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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