Page 1 Patient assessment
A- announce and introduce yourself
W- wash hands (prior to giving any patient care)
I- identified patient utilizing two identify : inquire any allergies to medication, food, or latex.
P- provide for privacy closing the curtain. Wash hands after touching the curtain.
E- explained the patient why are you there and what the procedure is.
Assess the room to make sure it is clean (prepare environment effectively for procedure).
Perform a second identify verifying physicians order to patients wristband.
Ask patient about any pain (0-10 scale), ask about any cultural consideration and if it’s okay to
proceed.
Assess time place and person: ask current date, place and person.
Raise the bed to a working height (waist)
head and neck
position bed to a 45° upright (patient will be sitting in bed).
assess the overall hygiene of patient. State patients hair is well-groomed, hair is equally
distributed Hair is not dry and brittle
I’m going to palpate your head. I feel no bumps no lumps or see any laceration.
I’m going to inspect your ears skin is intact, I see no redness or drainage no excessive cerumen is
seen.
I’m observing the patient’s face skin color is normal for ethnicity and intact. I’m going to palpate
your skin of your face with the back of my hand. Warm to touch. And at this time going to
palpate your face to check for any tenderness around sinus area (forehead and cheeks)
Palpate the neck. Check for any swollen lymph nodes under jaw and neck.
Have the patient look both sides to check for JVD (Jugular vein distention).
I’m going to dim the light of the room. Check pupils for response and size (3mm).
Check nostril for drainage, laceration and polyps, mucous membrane pink and moist. Septum is
midline. No sores in nose.
Check mouth. Inquire if they have dentures. (if so have them remove them to inspect gums.
Moist mucous membrane, no cavities, no sores. Lips moist and supple, open mouth uvula
midline.
, Page 2.
Have the patient frown, puff the checks, and smile no visible signs of drooping. (could indicate a
stroke).
Turn light on . Check eyes by having patient follow movement of penlight: up, down, side to
side, far away and moving closer. PERRLA- pupils equal round reactive to light and
accommodation (cranial nerve oculomotor).
Place both hands on patient shoulders have him/her shrug.
Chest and back
Indicate to patient at this time you will remove the gown partially. (lower gown to expose chest).
Observe chest skin color (normal for ethnicity, skin warm to touch, hair equally distributed).
Observe landmarks:
Suprasternal notch, manubrium, and angle of louis.
Auscultate lung sounds anteriorly- instruct patient to take deep breath through mouth as you
move stethoscope side to side.
Ask for any coughs, difficult breathing, or sputum
A- announce and introduce yourself
W- wash hands (prior to giving any patient care)
I- identified patient utilizing two identify : inquire any allergies to medication, food, or latex.
P- provide for privacy closing the curtain. Wash hands after touching the curtain.
E- explained the patient why are you there and what the procedure is.
Assess the room to make sure it is clean (prepare environment effectively for procedure).
Perform a second identify verifying physicians order to patients wristband.
Ask patient about any pain (0-10 scale), ask about any cultural consideration and if it’s okay to
proceed.
Assess time place and person: ask current date, place and person.
Raise the bed to a working height (waist)
head and neck
position bed to a 45° upright (patient will be sitting in bed).
assess the overall hygiene of patient. State patients hair is well-groomed, hair is equally
distributed Hair is not dry and brittle
I’m going to palpate your head. I feel no bumps no lumps or see any laceration.
I’m going to inspect your ears skin is intact, I see no redness or drainage no excessive cerumen is
seen.
I’m observing the patient’s face skin color is normal for ethnicity and intact. I’m going to palpate
your skin of your face with the back of my hand. Warm to touch. And at this time going to
palpate your face to check for any tenderness around sinus area (forehead and cheeks)
Palpate the neck. Check for any swollen lymph nodes under jaw and neck.
Have the patient look both sides to check for JVD (Jugular vein distention).
I’m going to dim the light of the room. Check pupils for response and size (3mm).
Check nostril for drainage, laceration and polyps, mucous membrane pink and moist. Septum is
midline. No sores in nose.
Check mouth. Inquire if they have dentures. (if so have them remove them to inspect gums.
Moist mucous membrane, no cavities, no sores. Lips moist and supple, open mouth uvula
midline.
, Page 2.
Have the patient frown, puff the checks, and smile no visible signs of drooping. (could indicate a
stroke).
Turn light on . Check eyes by having patient follow movement of penlight: up, down, side to
side, far away and moving closer. PERRLA- pupils equal round reactive to light and
accommodation (cranial nerve oculomotor).
Place both hands on patient shoulders have him/her shrug.
Chest and back
Indicate to patient at this time you will remove the gown partially. (lower gown to expose chest).
Observe chest skin color (normal for ethnicity, skin warm to touch, hair equally distributed).
Observe landmarks:
Suprasternal notch, manubrium, and angle of louis.
Auscultate lung sounds anteriorly- instruct patient to take deep breath through mouth as you
move stethoscope side to side.
Ask for any coughs, difficult breathing, or sputum
