Before You Begin

• Hand hygiene; introduce yourself; verify patient with two identifiers
• Provide privacy; explain what you'll be doing
• General survey: appearance, position, distress level, mood, hygiene, mobility aids
• Vital signs (or verify most recent set) and pain assessment

Neurological

• Level of consciousness: alert and oriented ×4 (person, place, time, situation)
• Speech clear and appropriate; follows commands
• Pupils: equal, round, reactive to light (PERRL)
• Strength and sensation: hand grips and foot pushes, equal bilaterally

Head, Eyes, Ears, Nose, Throat

• Mucous membranes moist and pink; note dentures or oral concerns
• Swallowing intact; note hearing or vision aids in use

Cardiovascular

• Auscultate apical pulse: rate and rhythm (regular/irregular)
• Peripheral pulses (radial, pedal) present and equal
• Capillary refill < 3 seconds; note edema (location and severity)
• Telemetry, pacemaker, or vascular access noted

Respiratory

• Rate, rhythm, effort; use of accessory muscles?
• Auscultate anterior and posterior fields: clear, crackles, wheezes, diminished?
• SpO₂ and oxygen delivery (room air, nasal cannula, mask: flow rate)
• Cough present? Productive? Sputum character

Gastrointestinal

• Inspect abdomen; auscultate bowel sounds ×4 quadrants; palpate lightly for tenderness
• Last bowel movement; nausea/vomiting; diet tolerated
• Feeding tubes: placement verified per policy, site condition

Genitourinary

• Voiding pattern; urine color, clarity, amount
• Catheter: securement, tubing position, output character

Musculoskeletal & Mobility

• Range of motion; strength; gait and balance if ambulatory
• Fall risk score current; bed low, locked, call light in reach

Skin

• Color, temperature, moisture, turgor
• Inspect pressure points (sacrum, heels, elbows, occiput), braden/pressure-injury risk current
• Wounds and dressings: location, appearance, drainage, dressing intact

Lines, Tubes & Drains

• IV sites: patent, no redness/swelling, dressing dated and intact
• All infusions: right fluid, right rate, pump programmed correctly
• Drains: output amount and character; securement

Closing

• Ask: "Is there anything you need or anything worrying you?"
• Environment safe; hand hygiene; document promptly
• Report abnormal or changed findings using SBAR