Student:

Patient Initials: ______ Unit: _____ Room: _____ Date/Time: __________

Med DX: __________________________________________Surgery __________________________________________
Time:
VS T _____ P _____ R _____ BP _____
Ht. _____
ID BAND Y N
Time:
VS T _____ P _____ R _____ BP _____
Wt _____
ALLERGY BAND Y N
NEUROLOGIC ASSESSMENT
A & O x ______ to Person Place Time Situation LOC: Awake Alert
Lethargic
Obtunded Stuporous Comatose
Memory: Immediate
Past
Abstract Reasoning
Appropriate Expression of Words
Behavior: Cooperative
Follow Commands Appropriate
Agitated
Combative
Hostile
Lethargic Unresponsive
Speech: Clear
Understandable
Appropriate
Slurred
Aphasic
Incomprehensible
Sensory System: Identifies: Light touch
Dull
Sharp
Direction of movement
Objects
Cranial Nerves: I - olfactory, II - optic, III - oculomotor, IV - trochlear, V - trigeminal, VI - abducens, VII - facial, VIII - acoustic,
IX - glossopharyngeal, X - vagus, XI - spinal accessory, XII hypoglossal
Coordination: Rapid finger to nose movement: Y N Heel straight down shin: Y N
Reflexes: Bicep brachioradialis
triceps
patellar
achilles
planter
ankle clonus
PAIN ASSESSMENT: Location
Duration
Intensity on Pain Scale of 0 to 10 _______
Describe: sharp dull stab throb ache ; localized radiates
EYES, EARS, NOSE, THROAT ASSESSMENT
EYES: PERLA Sluggish R
L Nonreactive R L Pupil Size R
L
Glasses
Contacts
Artificial eye
Eyelids: Able to close
Unable to close Redness Swelling Discharge Lesions R
L
Eyeballs: Symmetrically aligned Exophthalmos Sunken Conjunctiva: Pink Moist Redness Dryness Cyanosis R L
Sclera: White Jaundice
Redness R L Vision: Sight both eyes
Myopia
Presbyopia
Blind
EARS: External: Equal Size
Auricles Aligned
Lumps
Lesions
Discharge
Pain
Swelling
Hearing: In Both Ears
Hard of Hearing R
L
Hearing Aid R L
Deaf
MOUTH: Lips: Pink
Moist
Dry
Pallor
Cyanotic Red
Edema
Lesions
Cleft
Teeth: Full Set Missing (Dentures: upper lower ) Partial Gums: pink moist firm red swollen bleeding
Tongue: Pink Moist Dry
Black/hairy
Smooth/reddish/shinny Coated
Enlarged
Lesions
Breath Odor: No unusual odor
Foul
Fruity
Acetone
Ammonia
Fecal
Sulfur
NOSE: Nares: Symmetrical Patent Blocked R L Nasal Exudate: None Watery Thick Yellow / Green Bloody
SINUSES: Frontal:
Non Tender Tender/Pain Maxillary: Non Tender Tender/Pain
Throat: Lymph Nodes: preauricular, postauricular, occipital, tonsillar, submandibul;ar, submental, superficial cerival, posterior
cervical, supraclavicular.
Thyroid Assessment:
Thyroid Bruit:
SKIN, HAIR, NAILS ASSESSMENT
SKIN: Color: Appropriate for Ethnicity Pallor Cyanosis Jaundice Flushed Temperature: Warm Cool Hot Cold
Moisture: Dry Moist Diaphoresis Clammy Body Odor: None
Strong
Foul
Texture: Smooth and Even
Rough
Flaky Dry
Thickness: Appropriate for age Very Thin Thick Atrophy
Turgor: Normal (pinches easily / immediately returns to normal)
Decreased (return to normal takes > 30 seconds)
Skin Integrity: Intact Open Wound Skin Tear Laceration Abrasion Location:
Characteristics:
Decubitus: Location:
Stage:
Drainage:
Dressing:
HAIR: Color
Distribution on scalp and body: Even distribution
Patchy Hair Loss
Hirsutism
Absent
Hair Texture: Fine
Coarse
Dull
Fragile
Dry
Oily
Scalp: Clean Lesions Parasites Scaliness
FINGER NAILS: Clean
Artificial Nails
Beaus Line
Spoon Nails
Clubbing
Pitting
Paronychia
TOE NAILS: Clean
Very Long
Very Short
Thick
Yellow
HEART AND NECK VESSEL ASSESSMENT / CIRCULATION/CARDIAC
Apical Pulse Rate _____ quality
/4 Regular Irregular
Tachycardia
Bradycardia
Radial Pulse Rate: R ______
/4
L _____
/4
Carotid Pulse Rate: R _____
/4 L _____
/4
Carotid Bruit R Y
N L Y
N
Pulses: Diminished
Absent
Extra Heart Sounds Y N
Capillary Refill
fingers <3 >3
toes <3 >3 Julgular Neck Vein Distension Absent Present @ _____ degrees
EKG Rhythm
Generalized Edema Scale
0 1+
2+
3+
4+
Pitting Non pitting Location:

THORACIC AND LUNG ASSESSMENT / RESPIRATORY

Respiratory Rate_____Rhythm: Regular Irregular Labored Shallow Fremitus Y N Bilateral Expansion Equal Not equal
Breathing pattern: Even Dyspnea Tachypnea
Bradypnea
Orthopnea
Apnea
Hyperventilation
Hypo-ventilation
Cheyne-Stokes
Biots
Breath sounds: Clear
Diminished: (specify lobe RUL LUL RML RLL LLL)
Crackles: Fine Coarse (specify lobe RUL LUL RLL LLL )
Pleural Friction Rub: Y N
Wheezes: Inspiratory
Expiratory
Sibilant
Sonorous ( specify lobe RUL LUL RML RLL LLL)
Cough: Non Productive
Productive
Sputum: Describe:
Accessory Muscle Use: None Neck Abdomen Nasal Flaring
Pursed Lips
Retraction Intercostals
General Cyanosis: Lips
Nail beds
Mucous Membranes
O2 _______ L/M
Pulse Oximeter ____
Chest configuration: Symmetrical
Barrel Chest Pectus Excavatum Pectus Carinatum
Kyphosis
Scoliosis
PERIPHERAL VASCULAR ASSESSMENT
EXTREMITIES: ARMS:

Bilaterally symmetrical
Rapid Change of Color
Swelling
Pain
Numbness Tingling
Burning
Throbbing
Coldness
Pulses: Ulnar
R _______ /4
L _______
/4
Brachial
R ______ /4
L _______ /4
Temporal R _______ /4 L __________ /4
IV SITE: Location:
Condition: clean and dry
redness
swelling
pain
leaking
EXTREMITIES: LEGS: Bilaterally symmetrical
Temperature:
warm
cool
warm to cool
Pulses: Femoral
R _______
/4
L _______
/4
Popiteal
R _______ /4
L _______ /4
Pulses: Dorsalis Pedis R
/4
L
/4
Posterior Tibial
R
/4
L
/4
Femoral Bruit:
Varicose Veins:
Absent Present
Peripheral Edema: None Location:
Right: Non Pitting
Pitting
Scale 1+
2+
3+
4+
Left: Non Pitting
Pitting
Scale 1+
2+
3+
4+
Leg Ulcer: Absent
Present
Describe:
Location:
Margins:
Tissue:
Drainage:
Skin:
Pain:
ABDOMINAL ASSESSMENT
TYPE OF DIET:
Intake
Output
Tolerates: All

None
NPO
Nausea
Vomiting NG Tube
PEG Colostomy
Abdomen: Flat Rounded
Scaphoid
Protuberant
Distended
Soft
Firm
Non Tender
Tender
Masses
Abdominal Girth: _______ cm
Ascites: Y N
Bowel Sounds: Present X 4
Normal Active
Hyperactive
Hypoactive
Absent: RUQ
RLQ
LUQ
LLQ
Scars Incisions Sutures / Staples Dressings
Location & Characteristics:
LAST BM:
Urinary System:
Urine: Color:
Bladder: Not distended Distended
Continent
Incontinent
Foley

Color:
Clarity:
Voids Freely Hesitancy
Suprapubic
Urostomy

Consistency:
Odor :
Frequency
Urgency

Continent

Incontinent

Dysuria

MUSCLOSKELETAL ASSESSMENT
UPPER EXTREMITIES: ROM:
Shoulders R
L
Elbows R L
Wrist R L
Paralyzed
Amputation
Handgrips: Bilateral Equal
Not Equal
Strong R L
Weak R L
Arms: Muscle Tone:
Strong
Atrophy
Flaccidity
Tremors
Pain
LOWER EXTREMITIES: ROM: Hips
R
L
Knee
R
L
Ankles R L
Paralyzed
Amputation
Quad Lift: Strong R
L
Weak R
L Pedal Push: Strong R
L
Weak R
L
Gait: Steady
Coordinated
Balanced
Unsteady
Cerebellar Ataxia
Parkinsonian Gait
Scissors Gait
Legs: Muscle Tone::
Strong
Atrophy
Flaccidity
Tremors
Pain
Footdrop
JOINTS: Flexion
Extension
Hyperextension Abduction
Adduction
Supination
Pronation
Deformity Pain
Swelling Crepitation
Specify location of abnormalities:

Nurses Notes