PHYSICAL ASSESSMENT I. INTEGUMENTARY Inspect -skin integrity for color variations, lesions, etc. -scalp -hair (color, quantity, distribution) -nails -note smell/odors -edema (if appropriate) u e...
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nursing health examFull description
Nursing
Physical Assessment Exam Study GuideFull description
Special Notes: ___________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ____ HEENT 1. Eyes Eyes a. Pupils
PERRLA equal round raxn to light accom convergence convergen ce Size:
_____mm
nearsighted farsighted glasses b. Vision 2. Ears Ears ear a. Hearing ai aids left ear right none ear none b. b. Pain Pain/W /Wax ax buil build d up left ear right yes no c. Com Compreh prehen enssion 3. Nose Nose a. Drainage yes no b. Blockage kagess yes no c. Sense ense of Smel Smelll yes no d. Congestion yes no pink pale pallor e. Mucou ucouss Memb Membrranes anes moist 4. Thr Throat/ oat/Mou Mouth th moist pink pale pallor a. Mucou ucouss Memb Membrranes anes teeth dentures good poor b. b. Oral Oral Hyg Hygiene iene easy difficult painful c. Swallowing d. Lymph no nodes normal enlarged
contacts
Special Notes: ___________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ____
Neuro
1. 2. 3. 4. 5. 6.
LOC alert lethargic obtunded stupor coma person place time Ori Orienta entattion ion x3 Mood happy depressed anxious angry confused unclear/ineffective partial Communication clear/effective unsteady/weak partial Motor Function steady/strong Glasgow Coma Scale
jaundice pallor ashen dusky erythema cyanotic aprop to race Color pink Hair Hair Dis Distr trib ibut utio ion n even uneven Moisture wet moist dry clammy hot warm cool cold Tempe emperratur aturee smooth rough Texture Turgor ____ seconds high normal low Vascu ascullarit arity y none little yes location: _________________ Ed e m a Lesions no yes location: ________________shape: _______________ type: ______________color: _______________
Special Notes: ___________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ __ Chest/Thoracic 1. Cardi Cardiac ac a. A/P (S2 “dub”) clearly audible muffled murmur gallops clearly audible muffled murmur b. Erbs Pt gallops clearly audible muffled murmur gallops c. T/M (S1 “lub”) regular irregular d. Heart Be Beat e. Apic Apical al rate rate ____ ______ __ f. Apical Rhyt hythm regular irregular yes ___________ no g. PMI lo located h. Cap refill ______ seconds brisk rapid rapid sluggish slugg ish 2. Respirat Respiratory ory wheezes whee zes crackles a. Breath ath So Sounds nds Anterior clear Posterior clear crackles wheezes reg irreg labored shallow deep b. b. Res Respir pirati ation rate: _____ even c. Ches Chestt Exp Expan ansi sion on symmetrical unsymmetrical d. Cough no yes non-productive productive color:_________ amount: ___________
no little difficulty w/ respirations e. SOB yes Special Notes: ___________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ___ GI/Abdomen
1. Inspec pection flat round active hyperactive hyperac tive hypoactive faint absent 2. Bowel owel So Sounds x4 RLQ active hyperactive hyperac tive hypoactive faint fai nt absent RUQ active hyperactive hyperac tive hypoactive faint fai nt absent LUQ active hyperactive hyperac tive hypoactive faint faint absent LLQ active hyperactive hypoactive faint absent hard firm tender non-tender distended 3. Palpation soft average poor tube 4. Diet good 5. Toler olerat atio ion n of die diett good average poor 6. Chan Change ge in appe appeti tite te yes no gain loss 7. Rece Recent nt wei weigh ghtt chan change ge none 8. NG/GT tube no yes intact flushed continuous bolus feeds Special Notes: ________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ___ Elimination
1. Urine continent incontinent clear cloudy yellow amber bloody tea-colored foul smelling diapers catheter 2. Last Last BM: ________ _________ _ how often: often:____ _______ _______ ____ brown yellow black tarry green watery soft hard formed diarrhea Special Notes: ___________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ ___ Musculo-Skeletal partial active passive assistive 1. ROM Upper extremities full Lower extremities full partial active passive assistive 2+ 3+ 4+ 2. Strength Upper extremities 1+ Lower extremities 1+ 2+ 3+ 4+ 2+ 3+ 4+ dorsalis pedis 1+ 2+ 3+ 4+ 3. Pulses radial 1+ 4. Gait steady/balanced unsteady/unbalanced limping shuffled 5. Posture straight slumped assistance w/ assistance crutches walker cane wheelchair 6. Ambulates w/o 7. Hist Histor ory y of fall fallss no yes how often: _______________ 8. Abil Abilit ity y to to perf perfor orm m ADLs ADLs yes no 9. Edema no yes location: _____________ yes description: _________________________________ 10. Abnormaliti Abnormalities es no
Special Notes: ___________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _____ %IBM/BMI
Height: _____ ___lbs.
Weight: ___ ______i __in.
BMI: ______ ____
BMI: BMI: weig weight ht / (he (heig ight ht)² )² x 705 705 Less than 18.5 underweight 18.5 – 24.9 normal weight actual weight x 100 Ideal weight Less than 70% severly underweight 90 – 110% adequate weight
