Nursing Physical Assessment

Patient Name:

MRN:

Date:

SYSTEM REVIEW
Eyes:

NSF
Blurred Vision
Yes
Near Sighted
Inflammation
Yes
Drainage
Yes
Other:

NO Glasses/Contacts
Yes
NO
Far Sighted
Astigmatism
NO Itching
Yes
NO
NO Color/Amt:____________________

Physical Findings:
(Describe and graph all abnormalities by number on Body Chart)
1. Abnormal Color:
2. Body Piercing :
3. Bruises:

Ears:

NSF
HOH:
Dizziness
Pain
Other:

Nose:
NSF
Congestion
Nosebleeds
Pain
Other:

Yes
Yes
Yes

NO (R) (L)
Deaf:
NO Balance Problems
NO
Drainage

Yes
Yes
Yes

NO
NO
NO

4. Decubitus:
5. Dryness:
6. Incisions:
7. Lacerations:

Yes
Yes
Yes

Mouth:
NSF
Bleeding Gums
Sense of Taste
Dental Hygene
Other:

NO Sinus Problems
Yes
NO
NO Frequency: _______________________
NO Drainage: ________________________

8. Lesions:
9. :Rashes:
10. Scars:
11. Skin Tear:

Yes
Yes
Good

Throat/Neck:
NSF
Sore Throat
Yes
Swollen Glands
Yes
Stiffness
Yes
Other:

NO Lesions
Yes
NO
Fair
Poor

NO Hoarseness
NO
Lumps
NO
Pain

Yes
Yes
Yes

NO

12. Tattoos:
13. Vascular Access:
14. Other:

NO
NO
NO

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: __________

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:

Surgeon: ___________________ Where: _________________

Catheter: Dressing Clean & Dry

YES

NO

Location: ______________________Date Placed: __________

Surgeon: ___________________ Where: _________________
Brand: _____________________ Model: ________________
Art Vol: ____________________ Ven Vol: _______________

Signature:

Nursing Physical Assessment