Nurses Notes Physical Assessment Date/Time: Patient:
Vital Signs/Pain/Pulse Ox: Temp: _______ Location: O, A, R, T Apical Pulse: Rate = ____ BPM; Rhythm: Regular Irregular/erratic Thready Bounding Strong Respirations: Rate = ____ ; Rhythm: Even Regular Irregular Labored Strained Moderate Shallow Deep With stridor / retractions / apnea noted Blood Pressure: _____/_____; Arm: R / L ; Patients Position: Lying / Standing / Reclining / ___________ Pain: Scale (1 - 10) ___; Nonverbal cues: ________________; Loc: ______________; Onset: ________________; Duration: ____________ ; Quality: ____________________ Client states, Neuro: LOC: Alert & Oriented X: 1, 2, 3; Oriented to: Person, Place, Time; Disoriented to: Person, Place, Time Affect/Mood: Alert, Flat Affect, Tearful, Confused, Pleasant, ________________ Glascow Coma Scale: Total Score= ____ ; Eyes, open 4=Spontaneously, 3=to speech, 2=to pain, 1=n/a Verbal Response: 5=oriented, 4=confused, 3=inappropriate words, 2=incomphnsble sounds, 1=n/a Motor Response: 6= obeys commands, 5=localized pain, 4=flexion w/drawl, 3=abnrml flexion, 2=abnrml extension, 1=flaccid Pupil Size & Reaction: PERRLA, unequal, misshapen, unreactive to light, no accommodation Vision: Left = ____/____ Right = ____/_____ , Nearsighted, Farsighted, Astigmatism (L or R) Corrective lenses: Glasses, Contacts, Abnormal findings: _____________________________ Hearing: Normal, Loss (L or R) Degree: ____________, Hearing aid, Pain, Ringing Rushing Communication: Lucid Coherent Incoherent Slurred speech ________________ Facial Symmetry: Symmetrical Unsymmetrical (location) ______________ Client states, Cardiac: Heart sounds: clearly audible, muffled at A, P, E, T, M Sounds are: with free of murmurs and / or gallops PMI: Location of palpation = ___________________ Apical Pulse: Rate = ____ BPM; Rhythm: Regular Irregular/erratic; Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Brachial Pulse: Rate = ____ BPM; Rhythm: Regular Irregular/erratic; Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Temporal Pulse: Rate = ____ BPM; Rhythm: Regular Irregular/erratic; Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Carotid Pulse: Rate = ____ BPM; Rhythm: Regular Irregular/erratic; Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Femoral Pulse: Rate = ____ BPM; Rhythm: Regular Irregular/erratic; Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Popliteal Pulse: Rate = ____ BPM; Rhythm: Regular Irregular/erratic; Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Posterior Tibial: Rate = ____ BPM; Rhythm: Regular Irregular/erratic; Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Dorsalis Pedis: Rate = ____ BPM; Rhythm: Regular Irregular/erratic;
Nurses Notes Physical Assessment Date/Time: Patient:
Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Capillary Refill: fingernail / toenail, Brisk, Rapid, Sluggish (1, 2, 3, __ seconds) Client states,
Respiratory Respirations are: Even, Regular, Irregular, Labored, Strained, Deep, Shallow With: Stridor, Reactions, Apnea noted Chest expansion is symmetrical not symmetrical (more rise on left, right) Breath sounds are: Clear anteriorly & posteriorly, Clear bi-laterally, Free of adventitious sounds, w/ wheezes noted in __________________, w/ crackles noted in __________________________ Patient experiences: shortness of breath, difficulty with respirations Cough is: productive, nonproductive; Sputum description: _______________________________________ GI/ Abdomen Abdomen is: Soft, Round, Hard, Protuberant, Flat, Firm, Tender to palpation, Nontender, Distended, Nondistended Bowel sounds are: Audible X 4, Inaudible in ___Q, Active X 4, Inactive in ___Q, Hyperactive, Hypoactive, Faint Abdominal skin exhibits: Edema, bruises, Lesions, Rashes, Ulcers, Scarring, Stretch marks coloration ________, Location of findings: _______________________________________________________ Normal elimination patterns: Bowels = ________, Urinary = ________ Last BM = ________________, Last Urination = _________________ Has catheter. Note color, odor, consistency, and amount of urine: _____________________________________ ____________________________________________________________________________________________ Stool is: Color: ____________, Watery, Soft, Diarrhea, Uniform, Hard, Tarry, Loose Urine is: Straw colored, clear, cloudy, w/ sediment noted, yellow, amber, bloody, tea-colored, malodorous Patient: is continent, incontinent, wears adult briefs Musculo-skeletal: Extremities Muscle strength in legs & feet (foot push): Strong, Weak, Equal, Exhibits Homans sign Hand Grasps: Firm, Weak, Equal, Unequal (stronger in ___ hand). ROM: Limited, Partial, Full, Active, Passive ADLs: Requires assistance for: Feeding, Bathing, Dressing, Toileting, Transferring, Continence Gait/balance: movements are uncoordinated coordinated ( arms swing freely, head & face lead body) Client has history of falls. How often = _________________, Last fall = ___________________ Client ambulates with, without assistance. Client moves with use of assistance devices ( Cane, Walker, Crutches, Wheelchair, ____________) Patient exhibits in extremities: lack of sensation, Edema, Missing Limbs Note location of findings: ________________________________________________________ Integumentary
Nurses Notes Physical Assessment Date/Time: Patient:
Skin color = pink, jaundiced, ashen, pallor, pale, reddened/erythema, cyanotic, ___________ Skin temp = warm, cool, cold, hot, clammy Skin Turgor: after pinching, skin on sternum returns to normal in ____ sec. Skin is dry, moist, with lesions, w/o lesions, with breaks, with rash Note location of findings: _________________________________________________________ Patient has incisions, wounds dressings (location:______________________________________________) Mucous membranes are: moist, pale, pink, pallor Condition of teeth & gums: missing teeth, edentulous, wears dentures (note fit: ______________________) dental caries, bleeding gums, dry mouth, moist mouth, _______________ Other: Height = ______ in.; Weight = ________lbs.; BMI (weight/height2 X 704) = ________ (optimal BMI = 19-25)
