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   NO            Pain           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   NO           Dental 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   NO            Lung Sounds: ____________________________________________           Other:
Cardiovascular:   NSF           Heart Rate   Reg   Irreg   Brady   Tachy           Pulses   Equal Bilat,  _____________________________________           Edema – Location: ________________________________________                       Pitting    None-pitting            JVD   Yes   NO            Pain   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: