Comprehensive Nursing Assessment Checklist

Comprehensive Nursing Assessment Checklist

Assessment Checklists
100 Items
Thorough nursing assessment checklist covering all body systems and patient care areas to ensure accurate, consistent, and holistic patient evaluation.

Comprehensive Nursing Assessment Guide

This comprehensive nursing assessment guide provides a structured checklist to support nurses in performing accurate, complete patient evaluations. It covers all major body systems—neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, integumentary, and genitourinary—along with vital signs, pain assessment, and psychosocial factors. Designed to improve documentation, ensure continuity of care, and promote early detection of health issues in clinical settings.

1. Patient Overview / General Survey

1Confirm patient identity using two identifiers (e.g. name, date of birth)
2Assess level of consciousness / orientation (person, place, time, situation)
3Note general appearance (hygiene, dress, posture, distress)
4Observe behavior, mood, communication (speech clarity, affect)
5Assess mobility, gait, ability to reposition, use of assistive devices
6Note respiratory effort (e.g. labored breathing, use of accessory muscles)
7Assess signs of distress (e.g. diaphoresis, pallor, cyanosis)
8Check nutritional state (weight, BMI, muscle wasting, edema)
9Assess hydration status (skin turgor, mucous membranes, capillary refill)
10Ask about chief complaint / presenting symptoms (onset, location, severity, pattern)

2. Vital Signs & Pain Assessment

1Measure temperature, heart rate, respiratory rate, blood pressure, oxygen saturation
2Measure capillary refill
3Assess pain: use a pain scale (0–10, faces, etc.)
4Use pain assessment mnemonic (e.g. PQRST or SOCRATES) to characterize pain
5Check pulse (rate, rhythm, amplitude) at peripheral sites
6Monitor for changes/trends compared to baseline
7Assess for presence of fever, hypothermia, abnormal vital patterns
8Document time, method, conditions of measurement (position, rest)
9Reassess pain after analgesic intervention or over time
10Report critical vital sign values immediately (per protocol)

3. Skin, Hair, Nails & Integumentary System

1Inspect skin color, moisture, temperature, texture
2Check for lesions, rashes, bruises, scars, pressure areas
3Palpate skin turgor / elasticity
4Check for edema (pitting, nonpitting) and note grade
5Assess integrity of skin in pressure points (heels, sacrum, elbows, occiput)
6Assess wounds, incisions, drains: location, size, depth, exudate, odor
7Inspect hair distribution, scalp condition, lice, alopecia
8Inspect nails (color, shape, capillary refill, clubbing)
9Assess for signs of skin breakdown or moisture-associated damage
10Check for signs of infection (redness, warmth, swelling, pain)

4. Head, Eyes, Ears, Nose, Mouth, Throat

1Inspect head shape, symmetry, scalp, facial features
2Inspect eyes: eyelids, conjunctiva, sclera, pupils (size, equality)
3Test pupillary reaction to light (PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation)
4Assess extraocular movements (six directions)
5Inspect ears: external appearance, canal, discharge, hearing (whisper test)
6Inspect nose: symmetry, patency, mucous membranes, septum
7Assess sinuses (palpate for tenderness)
8Inspect mouth, lips, gums, tongue, mucosa, teeth, throat, uvula
9Check swallowing ability, gag reflex (if indicated)
10Assess sense of smell (if applicable)

5. Neck, Lymphatic, Endocrine

1Inspect neck symmetry, skin, visible pulsations
2Palpate trachea for position and deviation
3Palpate thyroid gland (size, nodules, tenderness)
4Check range of motion of neck (flexion, extension, rotation, lateral flexion)
5Palpate for lymph nodes (preauricular, postauricular, submandibular, cervical, supraclavicular)
6Assess carotid pulses one side at a time, listen for bruits
7Observe jugular venous pressure / distention (JVP)
8Check for signs of endocrine dysfunction (goiter, tremor, dry skin)
9Note any swelling, masses, tenderness in neck structures
10Assess accessory muscle strength (e.g. shrug resistance)

6. Cardiovascular & Peripheral Vascular System

1Auscultate heart sounds (S1, S2, extra sounds, murmurs)
2Palpate apical pulse (if required)
3Check bilateral peripheral pulses (radial, brachial, dorsalis pedis, posterior tibial)
4Assess pulse symmetry, rate, rhythm, strength
5Check capillary refill in extremities
6Inspect extremities for color, temperature, edema
7Assess for venous insufficiency signs: varicosities, stasis changes
8Check for peripheral perfusion (coolness, pallor)
9Assess for skin changes (hair loss on extremities, ulcerations)
10Monitor for signs of deep vein thrombosis (pain, swelling, redness)

7. Respiratory / Pulmonary System

1Inspect chest shape, symmetry, use of accessory muscles
2Assess chest expansion / symmetry (palpation)
3Auscultate lung fields (anterior, posterior, lateral) comparing side-to-side
4Note breath sounds (vesicular, bronchial, crackles, wheezes, rhonchi)
5Ask about cough, sputum (color, quantity, consistency)
6Assess for shortness of breath, orthopnea, dyspnea on exertion
7Monitor respiratory rate, oxygen saturation, and use of supplemental O₂
8Percuss lung fields if indicated (resonance, dullness)
9Check for signs of respiratory distress (retractions, nasal flaring)
10Assess for risk of aspiration (swallowing, gag reflex)

8. Gastrointestinal / Abdominal / Genitourinary

1Ask about appetite, nausea, vomiting, dysphagia
2Inspect abdomen (contour, symmetry, distension, scars)
3Auscultate bowel sounds in all four quadrants
4Percuss abdomen (tympany, dullness)
5Palpate lightly then more deeply for tenderness, masses, organomegaly
6Ask about bowel habits (frequency, consistency, color, change)
7Assess urinary function (frequency, dysuria, incontinence, retention)
8Monitor intake and output (urine, stool, drains)
9Inspect genitalia/perineum (if indicated) for lesions, discharge
10Assess for signs of fluid overload or dehydration (ascites, edema)

9. Musculoskeletal / Neuromuscular / Mobility

1Assess range of motion (active / passive) in joints (upper & lower extremities)
2Evaluate muscle strength / tone bilaterally
3Inspect posture, alignment, deformities
4Assess gait, balance, ability to ambulate
5Check for joint swelling, redness, tenderness, crepitus
6Assess coordination, fine motor skills (e.g. finger-to-nose)
7Test reflexes (if indicated)
8Evaluate sensation (light touch, pain, temperature) in extremities
9Assess risk for falls (e.g. previous falls, weakness)
10Check any assistive device function (walker, cane, braces)

10. Neurological / Cognitive / Psychosocial / Safety

1Assess level of consciousness (alert, lethargic, stuporous, comatose)
2Orientation to person, place, time, situation
3Assess speech clarity, language comprehension
4Evaluate memory (short & long term)
5Test cranial nerve functions (if indicated)
6Assess mood, affect, emotional state, coping, support system
7Ask about sleep patterns, fatigue, restlessness
8Evaluate risk of self-harm, safety, environment hazards
9Assess ability to make decisions, insight, judgment
10Document changes in mental status, delirium signs, or confusion
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