Guidelines for Initial Assessment Notes
| Assessment Area | Criteria |
|---|---|
| Neurological | Level of consciousness, orientation, verbal response, pupil size and reaction, incisions or head dressings, intracranial pressure monitor, sensory or mobility deficits (if applicable, expand musculoskeletal—mobility limitations, cast or traction, and extremity status) Safety measures: side rails, restraints (skin status and care) |
| Respiratory | Respiratory rate, depth, character, dyspnea, symmetry of chest movement, breath sounds, secretions, cough, incisions, dressings, oxygen therapy, chest tubes |
| Circulatory | Skin color, temperature, capillary refill, heart sounds, pulse rate, rhythm, ECG pattern (if available), heart sounds, pulse assessment (absent to 4+), skin turgor, edema, neck vein distention, hemodynamic pressures (if available), intravenous therapy (with counts), incisions/dressings |
| Gastrointestinal | Bowel sounds, shape and feel of abdomen, tenderness, nausea, emesis, diet and intake, dysphagia, bowel movements, nasogastric tube/tube feeding, ostomy site, stoma, drainage and care, incision/dressings |
| Genitourinary | Urinary output, continence, appearance of urine, Foley catheter status |
| Supportive therapy | Wound drains, irrigations, invasive lines, paincontrol measures (transcutaneous electrical nerve stimulation unit, patient-controlled analgesia pump) |