Systems assessment

I can't claim authorship. I found the original information on one of the boards here. I print on both sides of a 4x6 index card then can lay them out 3 to a standard sheet, laminate them then trim them. The students love them, and I love sneaking up on them and see them using them. You should be able to just copy and paste the information below to a word document. To use the 4x6 card you need to go to the page set up and choose A6 as your paper size. I have also done it in two columns on a standard 8/5x11 then folded, trimmed to the pocket card size. Hope this as helpful to you and your students as it has been for us. I am using it with my third group and really feel it enhances their skill development.

Side 1:

Head to toe assessment


LOC (alert/lethargic/non-responsive)
Orientation (to person, place and time)
Neuro check, if applicable
Skin-color (pale/ pink/ruddy)
Temp (cool/cold/warm/hot)
Texture (dry/diaphoretic)
*Any O2, NG tubes would go here
Apical-rate
rhythm (regular/irregular or normal/abnormal)
intensity(loud/distant)
Respirations-rate
effort (easy/non-labored)
deepth (deep/shallow/blowing)
*Chest tubes would go here
Upper extremities- If IV present, note the solution, the rate and the site. Note the site for warmth, redness,edema etc.
Abdomen-look (round/flat)
listen (BOSO present x 4 quads?Rhythm of BOSO-normal/hyper/hypoactive and the intensity-high/low-pitched)
feel (soft/firm/hard)>>

Side 2:

*Any PEG, PEJ, etc. tubes would go here.
Bowel and Bladder- voiding (color, clarity, amount)
Postop flatus?
Foley? (patent, note drainage system)
Ostomy? (note stoma)
*This would include any suprapubic caths,drains,etc.
Lower Extremities-
Homan's sign (negative/positive)
Pedal pulses (+1=weak/faint, +2 palpitable, +3 bonding)
Capillary refill (brisk/sluggish-how long if >3 seconds)
**Put any dressings or wounds in the order they came. For example, a forearm dressing would go with the upper extremities. A cast would include a circ check with the corresponding area. Edema include pitting (and the deepth) or nonpitting at the correspodning area.>>