Adult Med/Surg Assessment Worksheet

Neurological Abnormal Findings:

Normal Findings:
Alert and oriented x 3
Speech is clear
Memory intact
Follows commands and converses
Absence of seizures
Behavior appropriate to situation
When upright: Balance steady
Gross motor coordination intact
Hand grasps strong/equal
PERRLA, Foot presses and pulls strong and equal
Gag, cough, blink reflexes intact
Respiratory Abnormal Findings:
Normal Findings:
Breath sounds clear and equal in all lobes.
Respirations regular, non-labored, without use of accessory
muscles
Mucus membranes pink
Chest excursion symmetrical
Trachea midline
If cough present, non-persistent
Sputum clear or absent
Cardiovascular Abnormal Findings:
Normal Findings:
Regular rhythm, heart sounds S1 S2 present
Blood pressure within patient norms
If alert, denies chest pain
Periorbital, sacral, pedal & generalized edema absent
Skin warm & dry to slightly moist
Neurovascular Abnormal Findings:
Normal Findings:
Nailbeds pink
Capillary refill < 3 sees
Affected extremity color pink, temperature warm
If alert, patient denies numbness, tingling, or other
paresthesia of extremity
Movement intact on flexion and extension
Pulses palpable or present with Doppler, edema absent
Gastrointestinal/Nutrition Abnormal Findings:
Normal Findings:
Bowel sounds active in all quadrants
Abdomen soft, non-distended, non-tender
Receives and tolerates nutrition and fluids
Absence of nausea, vomiting, cramping, diarrhea or
constipation
If alert, no complaints of nausea, vomiting, or abdomen
pain with palpation
Skin Abnormal Findings:
Normal Findings:
Color within patient's norm
Temperature warm, dry to slightly moist
Turgor normal, mucous membranes moist
Intact without breakdown, rash, redness, blanching
Wounds Abnormal Findings:
Normal Findings:
Edges approximated and clean
Surrounding tissues free from signs & symptoms of
infection
Dressing dry & intact: drainage absent
GU/Elimination Abnormal Findings:
Normal Findings:
Urine clear, straw or amber: no unusual odor
Urine output within established parameters
Bladder nondistended
Pt is continent of urine or uses a collection device
Mobility/Functional Ability Abnormal Findings:
Normal Findings:
Active ROM of all extremities within physical limitations
Tolerates prescribed activity order
If ambulatory, gait steady
Able to complete 75% of ADL’s
Able to transfer with 75% participation
Psychosocial Abnormal Findings:
Normal Findings:
Participates in two way conversation, care and treatment
plan
If intubated/trached, able to communicate needs
Patient and/or family coping mechanisms intact
Mood/affect/behavior appropriate to situation
Rest/Sleep Abnormal Findings:
Normal Findings:
Patient states or appears rested
Patient observed sleeping during shift
Pain/Comfort Abnormal Findings:
Normal Findings:
Patient rates or scores pain at zero
Safety/Restraints Behaviors:
There are no expected outcomes for Safety/Restraints. This
is assessed on all patients. Behavior and interventions are Interventions:
documented. Restraints require additional documentation
on Restrain Flowsheet.
Education Readiness:
There are no expected outcomes for education. This is
assessed on all patients. Patient readiness, content
reviewed, and evaluation of comprehension are Content Reviewed/To be taught
documented.

Evaluation: