Nursing Shift Assessment Checklist
Complete comprehensive nursing assessment at the start of each shift including vital signs, head-to-toe systems review, and care planning.
- Industry: Healthcare
- Frequency: Every shift
- Estimated Time: 15-20 minutes
- Role: Registered Nurse
- Total Items: 31
- Compliance: State Nurse Practice Act, Joint Commission Standards, ANA Standards of Practice
Vital Signs
Current vital signs
- Temperature recorded?
- Blood pressure recorded?
- Heart rate recorded?
- Respiratory rate recorded?
- Oxygen saturation recorded?
- Pain level assessed (0-10)?
Neurological Assessment
Neuro status
- Level of consciousness assessed?
- Orientation assessed (person, place, time)?
- Pupil response assessed?
- Motor strength assessed?
Cardiovascular Assessment
Cardiac status
- Heart sounds assessed?
- Peripheral pulses assessed?
- Edema assessed?
- Capillary refill assessed?
Respiratory Assessment
Pulmonary status
- Lung sounds auscultated?
- Breathing pattern assessed?
- Cough/sputum assessed?
- Oxygen therapy documented (if applicable)?
Gastrointestinal Assessment
GI status
- Bowel sounds assessed?
- Abdomen assessed (soft, distended)?
- Last bowel movement documented?
- Diet tolerance assessed?
Skin/Integumentary
Skin assessment
- Skin color assessed?
- Skin turgor assessed?
- Wounds/incisions assessed?
- Pressure points assessed?
- IV sites assessed?
Safety Assessment
Patient safety
- Fall risk assessed?
- Bed in lowest position?
- Call light within reach?
- Restraints assessed (if applicable)?
Related Healthcare Checklists
- Hand Hygiene Compliance
- Medication Safety Check
- Surgical Safety Checklist
- Fall Prevention Assessment
- Joint Commission Readiness
- HIPAA Compliance Audit