PHYSICAL ASSESSMENT

General Assessment
Medical/ Surgical Ward
Xavier University College of Nursing
Age
Name:
Civil Status:
Birthday:
Religion: Occupation:
Sex:

Address:
Relation:
Informant:
Time:
Admission Date:

Chief Complaint:

Attending Physician:

Diagnosis:

Admission Date & Time: Day 1 Day 2 Day 3

ACTIVITY/REST
SUBJECTIVE
Usual Activities or
Hobbies:

Leisure Time Activities:

Limitations Imposed by
Condition:

Number of Hours of
Sleep:
Naps:

Aids:

Difficulty in Sleeping:

Feeling on Awakening:

Others/Comments:

OBJECTIVE
Observed Response to
Activity:
Cardiovascular:
 Respiratory:

Mental Status:

Posture:

Limitation of Motion
(LOM):

Tremors:

CIRCULATION
SUBJECTIVE
History of Hypertension:

Heart Trouble:

Ankle/Leg Edema:

Claudication:

Cough/Hemoptysis:

Numbness in
Extremities:

Tingling in Extremities:

Change in
Frequency/Amount
of Urine:

OBJECTIVE
Blood Pressure:

Right Arm:
Left Arm:

Pulse Pressure:

Point of Maximal
Impulse (PMI):

Heart Rate/Sounds:

Rhythm:

Pulse:

Vascular Bruit:

Breath Sounds:

Jugular Vein Distention:

Extremities:
 Temperature
Color:

Capillary Refill Time:

Homan’s Sign:

SUBJECTIVE
Reports of Stress
Factors:

Ways of Handling
Stress:

Financial Concerns:

Relationship Status:

Lifestyle:

Recent Changes:

Feelings of
Helplessness:

Feelings of
Hopelessness:

Feelings of
Powerlessness:

Others/Comments:

OBJECTIVE
Emotional Status:

Observed Physiologic
Response:

ELIMINATION
SUBJECTIVE
Usual Bowel Pattern:

Character of Stool:

Last Bowel Movement:

Laxative Use:

History of Bleeding:

Hemorrhoids:
 Constipation:

Diarrhea:

Usual Voiding Pattern:

Incontinence:

Urgency:

Retention:

Frequency:

Pain/Burning/Difficulty
in Voiding:

History of Kidney/
Bladder Disease:

Others/Comments:

OBJECTIVE
Abdomen
Tender:
Soft/Firm:

Palpable Mass:

Size/Girth:

Other comments:
Bowel Sounds:

Bladder Palpable:

Distended:

FOOD AND FLUIDS

SUBJECTIVE
Usual Diet:

No. of Meals a Day:

Last Meal Intake:

Loss of Appetite:

Nausea/Vomiting:

Dentures:

Allergies/Food
Intolerance:

Heartburn/Indigestion:

Swallowing Problems:
 Weight
Usual:

Changes:

Diuretics:

OBJECTIVE
Current Weight:

Height:

Body Build:

Skin Turgor:

Mucous Membranes:

Hernia/Masses:

Edema: General
Dependent:

Periorbital:

Ascites:

Thyroid Enlarged:

Halitosis:

Condition of Teeth:

Appearance of Tongue:

Others/Comments:

HYGIENE
SUBJECTIVE
Activities of Daily Living
Mobility:
Hygiene:
Toileting:
Feeding:
Dressing:
Others:

Equipment/ Presence of
Devices Required:
Assistance Provided by:

Others/Comments:

OBJECTIVE
General Appearance:

Manner of Dress:
 Habits:

Body Odor:

Condition of Scalp:

Presence of Vermin:

Others/Comments:

NEUROSENSORY
SUBJECTIVE
Fainting Spells/
Dizziness:

Headache:

Location:

Frequency:

Tingling/Numbness/
Weakness Location:

Seizures:

Aura:

How Controlled:

Eyes
Vision Loss:
Last Examination:

Glaucoma:

Cataract:

Sense of Smell:

Epistaxis:

Others/Comments:

OBJECTIVE
Mental Status:
Alert:

Stuporous:

Combative:

Drowsy:

Lethargic:

Comatose:
 Cooperative:

Affect:

Delusions:

Hallucinations:

Memory
Recent:

Remote:

Speech Pattern:

Congruence:

Glasses:

Contacts:

Hearing Aids:

Pupil Size Reaction:

Left:

Right:

Facial Droop:

Swallowing:

Handgrip/Release
Right:

Left:

Posturing:

Deep Tendon Reflex:

Paralysis:

Others/Comments:

PAIN AND COMFORT

SUBJECTIVE
Onset:

Duration:

Location:

Frequency:

Intensity (1-10):

Quality:
 Description of Pain:

Precipitating Factors:

Aggravating Factors:

How Relieved:

Associated Symptoms:

Others/Comments:

OBJECTIVE
Observed Symptoms:

RESPIRATION
SUBJECTIVE
Dyspnea related to:

Cough/Sputum of:

Smoker:

Packs:

Brand:

Number of Years:

Use of Respiratory Aids:

Oxygen:

Others/Comments:

OBJECTIVE
Respiratory Rate:

Depth:

Symmetry:

Use of Accessory
Muscles:

Nasal Flaring:

Fremitus:

Breath Sounds:

Cyanosis:

Clubbing of Fingers:

Sputum Characteristics:

Restlessness:
 Others/Comments:

SAFETY
SUBJECTIVE
Allergies/Sensitivity:

Reaction:

History of STD
(Date/Type):

Blood Transfusion
Number:

When:

History of Accidental
Injuries:

Fractures/Dislocations:

Arthritis/Unstable Joints:

Back Problems:

Changes in Moles:

Enlarged Nodes:

Prosthesis:

Ambulatory Devices:

Expression of Ideation
of Violence (Self/
Others)

Others/Comments:

OBJECTIVE
Temperature:

Diaphoresis:

Skin Integrity:

Scars:

Rashes:
Lacerations:

Ulcerations:

Bruises

Blisters:

Burns (Degree %)
 Drainage (Note
Location):

General Strength:

Muscle Tone:

Gait:

Paresthesia/Paralysis:

Others/Comments:

SEXUALITY
Sexually Active:

Sexual Concerns/
Difficulties:

Recent Changes in
Frequency /Interest:

SOCIAL INTERACTIONS
SUBJECTIVE
Marital Status:

Years in Relationship:

Living with:

Concerns/Stresses:

Extended Family:

Other Support Person:

Role within Family

Structure:

Reports of Problems
related to Illness
Condition:

Others/Comments:

TEACHING/LEARNING
SUBJECTIVE
Dominant Language:

Literate:

Educational Level:

Health Beliefs/Practices: