Basic Nursing Physical Assessment

Norwalk Community College NU 120
Student________________________

Client initials____

Vital Signs: Temp. ________ Pulse _______ Res._________ BP __________
Pain scale ___________ Location ____________________ Type ___________________
Comments:
Integumentary: Color _______ Temp. ________ Turgor _______
Comments:

Intact: Yes No (explain)

Neurological:

Level of consciousness ____________
Orientation _____________________
Pupils react to light _______________
Movement of extremities: Equal
Not Equal
Strength of hand grasp: Equal
Not Equal
Comments:

EENT: Mucous membranes ____________________
Presence of drainage ____________________
Comments:
Respiratory:

Lung Sounds _____________
Respiratory Rate: ___________ Rhythm: ____________
Pulse oximetry: ___________O2 ________
Delivery system _______________
Comments:

Cardiovascular: Apical Rate: _____________Rhythm: ______________
Peripheral Pulses: Pedal – Present
Absent
Popliteal – Present
Absent
Capillary refill - ___________ seconds
Comments:
Genito-urinary: Difficulty voiding _______________
Urinary incontinence_____________
Urinary catheter ________________
Output (describe) ________________
Comments:

Type of IV solution:
Rate ordered (ml/hr):
Drip rate (gtt/min):
Amount in bag on arrival:
Appearance of IV site:

Gastrointestinal: Bowel sounds _____________
Appearance of abdomen _____________
Bowel movement (describe) ______________
Bowel incontinence ______________
Comments:
Musculoskeletal: Mobility _______________
Coordination: Gait __________
ROM ____________
Comments:
Intake: Oral ______________ Parenteral _________________ Appetite (%) ______________
Output: Other than urine (specify) ___________________

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