Faculty of Nursing – Damietta University

Medical surgical Nursing Dep.

2022-2023

Patients' Physical Assessment sheet

St. Name: _______________________________________ Group no: ________________________

Clinical area: __________________________________ Date of assessment: _________________________
Pt. Name: ________________________________ Initial diagnosis: ____________________________________
Age: ___________________ Gender : ____________________ Date of admission:_____________________
Occupation: _________________ Level of Education: ____________________ Marital Status: ______________

Patient health history

Present Diagnosis: ___________________________________________________________

Chief complaints on admission_______________________________________________________

Present Onset: ___________________ Duration: ___________________ Frequency: _________________

History
Predisposing factors: ______________________________________________________________

Reliving measures: ______________________________________ and its effect is ______________

Medical: _______________________________ Surgical: _____________________________

Past
Duration: _______________________________ Since: _______________________________
History
Controlled by ___________________________
Allergy Medications:_____________________ Foods:____________________ Others:_____________
History
Family Diagnosis / Relation: ______________________________________________________________
history
Location: Intensity: Quality: Frequency: Duration:
Pain ………………… -Mild -Burning Each Lasts for
Assessment ………………… -Moderate -Pressing …………………..…… …………………………
………………… -Severe -Throbbing ……………………….. …………………………
………………… -Squeezing ...................................... …………………………
Activities -Independent (3) Feeding Bathing Dressing Transferring Walking Toileting
of daily -Need Assist. (2)
living -Dependent (1)

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 Faculty of Nursing – Damietta University
Medical surgical Nursing Dep.
2022-2023

Systems assessment
System Items Y N System Items Y N
Respiratory Pattern: Cardiovascular Peripheral Pulse scale:
system - Tachypnea system -Rt. Radial
- Dyspnea 0= Absent pulse -Lt. Radial
- Labored 1= Thread pulse -Rt. Pedal
- Irregular 2= Weak pulse -Lt. Pedal
3= Normal pulse
4= Bound pulse
Cough: Capillary refill:
- Non-Productive -Normal
- Productive cough -Delayed
Secretion: Edema:
-Clear -Generalized
-Yellow -Localized
-Green -Non pitting
-Blood tinged -Pitting (degree)
-Thin (1) (2) (3) (4)
-Thick
Oxygen Therapy: Abnormalities:
-Room air - Chest pain
-Nasal cannula - Dizziness
-Mask - Cyanosis
-ETT Central
-Tracheostomy Peripheral
-Chest tube
Musculoskelet. -Unsteady gait Neurological Abnormalities:
System -Stiff joint system Headache
-Muscular pain Lethargic
- weakness Dysphasia
-Paralysis Peripheral parethesia
-Amputee
-Assistive device: Deep Tendon Reflex:
-Walker 0 = Absent
-Cane +1 = Weak
-Chair +2 = Normal
-Cast +3 = Hyperreflexia
-Traction
-Fixation

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 Faculty of Nursing – Damietta University
Medical surgical Nursing Dep.
2022-2023
Gastrointestin. Diet: Integumentary Skin condition:
System - Type of diet: system -Cold /clammy
…………………………. -Hot / dry
Type of feeding: Color:
-Oral -Pale
-NGT feeding -Flushed
-Enteral Feeding -Jaundiced
-TPN -Cyanotic
Bowel Sound: Turgor:
-Hypoactive -Fair
-Hyperactive -Sluggish
Eating difficulties: -Poor
- Dry mouth Integrity:
- Difficulty Chewing -Nodules
-Swallowing Precautions -Petechial
- Abdominal distension -Ecchymosis
-Dysphagia -Spider nevi
-Dyspepsia Pressure sores
-Nausea -Site
-Vomiting - Degree:
Elimination: Stoma:
- Diarrhea -Site:
- Constipation Appearance:
- Fecal impaction -Pink
- Melena -Necrotic
- Others Wound assessment:
- Site: ………………...
Voiding abnormality: - Open
Genitourinary - Incontinent - Closed
System -Dysuria - Clean
-Polyuria - Septic
-Oliguria - Color: ………………
-Hematuria - Odor: ……………….
-Urgency - Discharge
Urinary Catheter - Amount: …………….
- Odor: ………………..
Insomnia - Consistency:
Sleep Sleep pattern : …………………………
- Continuous - Drain
- Intermittent - Odor
Duration of day naps: - Consistency of
………………………… discharge: …..................

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Faculty of Nursing – Damietta University
Medical surgical Nursing Dep.
2022-2023

Patient sheet medication

Medication name Dose Frequency Route

Laboratory investigations
Lab Investigation Results Normal Ranges
Comments

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Faculty of Nursing – Damietta University
Medical surgical Nursing Dep.
2022-2023

Diagnostic Measures
Diagnostic procedure Results

Conclusion of patient problems:

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