Student Nurse Assessment Sheet
Pt. Initials_______________________________
VS: T_______P______R________ B/P
R_______ L______
Pain
Location_____ Scale 1-10_____ Onset_____
Duration______ Characteristics___________
Aggravating factors____________________
Relieving factors_______________________
Normal Assessment__________________________________Client Assessment_______
Y N
Neuro/ Motor:
Client is awake, alert
Oriented to person, place and time
Responds to voice and follows
commands
Equal, symmetrical strength all
extremities
Ambulates ad lib
Speech clear and understandable
Memory intact
Behavior appropriate
PERRLA
Cardiovascular:
Apical heart rate regular, rate 60-100
Palpable peripheral pulses all
extremities
Capillary refill within 3 seconds
Extremities warm to touch
No numbness or tingling
Normal skin color
No edema noted
No calf tenderness
No chest pain
Pulmonary:
Respirations regular, rate 12-20
No dyspnea at rest or on exertion
Breath sounds clear
No cough, no sputum
Pulse ox >93% on room air
Gastrointestinal:
Abdomen flat, non-tender
Positive bowel sounds all quadrants
No nausea/vomiting, tolerates diet
Oral mucosa intact
Soft, formed, brown, regular bowel
movements
Genitourinary:
Voids independently, no pain or
frequency
Bladder is not distended after
urination
Urine is clear, yellow to amber color
Skin:
Warm, dry and intact
Good skin turgor
No redness, swelling or breakdown
IV access:
Type_____ Location___________
No redness, drainage, swelling, pain
Flushes easily
Dressing intact
Surgical dressing or wound
assessment:
Dressing dry and intact
Sutures, staples, steri-strips intact
No redness, tenderness, increased
warmth
Wound edges well approximated
No drainage present
Decubitus ulcer assessment:
Stage_____
Size in cm: L____ W____ D_____
Appearance of wound base_______
Appearance of wound edges______
Drainage__________
Odor_______ Pain_______
Treatment____________________
Y
N