Before entering the room, review: the patient's primary diagnosis and admitting history; current medication list (particularly high-alert drugs, anticoagulants, vasopressors, sedation); most recent vital signs and trends; pending lab results or diagnostic studies; allergies; code status; isolation precautions required. This pre-assessment review lets you enter the room knowing what to look for — not discovering the diagnosis after you've already been in the room for 10 minutes.
Before any system-specific assessment, form an overall impression: Does the patient appear sick or well? What is their level of distress? Are they alert and tracking you, or are they confused, sedated, or unresponsive? What is their skin color and perfusion? Are they in pain? Is their breathing effortful? The general survey is rapid but enormously informative — it sets the urgency level for the rest of your assessment.
Assess using the AVPU scale (Alert, Voice-responsive, Pain-responsive, Unresponsive) as a rapid screen, or Glasgow Coma Scale (GCS) for more granular quantification (eyes + verbal + motor; normal = 15, severe impairment ≤8). Orientation: person (knows their own name), place (knows where they are), time (knows the date/day), and situation (knows why they're in the hospital). Document exactly what the patient was oriented to, not just "oriented x4" without verification.
For most patients: assess pupils (PERRLA — pupils equal, round, reactive to light and accommodation). Fixed and dilated pupils indicate herniation until proven otherwise — emergency. Unequal pupils (anisocoria) can be baseline (10–20% of the population has slight physiological anisocoria) or new (concerning for CN III compression). Assess facial symmetry (CN VII): smile, raise eyebrows, puff cheeks. Assess swallowing and gag if CNS pathology is suspected (CN IX/X).
Grip strength bilaterally. Arm drift (hold arms extended with eyes closed — a drifting arm indicates contralateral motor cortex dysfunction). Plantar flexion and dorsiflexion of the feet. Assess for focal weakness that was not present before. Any new motor deficit compared to baseline requires immediate provider notification.
Auscultate at the 4 classic areas: aortic (2nd right intercostal space); pulmonic (2nd left intercostal space); tricuspid (4th left intercostal space); mitral/apex (5th intercostal space, midclavicular line). S1 ("lub") = mitral and tricuspid closure, marks the beginning of systole. S2 ("dub") = aortic and pulmonic closure, marks the end of systole. S3 ("lub-dub-duh") = extra sound in early diastole; in adults suggests volume overload or heart failure. S4 ("luh-lub-dub") = extra sound in late diastole; suggests stiff, non-compliant ventricle; associated with hypertension, LVH, aortic stenosis. Murmurs: describe location, timing (systolic vs diastolic), radiation, and grade (I–VI).
Peripheral pulses: radial (rate, rhythm, quality), pedal pulses bilaterally (dorsal pedal and posterior tibial). Rate = slow or fast? Rhythm = regular or irregular? Quality = bounding, normal, weak, or absent? Capillary refill: press the nail bed until blanching, release, and count seconds until color returns — normal ≤2 seconds. Edema: press the pretibial area for 5 seconds — note depth and duration of pitting; document as 1+ (2 mm), 2+ (4 mm), 3+ (6 mm), or 4+ (8 mm).
Inspection: respiratory rate, rhythm, and depth; symmetric chest rise; work of breathing (retractions, accessory muscle use, nasal flaring). Auscultation: all lung fields bilaterally from apex to base (compare side to side at each level). Normal, crackles, wheezes, rhonchi, absent, or diminished. Oxygen delivery device and SpO2. Full guide: respiratory assessment nursing guide.
Always follow the correct sequence for abdominal assessment: inspection → auscultation → percussion → palpation. Palpation is last because it may alter bowel sounds if performed before auscultation.
Inspection: Abdominal contour (flat, rounded, distended, scaphoid); visible pulsations (aortic pulsation is normal in thin patients; prominent pulsation suggests AAA); skin condition; surgical incisions or drains.
Auscultation: Bowel sounds in all 4 quadrants — listen for at least 60 seconds in each quadrant before declaring absent. Normal: 5–30 sounds per minute. Hypoactive: <5/minute (post-op, ileus, peritonitis). Hyperactive: >30/minute (gastroenteritis, early obstruction, hunger). High-pitched rushing sounds with cramping suggest small bowel obstruction.
Percussion: Tympany (hollow, drum-like) over air-filled bowel — normal. Dullness over solid organs (liver, full bladder) or fluid (ascites). Shifting dullness: patient position changes cause the dull area to shift — classic for ascites.
Palpation: Light palpation first (tenderness, guarding, rigidity); deep palpation for organs and masses. Guarding (voluntary muscle contraction when you approach) vs. rigidity (involuntary, board-like stiffness — sign of peritoneal irritation/peritonitis). Rebound tenderness (pain worse when you quickly release pressure than during palpation) — sign of peritoneal inflammation.
Urinary output: minimum acceptable adult UO = 0.5 mL/kg/hr (for a 70 kg adult: minimum 35 mL/hr). Urine characteristics: color (pale yellow normal; dark amber suggests concentrated/dehydrated; red or pink = hematuria; brown or tea-colored = myoglobinuria, liver disease). Clarity: normally clear. Odor: normally mild; strong ammonia odor suggests concentrated or infected urine. Foley catheter if present: position, security, patency, drainage bag below bladder level. Catheter-free patients: assess voiding history (when was the last void? any difficulty? any urinary retention signs?)
Color: pink (normal perfusion), pallor (anemia, vasoconstriction, or poor perfusion), jaundice (yellow — bilirubin elevation; assess sclera), cyanosis (central vs peripheral), erythema (redness — inflammation, cellulitis, pressure injury), mottling (blotchy red-blue — poor perfusion). Turgor: pinch the skin over the forearm or sternum — normal skin returns immediately; tented skin that slowly returns indicates dehydration. Skin integrity: inspect all pressure points (sacrum, coccyx, heels, occiput, ischial tuberosities, lateral ankles, elbows) for pressure injury; document any wounds, bruising, petechiae, ecchymosis, or skin breakdown.
Related guides: Respiratory assessment | Vital signs | Documentation | Prioritization
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