Nursing assessment is an important step of the whole nursing process.

Assessment can be called

the “base or foundation” of the nursing process. With a weak or incorrect assessment, nurses can
create an incorrect nursing diagnosis and plans therefore creating wrong interventions and
evaluation. To prevent those kind of scenarios, we have created a cheat sheet that you can print
and use to guide you throughout the first step of the nursing process.

SEE ALSO: Nursing Health Assessment Mnemonics & Tips

Physical Assessment

Integument

 Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor. He has
a good skin turgor and skin’s temperature is within normal limit.
 Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of
body hair. There are also no signs of infection and infestation observed.
 Nails: The client has a light brown nails and has the shape of convex curve. It is smooth and is
intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails return
to usual color in less than 4 seconds.

Head

 Head: The head of the client is rounded; normocephalic and symmetrical.

 Skull: There are no nodules or masses and depressions when palpated.
 Face: The face of the client appeared smooth and has uniform consistency and with no presence
of nodules or masses.

Eyes and Vision

 Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned and
showed equal movement when asked to raise and lower eyebrows.
 Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.
 Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically
with involuntary blinks approximately 15-20 times per minute.
 Eyes
o The Bulbar conjunctiva appeared transparent with few capillaries evident.
o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and pink.
o There is no edema or tearing of the lacrimal gland.
o Cornea is transparent, smooth and shiny and the details of the iris are visible. The client
blinks when the cornea was touched.
o The pupils of the eyes are black and equal in size. The iris is flat and round. PERRLA
(pupils equally round respond to light accommodation), illuminated and non-illuminated
pupils constricts. Pupils constrict when looking at near object and dilate at far object.
Pupils converge when object is moved towards the nose.
o When assessing the peripheral visual field, the client can see objects in the periphery
when looking straight ahead.
 o When testing for the Extraocular Muscle, both eyes of the client coordinately moved in
unison with parallel alignment.
o The client was able to read the newsprint held at a distance of 14 inches.

Ears and Hearing

 Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles are
aligned with the outer canthus of eye. When palpating for the texture, the auricles are mobile,
firm and not tender. The pinna recoils when folded. During the assessment of Watch tick test,
the client was able to hear ticking in both ears.

Nose and Sinus

 Nose: The nose appeared symmetric, straight and uniform in color. There was no presence of
discharge or flaring. When lightly palpated, there were no tenderness and lesions
 Mouth:
o The lips of the client are uniformly pink; moist, symmetric and have a smooth texture.
The client was able to purse his lips when asked to whistle.
o Teeth and Gums: There are no discoloration of the enamels, no retraction of gums,
pinkish in color of gums
o The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening and
with elastic texture.
o The tongue of the client is centrally positioned. It is pink in color, moist and slightly
rough. There is a presence of thin whitish coating.
o The smooth palates are light pink and smooth while the hard palate has a more irregular
texture.
o The uvula of the client is positioned in the midline of the soft palate.
 Neck:
o The neck muscles are equal in size. The client showed coordinated, smooth head
movement with no discomfort.
o The lymph nodes of the client are not palpable.
o The trachea is placed in the midline of the neck.
o The thyroid gland is not visible on inspection and the glands ascend during swallowing
but are not visible.

Thorax, Lungs, and Abdomen

 Lungs / Chest: The chest wall is intact with no tenderness and masses. There’s a full and
symmetric expansion and the thumbs separate 2-3 cm during deep inspiration when assessing
for the respiratory excursion. The client manifested quiet, rhythmic and effortless respirations.
 The spine is vertically aligned. The right and left shoulders and hips are of the same height.
 Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no presence
of heaves or lifts.
 Abdomen: The abdomen of the client has an unblemished skin and is uniform in color. The
abdomen has a symmetric contour. There were symmetric movements caused associated with
client’s respiration.
o The jugular veins are not visible.
 o When nails pressed between the fingers (Blanch Test), the nails return to usual color in
less than 4 seconds.

Extremities

 The extremities are symmetrical in size and length.

 Muscles: The muscles are not palpable with the absence of tremors. They are normally firm and
showed smooth, coordinated movements.
 Bones: There were no presence of bone deformities, tenderness and swelling.
 Joints: There were no swelling, tenderness and joints move smoothly.

Nursing Assessment in Tabular Form

Assessment Findings

Integumentary

When skin is pinched it goes to previous state

 Skin immediately (2 seconds).
With fair complexion.
With dry skin
Evenly distributed hair.
 Hair
With short, black and shiny hair.
With presence of pediculosis Capitis.
Smooth and has intact epidermis
 Nails With short and clean fingernails and toenails.
Convex and with good capillary refill time of 2
seconds.
Rounded, normocephalic and symmetrical, smooth
Skull and has uniform consistency.Absence of nodules or
masses.

Symmetrical facial movement, palpebral fissures

Face
equal in size, symmetric nasolabial folds.

Eyes and Vision

Hair evenly distributed with skin intact.

 Eyebrows
Eyebrows are symmetrically aligned and have
equal movement.
 Eyelashes
Equally distributed and curled slightly outward.

 Eyelids Skin intact with no discharges and no discoloration.

Lids close symmetrically and blinks involuntary.
 Assessment Findings

 Bulbar conjunctiva
Transparent with capillaries slightly visible

 Palpebral Conjunctiva
Shiny, smooth, pink

 Sclera
Appears white.

 Lacrimal gland, Lacrimal sac, Nasolacrimal

No edema or tenderness over the lacrimal gland
duct
and no tearing.

Cornea

Transparent, smooth and shiny upon inspection by

 Clarity and texture
 Corneal sensitivity
Pupils
the use of a penlight which is held in an oblique
angle of the eye and moving the light slowly across
the eye.
Has [brown] eyes.
Blinks when the cornea is touched through a
cotton wisp from the back of the client.
Black, equal in size with consensual and direct
reaction, pupils equally rounded and reactive to
light and accommodation, pupils constrict when
looking at near objects, dilates at far objects,
converge when object is moved toward the nose at
four inches distance and by using penlight.

When looking straight ahead, the client can see

objects at the periphery which is done by having
the client sit directly facing the nurse at a distance
of 2-3 feet.
Visual Fields
The right eye is covered with a card and asked to
look directly at the student nurse’s nose. Hold
penlight in the periphery and ask the client when
the moving object is spotted.

Able to identify letter/read in the newsprints at a

distance of fourteen inches.
Visual Acuity
Patient was able to read the newsprint at a
distance of 8 inches.

Ear and Hearing

 Auricles Color of the auricles is same as facial skin,

symmetrical, auricle is aligned with the outer
 Assessment Findings

canthus of the eye, mobile, firm, non-tender, and

pinna recoils after it is being folded.
 External Ear Canal
Without impacted cerumen.

 Hearing Acuity Test

Voice sound audible.

Able to hear ticking on right ear at a distance of

 Watch Tick Test
one inch and was able to hear the ticking on the
left ear at the same distance
Nose and sinuses

Symmetric and straight, no flaring, uniform in

 External Nose
color, air moves freely as the clients breathes
through the nares.
 Nasal Cavity Mucosa is pink, no lesions and nasal septum intact
and in middle with no tenderness.
Symmetrical, pale lips, brown gums and able to
Mouth and Oropharynx
purse lips.

 Teeth
With dental caries and decayed lower molars

Central position, pink but with whitish coating

 Tongue and floor of the mouth
 Tongue movement
Uvula
which is normal, with veins prominent in the floor
of the mouth.
Moves when asked to move without difficulty and
without tenderness upon palpation.
Positioned midline of soft palate.

Present which is elicited through the use of a

Gag Reflex
tongue depressor.

Positioned at the midline without tenderness and

Neck
flexes easily. No masses palpated.

Coordinated, smooth movement with no

Head movement discomfort, head laterally flexes, head laterally
rotates and hyperextends.

Muscle strength With equal strength

Lymph Nodes Non-palpable, non tender

 Assessment Findings

Not visible on inspection, glands ascend but not

 Thyroid Gland
visible in female during swallowing and visible in
males.
Thorax and lungs

Posterior thorax Chest symmetrical

Spine vertically aligned, spinal column is straight,

 Spinal alignment
left and right shoulders and hips are at the same
height.
Breath Sounds With normal breath sounds without dyspnea.

 Anterior Thorax
Quiet, rhythmic and effortless respiration

Unblemished skin, uniform in color, symmetric

Abdomen
contour, not distended.

Abdominal movements Symmetrical movements cause by respirations.

 Auscultation of bowel sounds

With audible sounds of 23 bowel sounds/minute.

Upper Extremities Without scars and lesions on both extremities.

Lower Extremities With minimal scars on lower extremities

Equal in size both sides of the body, smooth

Muscles coordinated movements, 100% of normal full
movement against gravity and full resistance.

Bones and Joints No deformities or swelling, joints move smoothly.

Mental Status

Language Can express oneself by speech or sign.

Orientation Oriented to a person, place, date or time.

Able to concentrate as evidence by answering the

Attention span
questions appropriately.

A total of 15 points indicative of complete

Level of Consciousness
orientation and alertness.

Motor Function
 Assessment Findings

Gross Motor and Balance

 Walking gait Has upright posture and steady gait with opposing
arm swing unaided and maintaining balance.
Standing on one foot with eyes closed Maintained stance for at least five (5) seconds.

Heel toe walking Maintains a heel toe walking along a straight line

Toe or heel walking Able to walk several steps in toes/heels.

Fine motor test for Upper Extremities

Finger to nose test Repeatedly and rhythmically touches the nose.

Alternating supination and pronation of hands on Can alternately supinate and pronate hands at
knees rapid pace.

Finger to nose and to the nurse’s finger Perform with coordinating and rapidity.

Fingers to fingers Perform with accuracy and rapidity.

Rapidly touches each finger to thumb with each

Fingers to thumb
hand.

Fine motor test for the Lower Extremities

Able to discriminate between sharp and dull

Pain sensation
sensation when touched with needle and cotton.