7/27/2019 Nursing Physical AssessmentNursing Physical Assessment
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Nursing Physical Assessment
Patient Name: MRN: Date:SYSTEM REVIEW
Eyes: NSF
Blurred Vision Yes NO Glasses/Contacts Yes NO Near Sighted Far Sighted Astigmatism
Inflammation Yes NO Itching Yes NO
Drainage Yes NO Color/Amt:____________________ Other:
Physical Findings:
(Describe and graph all abnormalities by number on Body Chart)
1. Abnormal Color:
2. Body Piercing :
3. Bruises:
4. Decubitus:
5. Dryness:
6. Incisions:
7. Lacerations:
8. Lesions:
9. :Rashes:
10. Scars:
11. Skin Tear:
12. Tattoos:
13. Vascular Access:
14. Other:
Ears: NSF
HOH: Yes NO (R) (L) Deaf: Yes NO
Dizziness Yes NO Balance Problems Yes NOPain Yes NO Drainage Yes NO
Other:
Nose: NSF
Congestion Yes NO Sinus Problems Yes NO
Nosebleeds Yes NO Frequency: _______________________
Pain Yes NO Drainage: ________________________
Other:
Mouth: NSF
Bleeding Gums Yes NO Lesions Yes NO
Sense of Taste Yes NODental Hygene Good Fair Poor Other:
Throat/Neck: NSF
Sore Throat Yes NO Hoarseness Yes NO
Swollen Glands Yes NO Lumps Yes NO
Stiffness Yes NO Pain Yes NO
Other:
Neurological: NSF
LOC: Alert Confused Sedated Somnolent
Speech: Clear Slurred Aphasic Dysphasia
PEARL Yes NO Grip Equal Yes NO
Cooperative Yes NO ________________________________
Oriented to: Person Place Time
Other:
Respiratory: NSF
Dyspnea Yes NO w/ Activity At Rest Retractions
Cough Yes NO non-Productive Productive
Hemoptysis Yes NO Cyanosis Yes NOLung Sounds: ____________________________________________
Other:
Cardiovascular: NSF
Heart Rate Reg Irreg Brady Tachy
Pulses Equal Bilat, _____________________________________
Edema – Location: ________________________________________
Pitting None-pitting JVD Yes NOPain Yes NO ______________________________________
Other:
Vascular Access:
AVF: Mature YES NO
Location: ______________________Date Placed: __________
Surgeon: ___________________ Where: _________________
Graft:: Surgical Site Healed YES NO
Location: ______________________Date Placed: __________
Surgeon: ___________________ Where: _________________
Catheter: Dressing Clean & Dry YES NO
Location: ______________________Date Placed: __________
Surgeon: ___________________ Where: _________________
Brand: _____________________ Model: ________________
Art Vol: ____________________ Ven Vol: _______________
Gastrointestinal: NSF
Appetite Good Poor Recent Change _________________
Bowel Sounds All Quads ________________________________
Colostomy/Ileostomy Yes NO ________________________
Pain: ____________________________________________________ Other:
Genitourinary: NSF
Urine production per Day: ___________________________________ Pain Yes NO Incontinence Yes NO
Other:
Assessment performed by: Signature:
7/27/2019 Nursing Physical AssessmentNursing Physical Assessment
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