Here's a quick reference table to try to help understand what should be assessed under each body system.
This isn't an end all be all list. There's a lot of things that could be added or deleted. Different units will be focused more on certain things than others. That's fine. I've been working on an ICU lately, so there are some things on here that would most likely only show up on one of those units such as ventilator settings.
This isn't an end all be all list. There's a lot of things that could be added or deleted. Different units will be focused more on certain things than others. That's fine. I've been working on an ICU lately, so there are some things on here that would most likely only show up on one of those units such as ventilator settings.
System
|
Usual Assessment
|
Additional Assessments
|
Neuro
|
Level of
consciousness, orientation, motor ability, strength, ROM, speech, pupillary
reaction to light, color and condition of the sclerea, temporal pulses,
headache, vision, hearing, paresthesias, reflexes, intensity and perception
to pain
|
Restraints, cervical
collar, traction, surgical dressing, ICP monitoring device, level of
sedation, PCA device
|
Cardio
|
Pulses, capillary
refill, edema, heart sounds, murmurs, thrills, neck veins, PMI, ECG, arrhythmias,
chest pain, activity tolerance
|
vascular access,
cardiac output, pressure monitoring, pacemaker, compression stockings/device
|
Resp
|
Pulse oximeter, depth,
rate, rhythm, use of accessory muscles, cyanosis, sputum- color/amount,
cough, wheezes, stridor, position of trachea, suctioning tolerance
|
Supplemental O2, artificial
airway size/position, mechanical ventilator settings, pleural chest tube,
apnea monitor
|
GI/GU and Renal
|
Abdominal pain/ tenderness,
guarding, distention, tolerance to eating/feeding, nutritional status,
character of vomit/stool, nausea/vomiting, bowel sounds, urine
amount/quality, foley status
|
Feeding tube type/
size/ location, feeding formula/rate, GI tubes patency/ drainage, surgical
dressings
|
Skin
|
Color, texture,
turgor, temperature, rashes, abrasions, wounds, burns, bruises,
inflammations, itching, burning
|
Type of bed,
patient's tolerance of bed, decubitus dressing, protective aids
|
Extremities
|
Limitations in
movement, deformities, contractures, signs of ischemia: pain, pallor,
paresthesia, paralysis, pulselessness, cold
|
Traction: weight,
status, alignment, patient tolerance, pin site. Casts, splints, restraints,
compression device
|
Psych
|
Emotional state,
support systems, communication, coping ability, sleep/rest status
|
Patient/family
teaching needs, social service needs, transfer/discharge planning
|
I hope this helps! Let me know if you have any questions in the comment section below, or shoot me an email.
Xoxo,
Nightingale
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