STUDENT NURSE ASSESSMENT SHEET

Room #: ________________ | Age & Gender: ________________ | Today’s Date: ________________

MD/PA/NP/Team: ______________________ ________________________ | Nurse: ________________ |
Admit Date: ________________ | Admitting Diagnoses: ________________________________________ |

Vital Signs: [ Time: ________ ] | HR – ________ | B/P – ________ | RR – ________ | Temp – ________ |
SPO2 – ________ @ ________ via ________ | Pain – ________ [ Numerical/Wong-Baker/FLACC ] [ Location: ________________ ]
[ Type – Acute/Chronic/Sharp/Dull/Aching/Burning ] | Reassessed Score – ________ [ Time: ________ ] |

Vital Signs: [ Time: ________ ] | HR – ________ | B/P – ________ | RR – ________ | Temp – ________ |
SPO2 – ________ @ ________ via ________ | Pain – ________ [ Numerical/Wong-Baker/FLACC ] [ Location: ________________ ]
[ Type – Acute/Chronic/Sharp/Dull/Aching/Burning ] | Reassessed Score – ________ [ Time: ________ ] |

Health Maintenance: Reason for Admission (Patient’s Own Words): ________________________________________ |

Perception of Health – Good/Fair/Poor | Substance Use – Tobacco/ETOH/Drug Use/None [ Describe:
________________________________________ ] | Code Status – Full/DNR/DNI/CMO | Advanced Directive – Y/N | Living Will – Y/N |

Psychosocial: WNL - Cooperative, normal and appropriate affect; denies SI/HI; denies hallucinations and delusions. |
Primary Language: ________________ | Marital Status – Single/Married/Divorced/Widowed | Lives – Alone/With Spouse/
With Family/Assisted Living/Nursing Home | Mood: ________________ | Affect - Appropriate/Inappropriate/Congruent/Incongruent/
Normal/Blunted/Exaggerated | Behavior - Cooperative/Uncooperative/Withdrawn/Lethargic/Agitated/Combative | SI/HI – Y/N |
Hallucinations & Delusions – Y/N [ Type – Auditory/Olfactory/Visual ] |

Safety: Fall Risk – Low/Medium/High [ Score: ____ ] | Fall Precautions – Y/N | ID Bracelet On – Y/N | Oriented to Unit – Y/N |
Bed Low – Y/N | Nonskid Footwear – Y/N | Call Light Available – Y/N | Side Rails – 2/3/4 | Assist to Ambulate – None/1 Person/2
People/Unable to Ambulate | Restraints – Y/N [ Type: ________________ ] | C/O – Y/N [ Type: ________________ ] |

HEENT: WNL – Full head & neck ROM; trachea midline; non-palpable lymph nodes; eyes clear and white; ear auricles and
canals intact without masses/lesions/redness or drainage; nasal septum intact; moist pink mucus membranes; no sensory deficits. |
Full Head/Neck ROM – Y/N | Nuchal Rigidity – Y/N | Trachea Midline – Y/N | Palpable Lymph Nodes – Y/N
[ Describe: ________________________ ] | Eyes: [ Sclera – White/Yellow ] [ Conjunctiva – Clear/Cloudy/Pink ] | Vision Loss - Y/N
[ Describe: ________________ ] | Photophobia – Y/N | Contacts/Glasses - Y/N | Ears: [ Auricles: Intact/Masses/Lesions ] [ Canals:
Clear/Redness/Swelling/Lesions/Drainage ] [ Describe: ________________ ] | Hearing Loss - Y/N [ HOH – Left/Right/Both ]
[ Deaf – Y/N ] | Tinnitus – Y/N | Vertigo – Y/N | Hearing Aid - Y/N | Nose: [ Septum: Intact/Deviated ] | Loss of Smell - Y/N |
Epistaxis - Y/N | Mouth: [ Mucus Membranes – Dry/Moist/Pink/Pale/Lesions ] | Loss of Taste – Y/N | Dysphagia - Y/N | Dentures – Y/N |

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

 STUDENT NURSE ASSESSMENT SHEET

Neurological: WNL – GCS 15; RASS 0; AAO X 3; speech clear; PERRLA; facial movements symmetrical;
reflexes present (not Babinski). | GCS – ________ | RASS – ________ | LOC – Alert/Confused/Disoriented/Lethargic/Stupor/Coma |
Oriented – Person/Place/Time | Speech – Clear/Slurred/Difficulty Forming Words/Difficulty Following Commands/Non-Verbal |
Pupils – [ OS – Fixed/Round/Irregular/Reactive/Nonreactive ] [Size: ____ ] [ OD – Fixed/Round/Irregular/Reactive/Nonreactive ]
[Size: ____ ] | Facial Movement Symmetry – Symmetrical/Nonsymmetrical [ Describe: ________________ ] | Gag Reflex – Present/Absent |
Swallow – Present/Active | Corneal – Present/Absent | Babinski – Present/Absent |

Respiratory: WNL – Patent airway; respirations even and unlabored; lung sounds clear bilaterally; denies SOB/dyspnea;
SPO2 > 93% without supplemental oxygen; no tracheostomy or ventilator support; no chest tubes. | Appears in Acute Respiratory
Distress – Y/N | Respiratory Effort & Quality – Labored/Unlabored/Shallow/Deep | Lung Sounds – Clear/Course/Diminished/Crackles/
Wheezing/Rhonchi/Stridor/Friction Rub [ Location – Left/Right/Bilateral/Anterior/Posterior/LUL/LLL/RUL/RLL/Bases ]
[ Describe: ________________________________________________________ ] | Nasal Flaring – Y/N | Retractions – Y/N |
SOB/Dyspnea – Y/N | Cough – None/Productive/Non-Productive [ Sputum – Clear/White/Yellow/Green/Pink/Red/Brown ] [ Quantity –
Scant/Moderate/Copious ] [ Consistency – Thin/Thick/Foamy ] | O2 – Y/N [ Type/Amount - ________ via ________ ] |
Tracheostomy – Y/N [ Describe (Condition, Drainage, Type & Size): ________________________________________________________ ] |
ET Tube – Y/N [ Describe (Size, Position & Vent): ________________________________________________________ ] |
Chest Tube – Y/N [ Location: ________________ ] [ Condition: ________________ ] [ Describe (Treatments):
________________________________________________ ]

Cardiovascular: WNL – Regular apical pulse (S1, S2, no murmur); stable B/P; afebrile; denies angina/chest pain; cap. refill < 3 sec.;
unremarkable neck veins; no edema; positive peripheral pulses; no arterial line. | Heart: Apical Pulse - ________ [ Regular/Irregular ] |
Heart Sounds – [ Murmur – Y/N ] [ Rub – Y/N ] [ Gallup – Y/N ] [ Muffled – Y/N ] | Vital Signs Stable – Y/N | Chest Pain/Angina – Y/N |
Cap. Refill - ____ Sec. | Neck Veins - Distended/Unremarkable | Edema – [ ____ ] [ Location: LA/RA/LL/RL ] | Peripheral Pulses – L. Radial [
____ ] R. Radial [ ____ ] L. Post. Tibial [ ____ ] R. Post. Tibial [ ____ ] L. Dorsalis Pedis [ ____ ] R. Dorsalis Pedis [ ____ ] | Telemetry – Y/N
Rate – ________ Rhythm – ________________________ Box # – ________ | Arterial Line – Y/N [ Describe (Waveform, Condition):
________________________________________________________ ] |

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

 STUDENT NURSE ASSESSMENT SHEET

Integumentary: WNL – Skin is warm, dry and intact, color and tone are consistent with ethnicity;
no surgical incisions, rashes, eczema, ulcers or lesions. | Overall Skin Condition: Temp -
Cool/Warm/Hot | Moisture - Dry/Moist/Diaphoretic | Turgor – Elastic/Loose/Tight | Color -
Erythema/Pallor/Cyanosis/Jaundice/Ashen/Mottled [ Describe: ________________ ] | Tone - Consistent
with Ethnicity – Y/N | Integrity - Intact/Torn | Wounds: Y/N [ Stage: I/II/III/IV/Unstageable ] [ Size:
____________ ] [ Locations (Illustrate On Figure): ________________________ ] Dressings - Y/N [
Type: Sterile/Non-Sterile/Dry/Wet-Dry/Other ] [ Describe: ________________________ ] | IV
Lines/Tubes/Drains: [ Line #1: PIV/CVC/PICC/Port/Arterial/Triple Lumen] [Other: ________________
] [ Location: ________________ ] [Condition: ________________ ] [ Line #2:
PIV/CVC/PICC/Port/Arterial/Triple Lumen/] [Other: ________________ ] [ Location:
________________ ] [Condition: ________________ ] [ Drain Type: JP/Penrose/Wound-Vac] [Other Drain Type: ________________ ]
[Location: ________________ ] [ Condition: ________________ ] [ Describe (Treatments):
________________________________________________ ] | [ Other Skin Conditions (Illustrate On Figure): ____________________________ ] |

Gastrointestinal: WNL – Abdomen soft and non-distended and non-tender; active bowel sounds; denies N/V/D or constipation; continent of
stool. | Abdomen - Soft/Firm/Flat/Protuberant/Distended | Bowel Sounds - Normal/Hypoactive/Hyperactive/Absent | Diet - NPO/Soft/Clear
Liquid/Liquid/Regular/Advance As Tolerated [ Type: ________________ ] | Strict I&O - Y/N | Nausea/Vomiting/Diarrhea - N/V/D | Tube
feeding – Y/N [ Via: TPN/G Tube/ J Tube/NG Tube] [ Type: ________________ ] [Rate: ________ gtts/min or mL/hr] | Feces: [ Color:
________________ ] [ Consistency – Liquid/Loose/Formed/Hard ] [Describe (Size/Amount): ________________________ ] [Date of Last
BM: ________ ] | Flatus – Y/N | Constipation - Y/N | Continent - Y/N |

Genitourinary: WNL – Empties bladder without dysuria; bladder is non-distended after voiding; urine clear/yellow; no vaginal/penile
discharge; urine output avg. > 30 mL/HR; continent of urine. | Urine – [ Color: ________________ ] [ Appearance:
Clear/Cloudy/Hematuria/Abnormal Sediment ] [ Odor: Y/N ] [ Amount: ________ mL ( ____ AM/PM - ____ AM/PM) ] | Genital
Discharge – Y/N [ Color: ________ ] | Continent – Y/N | Catheterized – Y/N [ Type: Foley/Straight/Suprapubic/Condom ] |
Dysuria – Y/N | Urinary Hesitancy/Difficulty – Y/N |

Activity/Exercise: Absence of swelling and tenderness and normal ROM on all joints; no prosthesis required; no muscle weakness;
independent in ADLs & self-care. | Movement/ROM – Full/Limited/None | Muscle Weakness – Generalized/Left Sided/Right Sided |
Prosthesis – LA/RA/LL/RL/Other | Gait – Even (Normal)/Ataxic/Parkinsonian (Shuffling)/Scissor/Pigeon/High Stepping/Spastic/Myopathic
(Waddling) | Use of Assistive Devices – Walker/Wheelchair/Cane/Other. | ADLs/Self-Care – Self/Partial Assist/Full Assist | Position in Bed -
Decoriticate/Deceberate/Orthopenic/Fetal/Fowler/Semi-Fowler/Supine |

Rest & Comfort: WNL – Patient denies pain. Patient sleeps and rests comfortably. | Avg. Hours Sleep/Night – ________ |
Disturbances/Issues – Y/N [ Describe (Pain, Environment, Psychosocial Issues etc.): ________________________________________________ ] [
Sleep Aids: _________________________________ ] [ Nursing Interventions: ________________________________________________ ] |
Improved Sleep/Rest – Y/N |

Student Nurse Assessment Sheet © 2011 cjcsoon2brn

 STUDENT NURSE ASSESSMENT SHEET

Patient Education:

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Event Notes/Addendum:
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Student Nurse Assessment Sheet © 2011 cjcsoon2brn