Title Page
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Conducted on
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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 Knowledge of the patients condition and plan
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Is the primary nurse able to handover the patients using the ISBAR Hand Over?
Neurological Assessment
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Level of consciousness
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Eye
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Motor
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Verbal
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Motor Strength
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Sensory level
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Chest ,Head, Neck and Lymph Nodes
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Head Abnormalities EG Size, shape, masses or tenderness, and symmetry of the skull.<br>Face: e.g. shape, symmetry, involuntary movements, or swelling Throat <br>Respiratory :Pattern , Depth and Rhythm
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Neck<br> Inspect for symmetry of accessory neck muscles.<br> Assess range of motion.<br>
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Lymph Nodes<br> Palpate and note their size, shape, location, mobility, consistency, and tenderness
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Ear
Thorax and Lungs
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Breath Sounds <br> Cough; expectoration of sputum; shortness of breath or dyspnea; chest pain on <br>breathing; history of respiratory disease or infection
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Oral Secretion's Color ,Amount , Consistency,
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Note if there are lumps or lesions, note the shape and configuration of the chest<br>state if there are areas of tenderness and lumps, lesions, or masses,<br> Type of breath sounds Normal breath sounds: eg. Vesicular, Broncho vesicular, and Bronchial breath sounds. OR <br> Abnormal breath sounds: Also known as Adventitious sounds
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Cardiovascular System (Heart
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States if there is presence of the FFG <br> Heart Sounds <br>Assess S1 ("lub") and S2 ("dub") sounds, and listen for extra <br>heart sounds, as well as the presence of murmurs (blowing <br>or swooshing noise that can be faint or loud with a high, <br>medium, or low pitch) Cardiac Regularity /Rhythm . Jugular Venous Distension
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Is the Bedside Cardiac monitor placed on patient
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Pacemaker
Peripheral Vascular System
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Is the nurse able to explain how to inspect the lower extremities Eg changes in color and skin condition. Note skin and nail ,edema, and scars or ulcers. Compare the skin color while the <br>patient is lying and then while standing.. Capillary refill: Normally, Eg 2 to 3 seconds
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Integumentary
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Is the nurse able to state of skin generally ,Braden Scale Scoring Sensory , Moisture ,Activity , Mobility and Friction<br>checked skin, hair, nails and exocrine glands,skin color and note any alterations in appearance, including any <br>differences in color or pigmentation (such as hyperpigmentation, hypopigmentation, cyanosis or <br>jaundice). The nurse will also inspect the skin for any lesions ,skin turgor. T
Musculoskeletal<br>
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States Inspect gait and posture, and for cervical, thoracic, and lumbar curves, bones, joints, and surrounding muscles.<br>States muscle tone and strength during measurement of range of motion
Abdomen<br>States the appetite or weight, difficulty swallowing, dietary intake, intolerance<br>to certain foods, checked for any masses , or abnormalities Bowel sounds , Abdominal Distension, liver or spleen - abnormal sounds noted , Stools.
Genitourinary System<br>
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Urinary difficulties or symptoms such as frequency, urgency, or burning; vaginal <br>discharge; pain; lesions or discharges; medications being taken; family history of diabetes and <br>daily fluid intake.
Female Reproductive System
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The nurse states any reproductive history, or <br>sexually transmitted diseases, menstrual history, obstetrical history and contraceptive use Able to state any abnormalities in the external genitalia .
Male Reproductive System
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Condition of the <br>urethral meatus and scrotum , state if there are any abnormalities
Urine Assessment
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Urine Incontinence, Urine Color , Odor , Consistency , Amount
Psychosocial
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Patients mood , behavior, needs expressed, feelings , thoughts expressed, understands others .
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