Review of Systems

NURS 02 - HEALTH ASSESSMENT

 Review of Systems

Series of questions about all body systems that helps to

reveal concerns as part of a comprehensive health
assessment
When able, the patient fills out a form
Ask any symptoms related to each body system (e.g. cough
- respiratory system)
May integrate these questions during physical examination
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Purposes:
1. Evaluate the past and present health state of each
body system
2. To double check in case any significant data were
omitted in the present illness section
3. Evaluate health promotion practices
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May vary in sequence and format, depending on the

setting, the acuity or degree of illness, and urgency of
the problem, as well as the style of the nurse

ROS - subjective data

PE - objective data
 Review of Systems
 May identify the problems not uncovered previously in
the history and provides an opportunity to indicate client
strengths and liabilities.
 From cephalad to caudad

 Clients are instructed that they will be asked a number of

questions
 Both beginning and experienced interviewers normally
need a checklist or written reminder of the questions
usually asked each client.
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 In addition to ROS, obtain information from the patient

about health promotion practices
 Begin with a general question, e.g. How is your appetite?

 Then progress to more detail, e.g. Have you had any

nausea, allergies, or gastric reflux?
 Document not only the presence of findings but also the
absence of problems or symptoms. E.g. No nausea,
constipation, or diarrhea.
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 When arriving at the section of the review that includes the
presenting situation, ask only those questions that have not yet been
covered.
 Explain that although the review is lengthy, it is an opportunity to
double check for completeness and accuracy of past and current
problems.
 Adapt topics to the patient and direct conversation in a way that is
comfortable and logical.
 Use common lay language so that the patient better understands the
topics and questions.
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 General health state. Weight gain or loss, fatigue,
weakness, malaise, pain, usual activity, fever, and chills.

 Nutrition and hydration. A history of conditions that

increase the risk of malnutrition or obesity. Nausea and
vomiting. Norma; daily intake, weight and weight
change, noting if changes were intentional or not,
dehydration, dry skin, fluid excess with short. ness of
breath, or edema in the feet and legs. Diet practices to
promote health.
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 Skin, hair, and nails. A history of skin, hair, or nail

disease. Rash, itching, pigmentation or texture change,
lesions, sweating, dry skin, hair loss or change in texture,
brittle or thin'nails, and thick or yellow nails.

 Head and neck. A history of high or low thyroid

hormone level. Headaches, sync0pe, dizziness, and sinus
pain.
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 Eyes. A history of poor vision or vision problems,

glaucoma, cataracts. Use of contact lenses or glasses,
change in vision, blurring, diplopia, light sensitivity,
burning, redness, and discharge. Last eye examination
and any changes at that time.
 Ears. A history of ear or hearing problems, hearing loss,
and ear infections. Ear pain, change in hearing, tinnitus,
and vertigo. Last hearing evaluation and results and ear
protection.
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 Nose, mouth, and throat. A history of mouth or

throat cancer. Colds, sore throat, nasal obstruction,
nosebleeds, cold sores, bleeding or swollen gums,
tooth pain, tooth extractions, implants, dental caries,
ulcers, enlarged tonsils, and dry mouth or lips.
Difficulty chewing or swallowing and change in
voice. Last dental cleaning and exam, and results.
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 Thorax and lungs. A history of emphysema,

asthma, or lung cancer. Wheezing, cough, sputum,
dyspnea, last chest x-ray and results, and last
tuberculin skin test and results.
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 Heart and neck vessels. A history of congenital

heart problems, myocardial infarction, heart surgery,
heart failure, arrhythmia, and murmur. Chest pain
or discomfort, palpitations, and exercise tolerance.
Any screening tests such as electrocardiogram or
stress test, screening for cholesterol, triglycerides,
elevated lipids and results for any of these tests.
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 Peripheral vascular. A history of high blood

pressure, peripheral vascular disease,
thrombophlebitis, blood clots, peripheral edema,
ulcers, circulation, claudication, redness, pain, and
tenderness.
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 Breasts. A history of breast cancer or cystic breast

condition. For adolescents, for males, gynecomastia.
Pain, tenderness, discharge, lumps, last
mammogram and results, and frequency and date of
last self-examination.
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 Abdominal-gastrointestinal. A history of colon

cancer, gastrointestinal bleeding, choleiithiasis, liver
failure, hepatitis, pancreatitis, colitis, ulcer, or gastric
reflux. Appetite, nausea, vomiting, and diarrhea.
Food intolerance or allergy, constipation, diarrhea,
change in stool color, and blood in stool. Last
sigmoidoscopy, colonoscopy, and stool for occult
blood and results.
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Abdominal-urinary. Renal failure, polycystic

kidney disease, urinary tract infection, and
nephrolithiasis. Pain, change in urine, dysuria,
urgency, frequency, nocturia, and incontinence. For
children, toilet training and bed-wetting.

or tingling, and loss of sensation or coordination.

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 Musculoskeletal. A history of injury and arthritis.

Joint stiffness, pain, swelling, restricted movement,
deformity, change in gait or coordination, and
strength. Pain, cramps, and weakness.

 Neurological. A history of head or brain injury,

stroke, and seizures. Tremors, memory loss,
numbness
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 Male genitalia. A history of undescended testicle,

hernia, and testicular cancer. Pain, burning, lesions,
discharge, and swelling. Change in penis or scrotum,
and protection against pregnancy and sexually
transmitted infections. Testicular self-examination
and frequency.
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 Female genitalia. A history of ovarian or uterine

cancer, ovarian cyst, endometriosis, number of
pregnancies and children. Pain. homing, lesions,
discharge, itching, and rash. Menstrual and physical
changes, and protection against pregnancy and
sexually transmitted infections. Last Pap smear and
results.
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 Anus, rectum, and prostate. A history of

hemorrhoids; prostate cancer; benign prostatic
hyperplasia: urinary incontinence, Dill“. burning.
and itching; for men, hesitancy. dribbling, and loss
in force of urine stream. Screening prostate-specific
antigen test and result.
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 Endocrine and hematological system. A

history of diabetes mellitus, high or low thyroid
levels, and anemia. Polydipsia, polyuria. unexplained
weight gain or loss, changes in body hair and body
fat distribution, excessive sweating or diaphoresis,
intolerance to heat or cold, excessive bruising, and
lymph node swelling. Result of last blood glucose
test.