Instructions to student:
Perform this initial assessment on your clinical client. Check the appropriate response, yes or no. If the indicator is not
applicable, check “NA”. If the checked response is shaded, seek consultation with clinical faculty right away.
Initial Assessment Tool
AIRWAY
1.
2.
3.
4.
5.
YES
NO NA
YES
NO
Does the client manifest an altered level of consciousness?
Is the client maintaining their own airway?
Is there an adjunct airway such as a Trach tube or oral airway in use that is ineffective?
Is the client making any airway noises consistent with obstruction; snoring, barking, stridor?
Does client require any emergency assistant to establish/maintain an airway?
BREATHING
6.
7.
8.
9.
Does your client exhibit a normal breathing pattern and rate?
Is there evidence of excessive chest wall movement?
Is there evidence of use of accessory muscles?
Is the client making audible sounds when breathing that are cause for alarm?
CIRCULATION
10. Does your client complain of chest pain, shortness of breath, diaphoresis, and evidence of
bleeding or hemorrhage?
11. Does your client have a pulse?
12. Does your client exhibit and abnormal skin color patterns consistent with an alteration in
circulation; pallor, cyanosis, rubor, erythema or mottling?
13. Does the client have malaise, fever, and/ or chills?
I/O
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Does your client have an IV infusing or a Normal saline lock that is patent?
Is the dressing loose or is there redness, swelling, warmth or edema at the site?
Is the correct solution infusing at the correct rate and the tubing unexpired?
Does your client have a Foley catheter in place that is draining clear amber urine?
If the client is on daily weights, has the weight been done before breakfast?
If your client has BRP on I/O does the client state understanding of compliance?
If the client is NPO, does the client state understanding?
If the client is on aspiration precautions, is the bed positioned appropriately and prescribed
diet followed?
If the client is a diabetic, did they have their blood sugar checked yet?
Are drainage tubes present, patent and set to appropriate levels of suction as ordered?
Is the client receiving a gastric feeding to a patent gastric tube without leakage?
If so, is the rate, product correct and tubing unexpired?
WOUND
26. Is the dressing dry and intact, dated and timed?
27. Is there evidence of decubitus at areas of pressure or bony prominence?
28. Should you initiate decubitus precautions?
PAIN
29. Is the client meeting their goals for pain management?
30. Does the client need their pain medications now?
31. If the client has a pump, are the settings accurate the pump working correctly?
SAFETY
32.
33.
34.
35.
36.
If restraints are in use, is a monitoring protocol to prevent harm in place?
Is the bed low and the call bell in reach?
Should the side rails be up?
Are skid proof slippers provided for ambulatory patients?
Are their internal or external factors that indicate that your client is at risk for falls?
References
Fitspatrick J. B. & Shinners M.C. (1996, August). How to make assessment as easy as A, B, C. Nursing 1996. page 51.
Katz,smccabe
M. (2006) Save time! Do a 5-minute initial assessment,
Retrieved
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