CHAPTER 29

Bedside Assessment of the

Hospitalized Adult

Subjective and Objective Data

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Assist the patient into bed. During the examination,

the patient is in bed, and the bed is at a level
comfortable for the examiner. Both subjective
and objective data are collected
simultaneously throughout the bedside
assessment using a systems approach.
Abnormal findings may prompt a more
comprehensive assessment of the affected
systems

THE HEALTH HISTORY

creates/maintains safe environment,

professionalism (introduction, patient
verification,)

On your way into the patient's room, verify that

any necessary markers or flags are in place at
the doorway with regard to such conditions as
isolation precautions, latex allergies, or fall
precautions. Once in the room, introduce
yourself as the patient's nurse for the next 8
(or 12) hours.
Make direct eye contact, and do not allow
yourself to be distracted by intravenous (IV)
pumps or other equipment as you ask how he
or she is feeling and how he or she spent the
previous shift. Refer to what you have heard
from the previous shift in the process of your
own questioning; this alleviates the patient's
frustration with answering the same questions
every time with a new staff member. Assess
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for pain: “Are you currently having any pain

or discomfort?” You should know when pain
medication was most recently administered
and what physician orders are written.
Determine whether further dosing is needed
or whether you need to contact the physician.
With regard to the written orders, confirm
settings on the patient-controlled analgesia
(PCA) pump or epidural setting if one of
these is in place. Confirm that the IV solution
hanging matches orders for rate and type.

Wash your hands in the patient's presence. Offer

water as a courtesy if the patient is allowed
water, but also note the physical data that this
offer elicits: the patient's ability to hear, to
follow directions, to cross the midline, and,
especially, ability to swallow. Complete your
initial overview by verifying that the correct
name band has been applied to the patient's
wrist. As you proceed with the examination
continue to question the patient to elicit both
subjective and objective data related to each
of the body systems. As you collect and
document these data, note the following.

GENERAL APPEARANCE 1-8

1. Facial expression: whether appropriate for the

situation.
2. Body position: whether (a) relaxed and
comfortable or (b) tense or in pain.
3. Level of consciousness: whether alert and
oriented, attentive to your questions, and
responding appropriately.
4. Skin colour: whether tone is even and consistent
with ethnocultural heritage.
5. Nutritional status: whether weight appears in
healthy range, fat distribution is even, and
hydration appears healthy.
6. Speech: whether articulation is clear and
understandable, pattern is fluent and even, and
content is appropriate.
7. Hearing: whether responses and facial expression
are consistent with what you have said.
8. Personal hygiene: ability to attend to hair,
makeup, shaving.
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MEASUREMENT

NOT TESTED for demonstration (but

still part of assessment in real life)

1. Measure baseline vital signs now: temperature,

pulse, respirations, BP. Note whether you
must avoid an arm because of surgery or IV
access. Collect and document vital signs more
frequently if the patient is unstable or if the
patient's condition changes.
2. Measure oxygen saturation (pulse oximetry):
Maintain at 92% or higher, or as ordered.
3. Ask the patient to rate pain level on scale of 0
to 10, at rest and with activity, and note
location of pain.
4. Assess pain intensity on scale of 0 to 10 before
and after administration of analgesics; note
response in 15 minutes for IV administration
and in 1 hour for oral administration.

NEUROLOGICAL SYSTEM

1, 3-7, and 9

OMIT 2, 8

1. Note whether the patient's eyes open

spontaneously to name.
X 2. Note whether the patient's motor response is
strong and equal bilaterally.
3. Note whether the patient's verbal response
makes sense and the speech is clear and
articulate.
4. Measure right and left pupil sizes in
millimetres, and assess reaction to light.
5. Assess muscle strength of right and left upper
extremities, with the use of hand grips.
6. Assess muscle strength of right and left lower
extremities, pushing feet against your palms.
7. Note any ptosis or facial droop.
X 8. Evaluate sensation (omit unless indicated).
9. Assess the patient's ability to swallow.
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RESPIRATORY SYSTEM

3-6

OMIT 1, 2, 7

X 1. If the patient is receiving oxygen by mask or

nasal prongs, check fitting.
X 2. Note fraction of inspired oxygen (FiO ).2

3. Assess respiratory effort.

4. Inquire whether short of breath at rest or on
exertion.
5. Auscultate breath sounds, and compare sides:
Anterior lobes: right upper, left upper, right
middle and lower, left lower
Posterior lobes: left upper, right upper, left
lower, right lower (If the patient is not able to
sit up, have another nurse hold patient to each
side.)
6. Instruct the patient to cough and breathe
deeply. If any mucus is expelled, check
colour and amount.
X 7. If use of an incentive spirometer is ordered,
encourage the patient to use it every hour for
10 inspirations. If pulse oximetry percentage
or respiratory rate drops, encourage its use
every 15 minutes.
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CARDIOVASCULAR SYSTEM

1-6   (steps 1-3 can be done on

chester)

OMIT-7

1. Auscultate rhythm at apex: Is it regular or

irregular? (Do not listen over the patient's
gown.)
2. Check apical pulse against radial pulse, noting
perfusion of all beats.
3. Assess heart sounds in all auscultatory areas:
first with the diaphragm of the stethoscope
and then with the bell.- left side (bell,
apical)), leaning forward (Diaphragm A and
P)
4. Check capillary refill for prompt return. (need
to do hand only)
5. Check for pretibial edema.
6. Palpate the posterior tibial pulse and dorsalis
pedis pulse in both feet. (Be prepared to
assess pulses in the lower extremities by
Doppler technique, if you cannot find them by
palpation.)
X7. Verify that the correct IV solution is hanging
and flowing at the correct rate according to
both the physician's orders and your own
assessment of the patient's needs.
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SKIN

1-4

OMIT 5-7

1. Note skin colour and whether it is consistent

with the patient's ethnocultural heritage.
2. Palpate skin temperature; expect the skin to be
warm and dry.
3. Pinch up a fold of skin under the clavicle or on
the forearm to note mobility and turgor.
4. Note skin integrity, any lesions, and the
condition of any dressings. Note any bleeding
or infection, but do not change dressing until
after physical examination.
X5. Note the date on the IV site and the
surrounding skin condition.
X6. Complete any standardized scales used to
quantify the risk of skin breakdown (see
Braden Risk Assessment Scale in Table 13-1,
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p. 230).
X 7. Verify that any air loss or alternating
pressure mattresses being used are properly
applied and operating at the correct settings.

ABDOMEN

1-5, 8

OMIT 6-7

1. Assess contour of abdomen: flat, rounded, or

protuberant.
2. Listen to bowel sounds in all four quadrants.
3. Perform light palpation in all four quadrants.
4. Inquire whether nauseated or vomiting.
5. Inquire whether the patient is passing flatus or
stool, or experiencing constipation or
diarrhea. Note date of most recent bowel
movement.
X 6. Check any drainage tube placement for
colour, consistency, odour, and amount of
drainage, and evaluate the integrity of the
insertion site. Assess all tubes from site to
source for kinks, leaks, and disconnections.
X 7. Check any stoma for colour, moisture,
excoriation, and bleeding, and evaluate the
integrity of the stomal appliance. Check
stomal drainage for colour, consistency,
odour, and amount.
8. With regard to diet orders, determine whether
the patient is tolerating ice chips, liquids, or
solids. Order the correct diet as it is advanced.
Note whether the patient is at high risk for
nutrition deficit.

GENITOURINARY SYSTEM  

1-2

OMIT 3, 4

1. Inquire whether the patient is voiding

regularly, or assess the indwelling urinary
catheter if indicated.
2. Check urine for colour and clarity.
X 3. If a Foley catheter is in place, check colour,
quantity, and clarity of urine with every check
of vital signs.
X 4. If urine output is less than the expected
amount, perform a bladder scan according to
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agency protocol. Determine whether the

problem is associated with the production of
urine or its retention.

ACTIVITY

ACTIVITY - NOT TESTED for

demonstration (but still part of
assessment in real life)     

1. With regard to activity orders, if the patient is

on bed rest, the head of bed should be angled
at 15 degrees or higher. Note whether the
patient is at high risk for skin breakdown.
2. If the patient is ambulatory, assist the patient
to a sitting position, and move him or her to a
chair. Increase activity as tolerated.
3. Note any assistance needed, how the patient
tolerates movement, the distance walked to
the chair, and the patient's ability to turn.
4. Note any need for ambulatory aid or
equipment.
5. Complete any standardized scales used to
quantify the patient's risk for falling.
6. If antiembolism compression (T.E.D.)
stockings and sequential compression devices
(SCDs) are ordered, the patient needs to use
them 22 of 24 hours. SCDs must be hooked
up and turned on, except during ambulation.

REPORT CRITICAL FINDINGS

Note examination findings that necessitate

immediate attention:

1. Systolic BP ≤ 90 or ≥160 mmHg

2. Temperature ≥ 38°C
3. Heart rate ≤ 60 or ≥ 100 bpm
4. Respiratory rate ≤ 10/minute or ≥ 28/minute
5. Oxygen saturation ≤ 92%
6. Urine output < 30 mL/hour for 2 hours
7. Dark amber urine or bloody urine (except for
urology patients)
8. Postoperative nausea or vomiting not relieved
with medication
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9. Surgical pain not controlled with medication;

any other unusual pain, such as chest pain
10. Bleeding
11. Altered level of consciousness, confusion
12. Sudden restlessness or anxiety
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