Professional Documents
Culture Documents
An Tsvi. Nursing Review Chart Iv. Physical Assessment
An Tsvi. Nursing Review Chart Iv. Physical Assessment
An Tsvi. Nursing Review Chart Iv. Physical Assessment
PHYSICAL ASSESSMENT
NURSING SYSTEM REVIEW CHART Name: XX Date: December 9, 2010 Vital Signs: Pulse:138 bpm BP: N/a
Temp: 36.0
Respi: 40 cpm
EENT [] impaired vision [] blind [] pain reddened [] drainage [] gums [] hard of hearing [] deaf [] burning [] edema [] lesion teeth [] asses eyes, ears, nose,throat for abnormality [X] no problem RESPIRATION [] asymmetric [] tachypnea [] barrel chest [] apnea [] rales [X] cough [] bradypnea [] shallow [] rhonchi [] sputum [] diminished [] dyspnea [] orthopnea [] labored [x] wheezing [] pain [] cyanotic [] assess resp rate, rhythm, depth, pattern [] breath sounds, comfort []no problem GASTRO INTESTINAL TRACT [] obese [] distention [] mass [] dysphagia [] rigidly [] pain [] asses abdomen, bowel habits, swallowing [] bowel sounds, comfort [X]no problem GENITO-URINARY and GYNE [] pain [] urine color [] vaginal bleeding [] hematuria [] discharge [] nocturia [] assess urine freq., control, color, odor, comfort [] grip, gait, coordination, speech, [X]no problem NEURO [] paralysis [] stuporous [] unsteady [] seizure [] lethargic [] comatose [] vertigo [] tremors [] confused [] vision [] grip [] assess motor function, sensation, LOC, strength [] grip, gait, coordination, speech, [X]no problem 2 MUSCULOSKELETAL and SKIN [] appliance [] stiffness [] itching [] petechiae [] hot [] drainage [] prosthesis [] swelling [] lesion [] poor turgor [] cool [] deformity [] atrophy [] pain [] ecchymosis [] diaphoretic [] assess mobility, motion, gait, alignment, joint function [] skin color, texture, turgor, integrity [x] no problem