SYSTEMS ASSESSMENT

NEUROLOGICAL ABNORMALITIES/COMMENTS
Best Verbal □ Oriented X____ □ Confused □ Inappropriate words
Response □ Incomprehensible sounds □ None
Sensation □ Intact □ Numbness _______________________
□ Absent □ Tingling _________________________
Communication □ Verbal □ Writes notes □ Mouths words
□ Nods head appropriately to yes/no questions
Miscellaneous □ Restless □ Drowsy □ Paralyzed (med.) □ Sedated
□ Restraints
General □ Unassisted □ Assisted □ Supervised □ Unable
Movement □ Weakness _____________ Paralysis __________________
Pain/Discomfort See Pain Assessment Sheet
Precautions □ None □ Seizure □ Spinal □ Fall □ Aspiration
PSYCHOLOGICAL/SOCIAL
Psychological □ Cooperative □ Uncooperative □ Anxious
□ Panicked □ Angry □ Tearful □ Talkative
□ Depressed □ Withdrawn
Significant □ N/A □ Effective
Other Coping □Needs Assistance __________________________ (specify)
RESPIRATORY
Respirations □ Eupneic (normal) □ Dyspneic
□ Periods of apnea □ Labored
□ Accessory muscle use □ Tachypneic
ANTERIOR POSTERIOR
R L L R

(Mark lung sounds on diagram: clear, diminished, crackles, rales, rhonchi, wheezes, absent)

Oxygen □ Room Air (RA) □ Nasal Cannula (NC) □ Mask □ O2 ________

Delivery □ Trach Sz.____ □ ET □ Vent Settings: FiO2 ______% TV
______mL Mode_____ Rate_____ Other ____________________
O2 □ N/A □ Periodic checks □ Continuous pulse oximeter
Saturation
Chest Config. □ Symmetrical □ Asymmetrical □ Flail
Cough □ No cough □ Weak □ Strong
□ Productive Sputum color ____________ □ Nonproductive
CARDIOVASCULAR
Heart Sounds: □ S1 □ S2 □ S3 □ S4 □ Other _______________________
Murmur: □ None Location ______________ Grade (I-VI) _______
Rhythm _____________________________ □ Regular □ Irregular
Arterial Pulses C B R F DP PT D-Doppler
A R A E A-Absent
R A D M 1+ - Barely Palpable
2+ - Weak Pt. Information
L R L R L R L R L R L R 3+ - Normal
4+ - Full Bounding
Initials / Room #
Capillary Refill □ Brisk □ Prolonged ____________sec.
Edema □ None □ Anasarca (generalized) □ JVD (@45° angle)
□ Non-pitting □ Pitting 1 + 2 + 3 + 4 (circle)
 GENITOURINARY ABNORMALITIES/COMMENTS
□ Voiding □ Incontinent □ Catheter □ Size __________French
GU Drainage □ 2-way catheter
□ Continuous Bladder Irrigation (CBI)
□ Clear □ Cloudy □ Sediment □ Blood Clots
Urine □ Light Yellow □ Dark Yellow □ Orange
□ Hematuria □ Other _________________
Genitalia □ Normal □ Bruised □ Swollen □Other_________________
GASTROINTESTINAL
Abdomen □ Soft □ Firm □ Hard □ Tender □ Distended
Bowel Sounds □ Normal □ Hyperactive □ Hypoactive □ Absent
GI Clamp Gravity Suction Color Comments
Drainage Tubes

Diet □ Type _________________ □ Tube Feeding _____mL/hr □ NPO □

TPN
Stool □ Formed □Loose □ Impacted Color: __________

Appliance □ Colostomy □ Ileostomy □ Rectal tube

Stoma □ N/A □ Pink □ Edematous □ Dusky
OTHER DRAINS/TUBES/SKIN
Drain/Tube Location Drainage Site Dressing (Dry/Intact?)
Type Appearance

SKIN ASSESSMENT KEY

A-Abrasion E-Ecchymosis S-Sutures/Staples D-Decubitus Ulcer
I-Inflammation C-Incision L-Laceration Sd-Surgical Drain
Skin Turgor □ Normal □ Loose □ Tight □ Shiny
Skin Temperature/Moisture □ Hot □ Warm □ Cool □ Cold
□ Dry □ Clammy □ Diaphoretic
Skin □ Normal □ Pale □ Cyanotic
Color □ Flushed □ Jaundiced □ Mottled
Mucus □ Moist □ Dry □ Cracked □ Lesions
Membranes □ Dusky/Cyanotic □ Other __________________
Isolation/Precautions □ None Type _______________ Location _____________
Date Time Signature