Auditors Information
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Inspection Date
1.Please take note that this audit must be conducted within 1 hour after the nurse has completed her documentation of assessing the patient . 2 2.Auditor to validate the nurse's documentation by accompanying her to the Patient .
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Prepared by
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Location
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Name of Nurse :
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Name of Shift in charge :
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MRN :
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Diagnosis :
General Assessment Standard
The nursing assessment includes gathering information concerning the patient's individual physiological, psychological, sociological, and spiritual needs. Subjective and objective data collection are an integral part of this process. The assessment identifies current and future care needs of the patient by allowing the formation of a nursing diagnosis. The nurse recognizes normal and abnormal patient physiology and helps prioritize interventions and care.
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Is the nurse aware of the patients general condition?
Neurological Standard
There are 12 pairs of cranial nerves. The nurse will systematically assess these nerves. Oculomotor (CN III), Trochlear (CN IV), Abducens (CN VI): Measure extraocular movement (EOM). Ask the patient to follow movement of the nurse's finger through the six cardinal positions of gaze. Trigeminal (CN V): Apply light sensation with a cotton ball to symmetric areas of face. Facial (CN VII): Observe face for symmetry. Have the patient frown, smile, puff out cheeks, and raise eyebrows. Glossopharyngeal (CN IX), Vagus (CN X), and Hypoglossal (CN XII): Assess speech, observe swallowing, and examine mouth. Accessory (CN XI) Have the patient sit upright and shrug shoulders while applying resistance with hands on his or her shoulders. Have the patient turn the head left and right while applying resistance with hands on the side of his or her head Optic (CN II) Examine the patient's distance vision using the Snellen chart. Assess extremities for sensation Apply pain, light touch, vibration and position. Assess motor and cerebellar function – through patient’s gait and Romberg’s test Assess deep tendon reflexes (DTRs) and Plantar response (Babinski reflex) Level of consciousness : Assess the client's behavior to determine level of consciousness (e.g., alertness, confusion, delirium, unconsciousness, stupor, coma). Eye opening Spontaneous 4 ,To speech 3, To pain 2 ,None Best verbal response Oriented Time , person place 5 ,Confused 4 ,Inappropriate words 3 ,Incomprehensible 2 ,None 1 Best motor response Obeying 6 ,Localizing 5 ,Withdrawal from pain 4 ,Abnormal Flexing 3 ,Abnormal Extending 2 ,None 1 Total score __/15
Glasco Coma scale
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Eye
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Verbal
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Motor
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Motor Strength
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Sensory level
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Cognition
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Speech
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Facial Symmetry
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Right Pupil size , shape and description, reaction
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Was a Penlight Used in this assessment ?
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Left pupil size shape and description
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Right Corneal
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Left Corneal
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Cough
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Gag
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Left Hand Grasp
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Right Pronator drift
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Left pronator drift
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Right Foot Dorsiflexion
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Left foot Dorsiflexion
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Right foot plantar flexion
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Left Foot Plantar flexion
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RUE Motor strength
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LUE Motor Strength
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LUE Sensation
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RLE Sensation
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R -Sensory Level
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L - Sensory Level
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Pre seizure Warning
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Seizure deviation
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Siezure motor Component
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Post Ictal
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Siezure interventions
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Siezure Tasking
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Tremor Location
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Tremor Severity
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Tremor Duration
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NIH Stroke scale
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Modified Rankin ( mRs)
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Cranial Nerves
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Spinal Cord Motor Function( Cervical Spine)
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Spinal Cord Motor Function( Lumbar sacral)
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Neurological Interventions
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Sedation Scale used
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Delirium Scale Used
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Delirium intervention
Respiratory System Standard
Type of breath sounds Normal breath sounds: eg. Vesicular, Broncho vesicular, and Bronchial breath sounds. OR Abnormal breath sounds: Also known as Adventitious sounds Breath Sounds Cough; expectoration of sputum; shortness of breath or dyspnea; chest pain on breathing; history of respiratory disease or infection
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Respiratory Pattern
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Respiratory Rate
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Respiratory Depth /Rhythm
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Respiratory Effort
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Dyspnea Occurrence
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Right Breath Sounds
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Left Breath Sounds
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Cough
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Airway
Localized Breath Sounds
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Right Upper Anterior
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Right mid Anterior
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Left Lower Anterior
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Left Upper Anterior
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Right Basilar
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Left Basilar
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Posterior breath Sounds
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Oral Secretion's Color ,Amount , Consistency,
Head, and Neck and Lymph nodes-Standard
Ask the client about headaches; episodes of dizziness (lightheadedness) or vertigo (spinning sensation); history of head injury; loss of consciousness; seizures; episodes of neck pain; limitations of range of motion; numbness or tingling in the shoulders, arms, or hands; lumps or swelling in the neck; difficulty swallowing; medications being taken; and history of surgery in the head and neck region. Head Inspect and palpate: Size, shape, masses or tenderness, and symmetry of the skull. Face: Inspect and palpate facial structures for shape, symmetry, involuntary movements, or swelling. Neck Inspect for symmetry of accessory neck muscles. Assess range of motion. Lymph Nodes Palpate and note their size, shape, location, mobility, consistency, and tenderness
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Head Abnormalities EG Size, shape,
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Masses or tenderness, and symmetry of the skull.<br>Face: e.g. shape, symmetry, involuntary movements, or swelling
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Assess range of motion.
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Neck<br> Inspect for symmetry of accessory neck muscles.
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Lymph nodes Note if there are lumps or lesions, note the shape and configuration of the chest state if there are areas of tenderness and lumps, lesions, or masses,
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- Non-Compliant
- Comment
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Ear, Check for symmetry ,
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- Non-Compliant
- Comment
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Lesions
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Discharges
Thorax and Lungs Standard
Thorax and Lungs Subjective data: Cough; expectoration of sputum; shortness of breath or dyspnea; chest pain on breathing; smoking history; environmental exposure to pollution or chemicals; medications being taken and history of respiratory disease or infection. Inspection of the anterior and posterior chest: Note skin color and condition and the rate and quality of respirations, look for lumps or lesions, note the shape and configuration of the chest wall, and note the position the client takes to breathe. Palpation: Palpate the entire chest wall, noting skin temperature and moisture and looking for areas of tenderness and lumps, lesions, or masses; assess chest excursion and tactile or vocal fremitus. Percussion: Starting at the apices, percuss across the top of the shoulders, moving to the interspaces, making a side-to-side comparison all the way down the lung area. Auscultation: Using the flat diaphragm end piece of the stethoscope, hold it firmly against the chest wall, and listen to at least 1 full respiration in each location (anterior, posterior, and lateral). Normal breath sounds: includes Vesicular, Bronchovesicular, and Bronchial breath sounds. Abnormal breath sounds: Also known as Adventitious sounds
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Was a stethoscope used?( Respiratory checks)
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Thorax<br>States the Subjective data findings
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Upon Inspection findings
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Upon Palpation findings
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Upon Percussion
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States Breath Sounds
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States Abnormal Breath Sounds
Cardiovascular System (Heart
Cardiovascular System (Heart) Subjective data: Chest pain, dyspnea, cough, fatigue, edema, nocturia, leg pain or cramps (claudication), changes in skin color, obesity, medications being taken, cardiovascular risk factors family history of cardiac or vascular problems, personal history of cardiac or vascular problems. Inspection: Inspect the anterior chest for pulsations (apical impulse) created as the left ventricle rotates against the chest wall during systole; not always visible. Palpation: Palpate the apical impulse at the fourth or fifth interspace, or medial to the midclavicular line (not palpable in obese clients or clients with thick chest walls). Percussion: May be performed to outline the heart's borders and to check for cardiac enlargement (denoted by resonance over the lung and dull notes over the heart). Auscultation: Auscultate heart rate and rhythm; check for a pulse deficit (auscultate the apical heartbeat while palpating an artery) if an irregularity is noted. Assess S1 ("lub") and S2 ("dub") sounds, and listen for extra heart sounds, as well as the presence of murmurs (blowing or swooshing noise that can be faint or loud with a high, medium, or low pitch).
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States Subjective data Findings
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Inspection Findings
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Palpation Findings
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Percussion Findings
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Auscultation findings
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Assesses for Rhythm
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Jugular Venous Distension
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Cardiac Regularity
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Checks for any pacemaker/Implants ?
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Peripheral Vascular System
Peripheral Vascular System Inspect the lower extremities for changes in color and skin condition. Note skin and nail texture, hair distribution, venous patterns, edema, and scars or ulcers. Compare the skin color while the patient is lying and then while standing. Changes like bilateral edema in the lower extremity is indicative of heart failure. Check capillary refill: Grasp the patient's fingernail or toenail, note the color of the nail bed, and apply gentle, firm pressure to the nail bed. Release quickly, watching for color change. Normally, circulation is restored and returns to a pink color in 2 to 3 seconds
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Is the nurse able to explain how to inspect the lower extremities Eg changes in color and skin condition.
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Note skin and nail ,edema, and scars or ulcers. Compare the skin color.
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Capillary refill: Normally, Eg 2 to 3 seconds
Integumentary
Integumentary System The integumentary system is comprised of the skin, hair, nails and exocrine glands. The nurse will inspect the skin color and note any alterations in appearance, including any differences in color or pigmentation (such as hyperpigmentation, hypopigmentation, cyanosis or jaundice). The nurse will also inspect the skin for any lesions. The nurse can evaluate hydration by assessing skin turgor. The nurse will gently pinch the skin over the sternum or on the forehead for adults.
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Is the nurse able to state of skin generally ?
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Braden Scale Scoring , (Moisture ,Activity , Mobility and Friction)<br>
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checked skin, hair, nails and exocrine glands,
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skin color and note any alterations in appearance, including any differences in color or pigmentation (such as hyperpigmentation, hypopigmentation,
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cyanosis
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or <br>jaundice).
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The nurse will also inspect the skin for any lesions
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Check for skin turgor.?
Musculoskeletal<br>
Musculoskeletal Inspection: Inspect gait and posture, and for cervical, thoracic, and lumbar curves. Palpation: Palpate all bones, joints, and surrounding muscles. Assess muscle tone and strength during measurement of range of motion.
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States -Inspect gait
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posture
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cervical, thoracic, <br>
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and lumbar curves,
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bones,
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joints,
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surrounding muscles.
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States muscle tone and strength during measurement of range of motion
Abdomen<br>
Abdomen Warm hands and stethoscope before touching client's abdomen. Subjective data: Changes in appetite or weight, difficulty swallowing, dietary intake, intolerance to certain foods, nausea or vomiting, pain, bowel habits, medications currently being taken, history of abdominal problems or abdominal surgery. Inspection: Inspect for contour, symmetry, umbilicus, skin surface, pulsations and peristaltic waves. Changes in contour and symmetry reveals underlying masses, gaseous distention and fluid accumulation within the peritoneal cavity (Ascites). Auscultation: Note the character and frequency of normal bowel sounds: high-pitched gurgling sounds occurring irregularly from 5 to 30 times a minute. Identify as normal, hypoactive, or hyperactive (borborygmus). Absent sounds: Auscultate for 5 minutes before determining that sounds are absent. Auscultate all four quadrants for bowel sounds; starting in the lower right quadrant. Percussion: All 4 quadrants are percussed lightly including the borders of the liver and spleen. Tympany should predominate over the abdomen, with dullness over the liver and spleen. Palpation: Begin with light palpation of all 4 quadrants, using the fingers to depress the skin about ,1 cm; next perform deep palpation, depressing 5 to 8 cm
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States the appetite or weight,<br>to certain foods, checked for any masses , or abnormalities
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States Difficulty swallowing, dietary intake, intolerance
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States Subjective Data
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Bowel sounds ,
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Abdominal Distension,
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liver or spleen - abnormal sounds noted ,
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Stools
Genitourinary System<br>
Genitourinary System Subjective data: Urinary difficulties or symptoms such as frequency, urgency, or burning; vaginal discharge; pain; lesions or discharges; medications being taken; family history of diabetes and daily fluid intake
Female /Male Urinary difficulties or symptoms such as frequency, urgency, or burning; vaginal discharge; pain; lesions or discharges; medications being taken; family history of diabetes and daily fluid intake.
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If female patient the nurse able to state the Genitourinary Findings
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If male patient is the nurse able to state the Genitourinary findings
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Urine Incontinence, Urine Color , Odor , Consistency , Amount
Reproductive System
The nurse states any reproductive history, sexually transmitted diseases, Female menstrual history, (obstetrical history and contraceptive use Able to state any abnormalities in the external genitalia )
Female Reproductive System The nurse should review the client's reproductive history, including any information about sexually transmitted diseases, menstrual history, obstetrical history and contraceptive use. The nurse will inspect the external genitalia for hair distribution, condition of the skin of the perineum, urethral orifice and vaginal orifice and anus.
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If Female Patient is the nurse able to State findings
Male Reproductive System The nurse will inspect the external genitalia for distribution of hair and the skin of the penis, urethral meatus and scrotum. Expected findings include symmetry of the scrotum, with the left testicle slightly lower than the right.
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Male (Condition of the urethral meatus and scrotum) , state if there are any abnormalities
Psychosocial
Patients mood , behavior, needs expressed, feelings , thoughts expressed, understands others .
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Is the nurse able to state the psychosocial findings
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