moderate pitting, indentation subsides rapidly.
 3+ deep pitting indentation, remains for a short time, leg looks swollen.
 4+ very deep pitting, indentation last a long time, leg is very swollen.
o Location: Indicate anatomical location
o Examples: sacrum; ankles; RLE (Rt lower extremity); BLEs (bilateral lower
extremities); Rt hand; periorbital, etc.
Homan’s Sign:
AV Shunt: Bruit ______ Thrill _________
6. Tissue Integrity: Integrumentary
 Skin Temperature: cool, warm, etc
 Skin Turgor: Assess status; options for sites: sternum, forehead, inner aspect of thigh.
o Examples: quick recoil; poor; tenting, etc
 Skin Condition
o Rashes: state location and appearance
o Petechiae: state location
o Lesions: Identify type of lesion and location
 Examples: abrasion left elbow
o Bruising: If present, state location/s
o Incisions: If no incision sites are present, write “none” or “Ø”
o Wound drainage
 Examples: purulent; sero-sanguineous; serous, etc
o Pressure Injuries:
 If no lesions or ulcers are noted, write “pressure points without redness”.
 If present, state location, stage, size, description of wound bed, etc
 Examples: Unstageable pressure injury R heel, wound base with thick
yellow covering, measures 10x12 cm, no drainage or warmth, surrounding
tissue intact
o IV sites: Indicate location, catheter site, and site appearance.
 Example: Angiocath 20 Ga 1 ½ inch in place Rt wrist with no erythema or
drainage; Angiocath 22 Ga 1 inch IV to Lt forearm noted with mild erythema,
warmth, no drainage, no pain; etc
7. Cognition: Neurological
 Level of Consciousness: Indicate level
o Examples: alert, lethargic, responds to painful stimuli, comatose
 Glasgow Coma Scale
o Eye opening: Indicate patient response and corresponding number.
o Verbal response: Indicate patient response and corresponding number.
o Motor response: Indicate patient response and corresponding number.
 Pupils: Note pupil size and reaction
o Examples: pupils 3 mm, PERRLA, etc.
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Numbness/Tingling: If present, state where.
o Examples: denies numbness/tingling, c/o numbness over right foot
Orientation: Describe client’s orientation to time, place, person, situation
o Examples: A&O x4; oriented to x2 - person, place only
Memory:
o Distant: Ask questions such as when is your birthday? etc.
o Recent: Ask questions such as what brought you to the hospital, what did you have for
breakfast?
Speech: Assess client’s ability to speak and understand
o Examples: clear, slurred, spontaneous, expressive aphasia, nonverbal
Language:
8. Mobility: Musculoskeletal
 Mobility: Note ability to move extremities, fingers, toes
o Examples: all extremities with symmetrical movement, unable to move RUE, etc.
 Gait/Balance: Describe
o Example: walks easily, has good balance; limps; poor BLE balance; fear of falling, etc
 Fall risk indication: State if client is a fall risk. If client is a fall risk, identify risk factors.
o Considerations for fall risk includes > 65 years, vision issues, weakness, urinary
frequency, gait/balance problems, cognitive dysfunction, medications (i.e., antihypertensives, narcotics, sedatives, anti-depressants)
 Hip precautions: List precautions.
 CPM @: State current setting/degree
 Assistive equipment: No or yes. If yes, list devices
o Examples: walker, cane, crutches, wheelchair, etc
 Activity order: Write current physician order.
 Muscle strength: Describe on a scale of 0 to 5.
o 5 = Full range of motion against normal resistance and gravity
o 4 = Full range of motion against moderate resistance and gravity
o 3 = Full range of motion against gravity only
o 2 = Full range of motion with gravity eliminated
o 1 = Slight muscle contraction palpable, but no movement noted
o 0 = No visible or palpable contraction, paralysis of limb
 Range of Motion: Identify is client has full, limited, or contractures of the extremities.
9. Elimination: Gastrointestinal
 Abdomen
o Inspection: Note contour, lesions, incisions
 Examples: flat, rounded, distended, midline incision
o Auscultation: Note bowel sounds over all 4 quadrants (RLQ, RUQ, LUQ, LLQ)
 Examples: normal, hypoactive, hyperactive, absent
o Palpation:
 Examples: soft; non-distended; firm; non-tender; tender (specify area);
presence of mass(es) (specify area); guarding, etc.
o Percussion: not a G140 assessment
 Bowel
o Flatus: State present or absent
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o Last BM/description: State date, describe amount, color, consistency, odor.
 Examples: small, moderate, large, brown, tarry, hard, watery, aromatic
(normal), pungent (strong smelling)
o Laxative use: Identify medication used and frequency.
NG/GT/JT: Mark if to suction or gravity. Record output for shift
o Example: 450 ml dark green gastric fluid over previous 24 hr; etc
Ostomy: State type (colostomy or ileostomy) and stool characteristics
o Examples: colostomy LLQ with liquid stool, etc.
10. Elimination: Urinary
 Appearance: Describe color, clarity, odor, presence of sediment
o Examples: yellow, cloudy, amber, bloody, clear, without foul odor
 Output:
o 24-hour output: obtain previous day output in EMR.
o Shift output: record in mL. If output not being measured, list number of times patient
voided (voided x 4)
 Catheter: Yes/No. If yes, indicate size.
o Examples: 16 Fr indwelling cath
 Incontinence: Yes/No. If yes, indicate type.
o Examples: stress incontinence, functional incontinence
11. Nutrition
 Weight: Record most recent weight in pounds
 Height: Record in feet and inches
 Diet: State current diet order
 NPO: State yes or no
o If yes, describe reason.
o Examples: surgery, bowel obstruction
 Appetite: Record % of meals consumed during your shift
 Supplements: List any supplement the client is on
o Examples: Ensure TID; Renal Source BID, etc
 NG/JPEG: Document formula and rate
 TPN/PPN: Identify which whether TPN or PPN and the rate
 Nausea: State yes or no
 Vomiting: State yes or no
o If yes, describe amount/frequency and appearance.
12. Fluid & Electrolytes
 IV solution & rate: Document
 24-Hour Intake & Output: review EMR for 24 Hour totals from previous day
 Tissue turgor: Assess status; options for sites: sternum, forehead, inner aspect of thigh.
o Example: quick recoil; poor; tenting, etc
 Mucous membranes: Assess conjunctival sacs, assess oral mucosa.
o Example: moist; dry; dry furrowed tongue, etc
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13. Metabolism: Endocrine
 Blood glucose: record accuchecks
 Thyroid/Pituitary: List disorders:
o Examples: Hypothyroidism, Hyperthyroidism, Cushing’s Disease
 Stressors: Identify any issues that is a stressor to the client
o Examples: hospitalization, recent death in family, cancer diagnosis, separation from
family, adjusting to disease, financial issues, etc.
14. Rest & Sleep
 Describe: # of hours slept; any interruptions during the night; any need to go to the bathroom
during the night, etc.
o Examples: c/o (complains of) frequent interruptions during nightly; feels rested upon
arising; sleeps apx. 6 hours during the night; frequent naps during the day
15. Support Systems/Coping
 Family Support: Identify significant individuals in the client’s life.
o Examples: Pt states her “sister is an important part of her life”, Pt states “his
grandchildren bring him joy”
 Acceptance of Support:
o Examples: pt allows family to assist; seems happy to see family; expresses glad to
receive phone calls; openly accepts hugs and kisses, etc
 Coping Mechanisms: Identify methods client uses to cope or not cope with situation.
o Examples: pt states her counselor helps her deal with loss of mobility; talks with family;
uses meditation to deal with pain; avoids discussion about illness, etc.
 Interactions with significant others and healthcare staff: Observe interactions.
o Examples: smiles; thanks family for visiting; hugs children/wife; talkative, etc.
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