Assess physical appearance,
mood, affect and grooming.
Assess orientation: Oriented to
Person, Place, Time and Situation.
Assess level of consciousness.
Assess speech.
1.
2.
3.
4.
Pulse: 60-100 bpm
Blood Pressure Systolic: 120
Diastolic: 80
Respiratory Rate: 12-18 bpm
O2 Saturation: 95-100%
Temperature: 36.5-37.5 degrees C
Assess head size, shape,
symmetry.
Inspect and palpate head,
scalp
Palpate sinuses and TMJ
Assess facial symmetry
Assess cranial nerve 7
1.
2.
3.
Face
1.
2.
Inspect external eye structures,
conjunctiva and sclera.
Test cranial nerve III, IV, VI
PERRLA- Pupils are Equal,
Round, Reactive to Light and
Accommodation.
Pupil size: 3-5mm
Ears: Assess for redness, drainage.
Test cranial nerve-
Vestibulocochlear
Nose: Assess shape, symmetry, size,
patency. Test cranial nerve I
HEART
Inspect, Auscultate, Percuss,
Palpate
Inspect skin color, contour and
aortic pulsations.
Auscultate bowel sounds from
RLQ clockwise.
1.
2.
3.
ABDOMENEyes/ Ears/ Nose
Palpate lymph node, carotid
artery, presence of goiter.
Auscultate for bruits.
Test cranial nerve 11
1.
2.
3.
Inspect lip color, sores, gums,
tongue, teeth, soft and hard
palate, uvula
Test cranial nerve 9, 12 and 10
1.
2.
NURSING ASSESSMENT REVIEW
GENERAL SURVEY
Vital Signs
Mouth
Neck
HEAD AND FACE
Inspect symmetrical chest
movement
Palpate for pain and lumps
Percuss using the Z-block
method
Auscultate lung sounds
1.
2.
3.
4.
Lungs
Auscultate heart sounds (Aortic,
Pumonic, Erb's Point, Tricuspid
and Mitral)
1.
Assess and inspect skin, nails,
muscle strength, ROM,
curvature of spine.
Palpate pulses
1.
2.
SKIN + EXTREMITIES
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