III.

PHYSICAL ASSESSMENT AND REVIEW OF SYSTEM

PATIENT’S NAME: _______________________________________________
CLINICAL DATE:________________

PHYSICAL ASSESSMENT

DATE/TIME INITIAL ASSESSMENT:______________________________________

CHIEF COMPLAINT: ___Shortness of breath________________________________
PAST MEDICAL HISTORY:______________________________________________
____________________________________________________________________
Date/Time*
____________________________________________________________________
Explanation of Abnormal Assessment Possible Related Nursing Diagnoses
ALLERGIES:_________________________________________________________
Factors
_
PAST SURGICAL HISTORY:_______ _____________________________________
____________________________________________________________________

__ Latex Allergy Response

Thin Obese Emaciated Well-developed __ Latex Allergy Response, Risk for
Well-nourished No Acute Distress
Height _____ Weight ___ BMI ______
Admitting Vital Signs BP:____ PULSE: _____ PAIN: _____
RESP: _____ TEMP: _____
Today’s Vital Signs BP:____ PULSE: _____ PAIN: _____
RESP: ____ TEMP: ______

I. PHYSIOLOGIC ASSESSMENT
A. OXYGENATION
1. BREATHING Gordon’s Pattern of Activity and Exercise __ Airway Clearance, Ineffective
__ Aspiration, Risk for
Respiratory Rate:________ Rhythm: Regular Irregular __ Breathing Pattern, Ineffective
Depth: Deep Shallow __ Gas Exchange, Impaired
No distress Dyspneic Apneic ____ sec. __ Infection, Risk for
Labored Accessory muscle use Tachypneic __ Sudden Infant Death Syndrome, Risk for
__ Suffocation, Risk for
BREATH SOUNDS/LOCATION of FINDINGS __ Ventilation, Impaired, Spontaneous
__ Ventilatory Weaning Response, Dysfunctional
Cl -Clear Pleural Rub
Cr -Crackles Rh- Rhonci
Wh - Wheezing R- Rales
D –Decreased A –Absent

Oxygen Therapy:
RA FiO2___ L / or % NC Mask Trach Other
O2 Saturation: N/A q       hr Continuous pulse oximeter
Pulse Oximetry Readings (Identify on R.A. or O2):      _;      _;      
Chest Config: Symmetrical Asymmetrical Flail
Cough: No cough Weak Strong Frequent Infrequent
Nonproductive Productive Description:      
Color       Odor       Viscosity       Incentive Spirometer
Shape of Chest: AP diameter 1:2, barrel, pectus excavatum,
(highlight or document) kyphotic; other     
Drainage: Chest Tube/Pleuravac: R L Water seal only
Suction     cm of water N/A
Medications R/T Breathing: Yes No Type      

__ Cardiac Output,
2. CIRCULATION Gordon’s Pattern of Activity and Exercise __ Decreased
__ Fluid Balance,
Heart Rate (Radial Pulse):_________ Rhythm: ______________ __ Readiness for
Heart Sounds: Describe: ______________________________________ Enhanced
___________________________________________________________ __ Fluid Volume Deficit
__ Fluid Volume Excess
Neck Veins (45o angle):_____ Flat Distended __ Fluid Volume, Risk for __ Deficit
BP: R____ L: ________ Apical Pulse:______ __ Fluid Volume, Risk for __ Imbalanced
__ Tissue Perfusion,
__ Ineffective (specify: renal, cerebral, cardiopulmonary,
Arterial
C B R F PT DP D – Doppler gastrointestinal, peripheral).
Pulses A – Absent
1+ - Barely Palpable
2+ - Weak
Right/ 3+ - Normal
Left 4+ - Full Bounding

Capillary Refill: Brisk <3 sec. Prolonged >3 sec. _____ sec.
Nail bed Color: Pink Pale Cyanotic

Chest Pain: No Yes Describe (If yes);_____________________

___________________________________________________________

Edema: None Generalized Non-pitting Pitting 1+ 2+

3+ 4+
Other
Location: _____________________________________

Pacemaker: N/A Permanent Type _____

External Rate_____
Location: _____
2. CIRCULATION (Continued) Date/Time
Related Nursing Diagnoses
Explanation of Abnormal
Assessment Factors
Homan’s sign: Left: pos. neg. Right: pos. neg.
Calf redness/tenderness: Left: yes no Right: yes no
Anti-embolism stockings: N/A Remove/Replaced q shift
Sequential compression device: N/A
Remove/Replaced q shift
Other: ___________________________________________

IV’s / INVASIVE LINE MONITORING

Type/Port ID** Solution Rate Dosage Location Site Code*
PNSS 20gtts/min 1L R-arm clear
NONE:____________________________________________________
__________________________________________________________
*SITE CODE: **ID INFUSION DEVICE:
C - Clear p - pump
S - Swelling pca+ - PCA
R - Redness g - gravity
I - Inflamed
DI - Dsg Dry & Intact

Medications R/T Circulation: Yes No Type; _______________

__________________________________________________________
__________________________________________________________
3. NEUROLOGICAL ___ Confusion, Acute
Level Of Consciousness: __ Confusion, Chronic
Awake Alert Oriented x 4 (time, place, person, event) __ Environmental
Restless Drowsy Sedated Confused __ Interpretation
Syndrome, Impaired
Glasgow Coma Scale: __ Infant Behavior,
a) Best eye opening: 4 Spontaneously 3 To Speech __ Disorganized
2 To Pain 1 None __ Infant Behavior,
__ Readiness for Enhanced
b) Best verbal response: __ Organized Infant
5 Oriented 4 Confused 3 Inappropriate words __ Behavior, Risk for Disorganized
2 Incomprehensible sounds 1 None __ Intracranial, DecreasedAdaptiveCapacity

c) Best motor response:

6 Obeys commands 5 Localizes to pain 4 Withdraws 3 Flexion (decorticate)
2 Extension (decerebrate) 1 None

Total Glasgow Coma Scale ____ / 15 (Add a, b, c above)

 A. NUTRITION Gordon’s Nutritional-Metabolic Pattern __ Breastfeeding Effective
__ Breastfeeding Ineffective
Abdomen:
PERRL Soft Pinpoint
Firm Hard
Fixed __ Breastfeeding Interrupted
Tender
Dilated, butDistended ____cm.
reactive to light Dilated, nonreactive __ Dentition, Impaired
Bowel
Unequal:Sounds: Active
R>L Hyper Dolls
L>R Hypoeyes Absent
Other __ Dentition, Impaired
Flatus: __ Failure to Thrive, Adult
Brain StemYes No ____ (+/-) cough ____ gag ____ corneal ____
Signs:N/A Date/Time Related Nursing Diagnose
__ Failure to Thrive, Adult
Diet: Type__DAT___ NPO
Babinski____ TPN Tube feeding Explanation of Abnormal Assessment Factors
__ Fluid Volume, Deficit, adult
Meal: Breakfast Lunch Dinner % taken _______
__ Fluid Volume, Deficit, Risk for
Type gastric tube____ N/A Placement Verified __ Memory, Impaired
__ Infant Feeding Pattern,Ineffective
Communication:
Purpose: Feeding Verbal
Decompression Writes notes
Other Mouths words __ Thought Processes, Disturbed
__ Nutrition: Imbalanced, Risk for More Than Body
Nods head cc’s
Formula: Type ____Rate____ appropriately
q ____ hrsto yes/no
N/Aquestions Requirements
Suction:
Medications N/A IntermittentCondition:
R/T Neurological Low continuous
Yes No Type: ______ __ Nutrition: Imbalanced, Risk for Less Than Body
Drainage: Describe ___________________________________________
___________________________________________________________ Requirements
Mucous Membranes:
3. NEUROVASCULAR Moist Dry Cracked __
__Dysreflexia, AutonomicforEnhancedOral Mucous
Nutrition, Readiness
Sores Patches Pink __ Dysreflexia,
__ Membranes, Risk for Autonomic
Impaired
Dusky
Extremities Other
Examined:____ CSM q _____ hr __
__Peripheral
Self-Care Neurovascular
Deficit,FeedingDysfunction, Risk for
Dentures:
Traction/Cast:Full N/A Upper Lower
Type _____ N/A __ Swallowing,Impaired
Color:
Diet toleration: PinkAnorexiaReddenedNausea BlueVomiting
Blanched
Temperature:
Weight Loss: AmountCool ________
Warm HotPeriod_____ N/A
Time
Movement:
24 o
Intake_____ Active Passive Balance:
24o Output__0__ Limited Positive Negative
Sensation:
Blood Numbnessq 4 hrs Tingling
Glucose Monitoring Pain
Time/Result _____ N/A
Restraints:
Self-feed N/A Type _____CSM
Assist-feed Swallowingq _____ hr
precautions
Restraint Protocol Instituted
Remove/Replaced
Medications q shift Yes
R/T Nutrition: No Type:_____________
__________________________________________________________
__________________________________________________________
B. ELIMINATION Gordon’s Pattern of Elimination Date/Time __ Constipation
Explanation of Abnormal __ Perceived Constipation, Risk for Diarrhea
1. BOWEL Assessment Factors __ Incontinence, Bowel
__ Nausea
Stool: Formed Loose Impacted Last BM _____
Color:________ Regular Irregular
Outlet: Rectum Colostomy Ileostomy
Rectal Tube Fistula
Output: Tube Drainage ______cc’s Describe: _____
Stoma: N/A Pink Edema Dusky
Surrounding Skin: D/I Excoriated Other _____
Toileting: Self Assist History Laxative Use: No Yes
Medications R/T Bowel: Yes No Type: ______________________
___________________________________________________________
2. URINARY __Fluid Volume, Risk for
Imbalanced
__ Infection, Risk for
GU Drainage: Voiding Straight Catheter q ____ hrs __ Incontinence, Functional
Indwelling Foley 3-way cath (irrigation) __ Incontinence, Reflex
External cath Other _____ _ __ Incontinence, Risk for Urge
Other: Bladder Training Catheter Care Hourly Urine Output __ Incontinence, Stress
__ Incontinence, Total
Bladder Irrigation: Continuous Manual Solution: _______ __ Incontinence, Urge
Urine: Clear Cloudy Sediment Odor: Faint Offensive __ Tissue Perfusion, Ineffective
Color: Light Yellow Dark Yellow Orange Clots Hematuria __ Urinary Elimination, Impaired
Patterns: Incontinent Polyuria Nocturia __ Urinary Elimination,
Oliguria Urgency Dysuria __ Readiness for Enhanced Urinary Retention
 Date/Time Related Nursing Diagnosis
F. SEXUAL Gordon’s sexuality-Reproductive Pattern Explanation of Abnormal
Assessment Factors
Reproductive: LMP______
Premenopausal Postmenopausal Male
Hysterectomy: Ovaries Removed Ovary/Ovaries Remain
Breast: Symmetrical AsymmetricalDescribe: _____
Self Breast/Testicle Exams: Yes No Freq: _____
Cancer Screen: Date ____ Test_____ Result:___________
Date______Test_____ Result____________ (Breast, Pap,
Prostate)
Sexual/Fertility Concerns_______________
Hormone Replacement:_______________
Medications Related to Sexuality: Yes No Type: ________
II. SAFETY AND SECURITY
Temperature: _______
Route Taken: Oral Tympanic Ax.
Rectal Temporal
Skin: Turgor: Location:_________
Elastic Tented Taut Shiny
Temp: Hot Warm Cool Dry
Clammy Diaphoretic
Color: Location: _________
Pink Pale Cyanotic
Flushed Jaundiced Mottled
Other ______________
Bony Prominences:
Skin Intact Reddened Gray
Pressure Sore Stage:_______ Location: ______
Wound Location : _____
Wound: N/A Sutures Staples
Drain Dehiscence Evisceration
Healing by secondary intention Other
Dressing N/A Dry/Intact Open to Air
Stained Saturated
Changed: q______hrs wet to dry Other Describe:      
Isolation/Precautions:
Standard Precautions Additional ___________
Protocols: Braden Scale Restraints
Special Bed Other ____________
Physical:
General Unassisted Supervised
Assisted Unable
Movement: Hemiparesis/plegia Paraparesis/plegia Quadriparesis/plegia
Bathing/Hygiene: Self Assist Total
Partial PM Care
Oral Care: Self Assist
Assistive Devices: N/A Type: _______________
Weight Bearing Status: FWB L PWB
R PWB NWB
Precautions: Swallowing Seizure Spinal
Fall Subarachnoid
Perception: Gordon’s Cognitive-Perceptual Pattern
Vision Deficits: Blind (legally) Glasses Contacts
Hearing Deficits: Deaf HOH
Hearing Aid(s): L R Bilat.
Other: ______________________
Precautions: none Danger to Self Danger to Others
Self Mutilation Suicide
Alcohol and Drug Withdrawal
Medications R/T Safety and Security: Yes No Type: ________
Pt.’s Highest Level of Education: ______ ______________
 VII. INTAKE AND OUTPUT MONITORING SHEET
PATIENT’S NAME: __________________________________________ DATE: ________________

INTAKE OUTPUT

SHIFT TIME IV ORAL NGT TOTAL SHIFT URINE NGT/DRAINS PTT/CTT BM OTHERS TOTAL

TOTAL:
TOTAL:

TOTAL INTAKE TOTAL OUTPUT BALANCE