EENT

_ Impaired Vision __Blind __Pain

__Reddened __Drainage __Gums
_ Hard of hearing __Edema __Lesions
__Teeth none
Comments:

Respiratory
__Asymmetric __tachypnea __apnea
__rales _cough __Barrel Chest __Shallow
__bronchi sputum __Diminished
__dyspnea __Orthopnea __labored
__wheezing __Pain __Cyanotic _/None
Comments:

Cardiovascular
__arrhythmia __tachycardia __Numbness
_Diminished pulses Edema __ Fatigue
__Irregular __bradycardia __murmur
__Tingling __Absent pulses __Pain
None
Comments:

Gastrointestinal Tract
__Obese __Distention __mass
__Dysphagia __rigid pain None
Comments:

Genitourinary
_Pain __Urine Color __Vaginal
__Bleeding __Hematuria __Discharge
__nocturia None
Comments:.

Neuro Musculoskeletal and Skin

__Paralysis __Stuporous Unsteady
__Seizures Lethargic __comatose
__vertigo __Tremors __Confused Vision
__Grip __None
Comments
__appliance __Stiffness _Itching __petichiae
__ hot __Drainage __Prosthesis __Swelling
__Lesions _Poor Turgor __Cool __Deformity
__wound __rash Skin color _Flushed
__Atrophy __pain __ecchymosis _diaphoretic
__moist
Comments:

NURSING SYSTEMS REVIEW CHART

HEAD TO TOE ASSESSMENT
V. NURSING ASSESSMENT

SUBJECTIVE OBJECTIVE
COMMUNICATION ( ) glasses ( ) languages
( ) Hearing loss ( ) contact lenses ( ) hearing aide
( ) Visual changes ( ) speech difficulties
( ) Denied Pupil size:
Comments
Reaction:

Oxygenation: Respiration: ( /)regular ( )irregular

( ) Dyspnea Describe:
( ) Smoking History Right:
( ) Cough Left:
( ) Sputum
( ) Denied
Comments:

CIRCULATION Heart rhythm. ( /) regular ( ) irregular

( ) chest pain ( ) Ankle edema:
( ) leg pain Pulse: CAR. RAD. DP. FEM.
( ) numbness of extremities R:
( ) denied L:
Comments:
Comment:

NUTRITION ( ) Dentures ( ) none

Diet: Full partial with patient
Character: Upper:
( ) Recent change in weight, Appetite Lower:
( ) Swallowing difficulty
( ) Denied
Comments:
ELIMINATION Bowel sounds:
Usual bowel pattern ( ) yes
Urinary frequency: ( ) no
Date of last BM: Urine ( color, consistency, odor )
( ) diarrhea character:
( ) urgency ( ) incontinence
( ) dysuria ( ) polyuria Comments:
( ) hematuria ( ) Foley catheter in
in place
( ) denied

Comments:

MGT OF HEALTH & ILLNES Briefly describe the patient ability to follow
( ) alcohol ( amount, frequency ) treatment ( diet, meds, etc. ) for chronic health
problems ( if present )
( ) denied
( ) BSE
Last pap smear LMP:

SKIN INTEGRITY ( ) Dry ( ) cold ( /) pale

( ) Dry ( /) Flushed ( ) warm ( ) moist
( ) Itching ( ) cyanotic
( ) Other:
( ) Denied
Comments:

ACTIVITY / SLEEP ( ) LOC and orientation

( ) Convulsion
( ) Dizziness Gait: ( ) walker ( ) cane ( )other
( ) Limited motion of joints ( ) steady ( ) unsteady
( ) Limitation in ability to ( ) sensory & motor losses in face or other
( ) Ambulates extremities
( ) Bathe self ( ) ROM Limitation
( ) Other Comment:
( ) Denied
Comments:

COMPORT / SLEEP / AWAKE ( ) facial grimaces

( )Pain ( ) Guarding
( ) Location- right inguinal ( ) Other signs of pain:
Frequency- upon touch ( ) side rails release from signed ( 60+ years )
( )N/A
( ) Nocturnal
( ) Sleep difficulties
( ) Denied
Comments:

COPING
Occupation:
Members of household:
Most supportive person: