St.

Michael’s College
College of Nursing
Iligan City

PHYSICAL ASSESSMENT FORM

Student: _______________________________ Group: __________ Agency/Department: __________________

Clinical Instructor: ________________________________ Date Submitted: ________________________

PATIENT’S PROFILE
Name of Patient: _________________________________________ Health Insurance:________________________

Address: ___________________________________________ Source of Information: ________________________

Age: __________ Sex: _____ Civil Status: __________ Religion: ____________ Primary Language: _____________

Date Admitted: ________________________ Time: ___________________ Day: _________________________

Arrived via: wheelchair stretcher ambulatory others (specify):

Blood Reaction: □Yes □No Allergy to Dyes/Shellfish: □Yes □No
Admitting Physician: ____________________ Attending Physician: __________________ Time Noted: ____________

NURSING ASSESSMENT
1. Chief Complaint:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

2. History of Present Illness:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Medical History (indicate if paternal or maternal side):
□Cardiac ____________________________________ □Gastro _____________________________________
□Hyper/hypotension ___________________________ □Arthritis ____________________________________
□Diabetes ___________________________________ □Stroke _____________________________________
□Cancer ____________________________________ □Glaucoma __________________________________
□Respiratory _________________________________ □Asthma ____________________________________
□Mental Disorder ______________________________ □Accidents/Injuries ____________________________
□Drug Allergies _______________________________ □Others (pls specify) ___________________________
4. Surgeries/Procedures/Hospitalizations: Date
_______________________________________ _______________________________
_______________________________________ _______________________________
_______________________________________ _______________________________

5. General Survey:

Anthropometric Measurement: Weight: ___kg Height: ___cm BMI:____ Head Circumference: ___cm
General Appearance: □No Signs of Distress □With Signs of Distress □Cardiorespiratory distress □Pain
Growth Development: □Endomorph □Mesomorph □Ectomorph
□Well developed □Fairly developed □Poorly developed
□Looks according to age □Appears older/younger than stated age
Hygiene: □ dress appropriately □ dress oddly □ dress inappropriately
6. Review of System A: Adult/Child

Pt Initials: _____________ Chief Complaints: _________________________________________________________

REMARKS
BODY
SYSTEM
CIRCLE ALL ABNORMAL FINDINGS IN RED AND NORMAL IN BLACK. (Significance with
Diagnostics, Labs, etc)
LOC: Alert Follows simple commands Sedated Lethargic Drowsy Unresponsive
Confused Obtunded Stupor Coma
Orientation: Person, Place, Purpose, Time
Behavior: appropriate (describe) inappropriate (describe)
Coordination/equilibrium: Balanced Dizziness Vertigo
Ext strength: Strong Weak Flaccid MAE Equal Unequal (describe)
Speech: Clear Coherent Slurred Appropriate Repetitive Hoarseness
Dysphonia
Dysarthria Aphasia (receptive/expressive) High-pitch Monotonous Soft
Comprehension:
Memory: short/long anterograde/retrograde
Sensation: Intact Numbness Tingling
Pupils: equal reactive Size: Equal/Unequal R: ___mm L:___mm
Reaction to light: Right (brisk/sluggish/fixed) Left: (brisk/sluggish/fixed)
External ear pinnae: normoset symmetrical gross abnormalities
Neuro tenderness/swelling
External ear canal: impacted cerumen
Discharges: (-)/(+) serous/purulent/mucoid/foul-smell
Gross Hearing: symmetrical R/L Deafness
Pain: absent present (describe PQRST/COLDERRA) controlled /PCA Y/N
Glasgow Coma Scale: Eye Opening__ Verbal__ Motor __ Total ______
Head Configuration: Normocephalic Masses (describe) Others (specify)
Fontanelles: Closed Open Sunken Bulging
Hair: Fine Coarse Pliant Dry Oily Brittle Evenly-distributed Alopecia
Scalp: Clean Dandruff Lice Wounds/Lesions (describe) Scars
Lids: Symmetrical R/L Edema/Swelling R/L Ptosis
Periorbital Region: Edema Sunken Discoloration
Conjunctiva: Pink Pale Lesions (describe) Discharges (describe)
Sclera: Anicteric Subicteric Icteric Hemorrhages
Cornea/Lens: Smooth Clear Opacity Acrus Senilia Lesions (describe)
Visual Acuity: grossly normal farsighted nearsighted
Neck Thyroid: palpable/non-palpable Lymph Nodes: palpable /non-palpable
Apical Rhythm :Regular/Irregular Murmur/rub/click
(describe intensity pitch quality amplitude)
Radial __bpm Pedal ___bpm (Absent/diminished/normal/bounding) Equal: Y /N
Heart Sounds: Normal Abnormal (describe) Pulse deficit? Y/N ___bpm
Vascular sounds: aortic bruits venous hums
Edema: Y/N ___ Location: Scale: (0-+4) _________
CV
Varicosities: Y/N Location:
Hydration: Tenting </>3 sec Cap refill: </> 3 sec Skin turgor: </> 30 sec
Fontanels N/A Present (location) Jugular Vein Distention: Y/N
Telemetry: Rhythm___ BP _____mmHg Pulse pressure? Y/N____mmHg
Neck Vein distention: Y/N
Carotid: bruits amplitude equality
Nasolabial fold: symmetrical R/L shallow Septum: midline/deviated/perforated
Nasal Mucosa: pinkish/pale/reddish Discharges: serous/purulent/mucoid/bloody
Nasal Patency: patent/obstructed on exhalation R/L Sinuses: tender/non-tender
Nasal Flaring: Y/N
Gross Smell: symmetrical R/L olfactory deficiency
Chest Shape: anterior-posterior: lateral ratio AP:L_____
Barrel-chested Funnel Pigeon Others (describe)
Chest pulsations: normal thrills heaves lifts
Chest expansion/symmetry: equal unequal ICS: even/relaxed bulging/retracting
Rate:__cpm Pattern: Regular/Irregular Effortless Hyperventilate/Hypoventilate
Hyperpnea/Tachypnea/ Bradypnea/Dypsnea/Biot’s/Kussmauls/Cheyne-Stoke
respiration/Apnea ___sec
Respiratory effort: labored unlabored Respiratory pattern: regular/irregular
Resp
Airway: Obstructed Y/N with/without congestion
Accessory muscle use: Y/N Depth: Normal Shallow Deep
Sternal shape/position: level with ribs/depressed/projecting
Tracheal position: midline deviated R/L Rib Slope: </> 90° downward/horizontal
Breath sounds: Clear Absent all lobes RLL RML RUL LLL LUL Type: ______
Adventitious: (location) RLL RML RUL LLL LUL Type: _______
Upon percussion: resonance/hyperresonance/dullness/flatness/tympany Location:
Vocal/tactile fremitus: symmetrical ↑/↓ at_____
Cough: Y/N Nonproductive/Productive frequency Sputum+/- (describe color,
amount, odor, consistency)
O2 device: Y/N Venti-mask, NC, NRBM, simple mask
O2 flow: ___ L/min or ____ % SpO2 ______ %
Trach present: Y/N Type: ___ Size ___ Cuff: inflated/deflated/fenestrated
Integum Appearance: intact warm/dry cool/moist Color: ____
entary Texture: smooth soft rough thick
 Lesions: +/- (describe location, type, amount, distribution/arrangement )
Pressure sites: Induration hyperemia breakdown blanches with return of color
Ulcers: size___ stage___ tunneling necrotic tissue exudate epithelialization
Wounds: +/- (describe type/size/location/pattern/condition/ drainage)
Mucous membranes: moist /dry pale/pink/cyanotic
Suture line: red/swollen/approximated Drainage Y/N Suture size:___mm
Suture used: staples/steri-strips
Dressing: intact / absent. Needs changing Y/N Braden Scale Score _ _
Nail color: pink/pale/cyanotic/yellow/opaque splinter hemorrhages Beau’s lines
Nail shape: round 160°base spooned clubbed ridged
Nail texture: hard immobile firm smooth thickened paronychia onycholysis
IV site condition: patent redness swelling pain
IV insertion date: __/__/__ Catheter gauge _____
IV solution: Rate: Site:
Mobility: coordinated/uncoordinated jerky tremor tic
Motor movement: fast/slow bizarre tense restless
Muscle tone/strength/size: equal/unequal strong/weak symmetrical/asymmetrical
Weakness/Atrophy/Flabby Y/N R/L Upper/Lower Scale/Rate:
Musculo/ Gait: coordinated/uncoordinated staggering shuffling stumbling limping smooth
Skeletal
Stance: wide/uneven/even base toes point straight/in/out bow-leg/knock-knee
Posture: erect stooped slumped Spinal curve: normal kyphosis lordosis scoliosis
ROM: Full/Limited tenderness/pain joint swelling ↑/↓ upon ____ passive/active
(describe exercises) Wt bearing stability: Y/N
Equipment: CPM Traction Splint Cast Pins Walker Cane Crutch
Location:
Lips: pinkish/pale/cyanotic moist/dry/cracks lesions (describe)
Tongue: midline R/L deviation hyper/atrophy fasciculation deep/beefy red
Teeth: complete missing teeth caries dentures braces/retainers
Gums: pinkish/pallor/bleeding/red/spongy/inflamed Mucosa:pinkish/pallor/cyanotic
Uvula: midline R/L deviation Oral Mucosa: pinkish/pallor
Tonsils: inflamed Y/N R/L exudates Y/N R/L
Abdomen: flat/rounded/distended soft/firm tender (direct/indirect)/non-tender
Abdominal girth: ___cm
Percussion: tympanic/hypertympanic/fluid wave/shifting/dullness/flatness
BS: Absent /Active Hyper/Hypo Locations: RUQ, RLQ, LUQ, LLQ ____sec/min
GI
Flatus: Continent/Incontinent Nausea/emesis: Y/N (describe)
Gag reflex: Y/N Chews/swallows with/without difficulty
Stool: color____ consistency_____ amount_____ frequency _____ heme +/-
Tube feeding: Y/N PEG/NG Size: ___Fr Verified placement: Y/N How: _ ____
Suction: ___cm intermittent/continuous
Enteral feeding: Type: Location:
Ostomy: N/Y (Describe type/location/drainage)
Drainage tubes: (describe type, location, drainage)
Diet:
Nutrition: well-nourished obese cachexic
Breast size: equal/unequal Breast appearance (describe):
Breast shape: symmetrical/asymmetrical round/pendulous
Breast color: pinkish/stria/reddish/blue hue/↑ vein engorgement
Breast surface: smooth retraction: +/- dimpling: +/- edema: +/- tenderness: +/-
elastic/lumpy non-tender/tender
Breast lesions/masses/discharge: -/+ (describe)
Repro
GU
Lymph nodes on breast: +/- palpable/nonpalpable </> 1cm
Bladder distended on palpation: Y/N 24 hr Intake ____ Output _ __
Urine: color_____ sediment_____ odor____ amount ____ frequency_____
Foley: Y/N Size: ____ Fr Type: indwelling condom; Taped: Y / N
Voiding: frequency burning residual incontinent/continent urgency dysuria
Penile lesions/discharge: -/+ (describe)
Vaginal lesions/discharge: -/+ (describe)
Sleep pattern Support System
Emotional/behavior status: Calm Worried Restless Tense Others(describe)
Mood & affect:
Psycho- Appearance and general behavior:
social Attitude:
Concerns/expectations (Tx, recovery):
Cultural/Spiritual Practices:
Religious preference:
T:__°C (oral/axilla/rectal) P:__bpm (regular/irregular R:__cpm (regular/irregular)
VS
BP: _____mmHg (sitting/lying/standing)
7. Review of Systems B: OB

Pt Initials: _____________ Chief Complaints: _________________________________________________________

BODY REMARKS
SYSTEM
CIRCLE ALL ABNORMAL FINDINGS IN RED AND NORMAL IN BLACK.
(Diagnostics, Labs, etc
Cognition/Perception WDL Pain Scale ____ Dizziness Diplopia Headache
Respiratory WDL Breath Sounds all Fields __________ Cough
Skin & Mucous Membranes WDL Rash Petechia Pallor Cardio WNL
Elimination: Voiding BM Flatus Bowel Sounds Fudus Firm Fundus level
Fundus massaged
Lochia: Amount Color Malodorous
Lochia comment:
Perineum:
Lacerations Swelling Inflammation Perineum cleaned Solution used
Appearance
OB Peri Care comment
Hemmorhoids Foley Drains N/V Ecchymosis
Nutrition / Metabolic WDL: NPO Special Diet Refused to eat
Breast engorgement Nipples inverted Nipple care
Activities / Exercise / Musculo WDL Up in chair Bed rest Bed
rest with BRP Homans
Coping / Independence WDL Social Services
IV’s Site Appearance Solution Rate
Complications of Delivery:
BRADEN SCALE: Moisture Activity Mobility Nutrition
WOUND Assessment: Location Dimension Depth Drainiage
Odor Surrounding tissues Tunneling
LOC: Alert Sedated Lethargic Unresponsive Others (describe)
Orientation: Person, Place, Purpose, Time (x4)
Coordination/equilibrium: Gait Dizziness Vertigo
Ext strength: Strong Weak Flaccid MAE Equal Unequal (describe)
Neuro
Speech: Clear Coherent Slurred Appropriate Aphasia
Sensation: Intact Numbness Tingling
Pupils: equal reactive Pain: absent present (0-10) controlled PCA
Glasgow Coma Scale Total ______ Alert- follows simple commands
Apical Pulse: Regular Irreg/irreg Reg/irreg Murmur/rub Radial __
Pedal (Absent/diminished/normal/bounding) _ _ Equal: Y/N Rate: Apical
___ Radial ___ Pulse deficit? Y/N
CV Edema: Y/N ___ Location: Scale: (0-+4) _________ Cap refill: <
3 sec >3 sec Skin color: Telemetry:
Rhythm________________________ BP _______________
Hydration: Tenting <3 sec >3 sec Fontanels
Rate:_______ Pattern: Regular Irregular Apnea ___sec. Effort: labored
unlabored Airway: not obstructed; without congestion Accessory
muscle use: Y/N Depth: Normal Shallow Deep
Breath sounds: Clear all lobes Adventitious: (location) RLL RML RUL
LLL LUL
Resp
Cough: Y/N Nonproductive Productive- Sputum (color, amount, swallows,
odor, consistency):
O2 device: Venti-mask, NC, NRBM, simple mask O2 flow: _____ L/min or ____
% SpO2 ______ %
Trach present: Y/N Type, size, cuff inflated/deflated
Mobility: Strength: Muscle tone: Gait:
ROM: Full Limited (describe) Wt bearing Y/N Equipment: CPM
Musculo/
Skeletal
Traction Splint
Walker
Location:
Gag reflex: Y/N Chews/swallows without difficulty Stool: color, consistency,
GI amount, heme +/-

Sleep pattern Support System

Psycho- Emotional/behavior status Mood & affect
social Appearance and general behavior Concerns/expectations (Tx, recovery)
Attitude Marital Status Religion Cultural/Spiritual Practices

VS
8. Review of Systems: Newborn

Pt Initials: _____________ Chief Complaints: _________________________________________________________

REMARKS
BODY
SYSTEM
CIRCLE ALL ABNORMAL FINDINGS IN RED AND NORMAL IN BLACK. (Diagnostics,
Labs, etc
Temperature: Source: Pulse: Source: Respirations: Source:
BP R arm: BP L arm; BP R leg: BP L leg: O2 sat: Probe change:
Cord care: Bath: Circumcision care: ID Bands: Infant to mother: Infant
to Nursery:
Abdomen: Blood Glucose: Bulb syr w/ baby:
ELIMINATION: NBN Stool type: # of stools Emesis: Diaper weight: # of
voids
Urine: Urine appear:
Comments:

Pain: Pain Scale:

Breast fed Right: Breast fed Left:
Latch scores:
Latch: Audible swallowing: Type of nipple: Comfort (breast/nipple)
Hold (positioning) total score:
Formula (type) Amount: Total time fed Gavage feed: IV Credit/mls:
Reposition: Reflux Board: Degrees

HEAD: Fontanels: depressed/ bulging ____ cm location:

EYES: sclera pupils
Newborn
HAIR:
NOSE:
MOUTH:
EARS:
NECK:
CHEST:
Breast: Nipples
RESPIRATORY: Newborn respiratory rate normal
NEUROLOGICAL: Activity Muscle tone
HEART: Sound Pulse Murmur Cap refill
ABDOMEN: Abdomen: cm: appearance: Bowel sounds
SKIN: appearance _____ texture _______ turgor ________ pigmentation _____ color
____ capillary refill _________ cord condition _______

MISCELLANEOUS:
Weight ___ gm; ____lbs ___ oz Previous day weight: ____gm or ___lbs
Weight loss/gain: Y/N ____gm or ____lbs
NICC unit used Radiant warmer Isolette temp
PKU Date of PKU
IV comment site appearance IV site
Newborn positioning:

REFLEX TESTING METHOD NORMAL RESPONSES ACTUAL RESPONSES IMPLICATION

Stroke one side of the neonate’s Neonate hyperextends the toes,
Babinski (plantar) for upward from the heal and dorsiflexes the great toe and fans
across the ball of the foot the toes outward.
Momentarily shine and bring the
Blink (corneal) light directly into the neonate’s Neonate blinks eyes.
eyes.
Place the neonate prone on a Neonate attempts to crawl forward
Crawl
flat surface using the arms and legs
Position the neonate supine; Neonate swiftly flexes and extends
extend one leg and stimulate the opposite leg as though trying to
Crossed Extension
the sole with a light pin prick or push the stimulus away from the
finger flick other foot.
with neonate supine, slowly turn
Dolls Eye Neonate’s eyes remain stationary.
the neonates head to either side
Using a fingernail, gently stroke
one side of the neonate’s spinal Neonate’s trunk curves toward the
Galant
column from the head to the stimulated side.
buttocks
Palmar reflex: place a finger in
the neonate’s palm Neonate grasps the finger.
Grasp Plantar reflex: place a finger Neonate’s toes curl downward and
against the base of the grasp the finger.
neonate’s toe
Neonate extends and abducts all
Suddenly but gently drop the extremities bilaterally and
Moro neonate’s head backward symmetrically forms a >c= shape
(relative to the trunk) with the thumb and forefinger;
adducts & flexes the extremities