An tsVI. NURSING REVIEW CHART IV.

PHYSICAL ASSESSMENT
NURSING SYSTEM REVIEW CHART Name: XX Date: December 9, 2010 Vital Signs: Pulse:138 bpm BP: N/a

Temp: 36.0

Respi: 40 cpm

EENT [] impaired vision [] blind [] pain reddened [] drainage [] gums [] hard of hearing [] deaf [] burning [] edema [] lesion teeth [] asses eyes, ears, nose,throat for abnormality [X] no problem RESPIRATION [] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [X] cough [] bradypnea [] shallow [] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [x] wheezing [] pain [] cyanotic [] assess resp rate, rhythm, depth, pattern [] breath sounds, comfort []no problem GASTRO INTESTINAL TRACT [] obese [] distention [] mass [] dysphagia [] rigidly [] pain [] asses abdomen, bowel habits, swallowing [] bowel sounds, comfort [X]no problem GENITO-URINARY and GYNE [] pain [] urine color [] vaginal bleeding [] hematuria [] discharge [] nocturia [] assess urine freq., control, color, odor, comfort [] grip, gait, coordination, speech, [X]no problem NEURO [] paralysis [] stuporous [] unsteady [] seizure [] lethargic [] comatose [] vertigo [] tremors [] confused [] vision [] grip [] assess motor function, sensation, LOC, strength [] grip, gait, coordination, speech, [X]no problem 2 MUSCULOSKELETAL and SKIN [] appliance [] stiffness [] itching [] petechiae [] hot [] drainage [] prosthesis [] swelling [] lesion [] poor turgor [] cool [] deformity [] atrophy [] pain [] ecchymosis [] diaphoretic [] assess mobility, motion, gait, alignment, joint function [] skin color, texture, turgor, integrity [x] no problem

Expelled white sputum Productive cough observed

Wheezing sound heard upon auscultation