NURSING SYSTEM REVIEW CHART

Name: Marjun Dallito Pulse Rate: 70bpm Respiratory Rate: 40cpm Bp: 90/60 Date: Temp: 37.4C Weight:

EENT: [ ] impaired vision [ ] blind [X] pain [ X ] reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes, ears, nose, throat for abnormality [ ] No problem RESP: [ ] asymmetric [ X ] tachypnea [ ] apnea [ ] rales [ X ] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [ X ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ X ] pain [ ] cyanotic Assess resp. rate, rhythm, depth, pattern, breath sounds, comfort [ ] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ X ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain Assess heart sounds, rate rhythm, pulse, blood Pressure, circ., fluid retention, comfort [ ] no problem GASTROINTESTINAL TRACT: [ ] obese [ X ] distention [ ] mass [ ] dysphagia [ ] rigidty [ ] pain Assess abdomen, bowel habits, swallowing, Bowel sounds, comfort [ ] no problem GENITO URINARY AND GYNE: [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] noctoria Assess urine freq., control, color, odor, Comfort / Gyn-bleeding, discharge [ X ] No problem NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizure [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip Assess motor function, sensation, LOC, strength Grip, gait, coordination, orientation, speech [ X ] no problem MUSCULOSKELETAL and SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechie [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] deformity [ X ] wound [ ] rash [ ] skin color [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ X ] diaphoretic [ ] Moist Assess mobility, motion gait, alignment, joint function/ Skin color, texture, turgor, integrity [ ] no problem