Client Profile

Initials__________________ Room # _________________

Admission
date____________________________________
Age:____________________Sex: (female/male)
Attending Physician _______________________________

Allergies ____________________________________
Height: ___________ft.

___________inch.

(ideal_________________lbs.)

Weight: (current ______________lbs)

________________weight in pounds

----------------------------------------------------------------------- X 703
BMI______________

____________height in inches X ____________height in inches

(Below 18.5 Underweight/ 18.5 -24.9 Normal/ 25 - 29.9 Overweight/ 30 & Above Obese)

Admitting diagnosis:
__________________________________________________________________________________________
___________________________________________________________________________________________________________
Medical history:
______________________________________________________________________________________________
____________________________________________________________________________________________________________
Surgical history:
______________________________________________________________________________________________
____________________________________________________________________________________________________________
MEDICATIONS

DIAGNOSTIS

INITIAL ASSESSMENT
Orientation :( Alert and oriented x3)

(confused/sedated/restless/lethargic/comatose)___________________________________________
_______________________________________________________________________________________________________________________
_ LOC: Glasgow Coma Scale (15) (>7=
coma)___________________________________________________________
1
2
Eyes
Does not open eyes
response to pain
Verbal
no sounds
Incomprehensible
Motor
no movements
Extension/ decerebrate
commands

3
4
in response to voice
spontaneously
inappropriate words
Confused
AN flexion/decorticate Flexion/Withdrawal

5
N/A
Oriented
Localizes

6
N/A
N/A
Obeys

General Appearance: describe what you

observe__________________________________________________________________________
_______________________________________________________________________________________________________________________
_
_______________________________________________________________________________________________________________________
_
Facial expressions: (no distress noted) (wincing frowning/grimacing/etc)
Posture: (relaxed,erect posture)(tense, slouched, bent, uncoordinated, tremors, unbalanced gait)
Walking gait: (steady gait with opposing arm swing; walks unaided, maintaining balance) (unsteady,
irregular/staggering gait with wide stance/bends legs only from hips/has rigid or no arm movements)
Grooming/Hygiene: (clean/neat)/dirty/unkempt, appropriate/inappropriate)
Body odor: (minimal/absent)(foul/ammonia/sweet/acetone)
Signs of health/illness: (well developed, well nourished, intact skin, easy breathing) (pallor/weakness/cough/lesions)
Attitude :( cooperative, able to follow directions) (inappropriate/uncooperative/anxious/negative/hostile)

Mood/Affect: (appropriate to situation) (appropriate/sudden changes/paranoid)

Quality/Quantity of speech-(Responds to questions and commands easily. Speech is clear and understandable.
Pitch, rate, and volume/understandable, moderate pace; clear tone ) (not understandable/fast/slow/slurred/aphasia)
Relevance/organization of thought :( logical sequence; makes sense; has sense of reality)
(Illogical sequence/flight of ideas/confusion/ generalizations/vague)

Vital signs:
Day 1 T:__________P:__________R:___________B/P: ___________O2:_________ Apical:________________
Day 2 T:__________P:__________R:___________B/P: ___________O2:_________ Apical:________________

98.6-99.5______(oral/tympanic/temporal/axillary/rectal)
(pyrexia/hyperpyrexia/febrile/afebrile/hypothermic)
Pulse: 60-100 (strong (2+), regular, and equal bilaterally at all sites)
Rate-(tachycardia/bradycardia)
Rhythm-(regular/irregular/arrhythmia/dysrhthmia)
Symmetry
(bilateral/unilateral)
Strength -(0 absent/1+ weak/ 2+ strong/ 3+ full/ 4+ bounding)
Temperature:

Pulse location:
Temporal
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Carotid
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Brachial
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+)
____________________________
Radial
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Apical
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Femoral
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+)
____________________________

Popliteal
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Posterior tibial R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Dorsalis pedis) R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Respirations: 12-20 (eupnic, regular, silent, unlabored, and equal bilaterally)

__________________________________________________________________________________________
Type-(Costal[thoracic]/diaphragmatic[abdominal])
Rate*- (eupnea*/ apnea/ bradypnea/ tachypnea)
Depth*-(Nonexaggerated and effortless.)(shallow/deep/hyperventilation/ hypoventilation)
Rhythm (Regular and even in rhythm)- (regular/irregular)
Quality-(Respirations heard few centimeters from clients nose by unaided ear) (silent/noisy/labored/unlabored) (sputum/coughing)
Symmetry (Thorax rises and falls in unison, no paradoxical movement )- (unilateral/bilateral)
Effectiveness (ABG/O2 95%-100%__________________)________________________________
Chest
movement________________________________________________________________________________________________________

Blood Pressure:

120/80 / 140/90 MAX

Pressure-(hypotension/hypertension 140+/90+/prehypertension 120-139/80-89/orthostatic hypotension)

Location- (L arm___________/R arm__________/ L thigh__________/R thigh______________)
(auscultated/palpated/cuff/doppler)
Position-(Fowlers/ semi-Fowlers/supine/standing)
Orthostatic-(a difference of 20mmHg diastolic or 10mHg systolic OR MORE)
5 minutes between
positions=(supine_________________________/Fowlers_____________________/standing____________________)

*Pain (reports no pain)

Location:____________________________________________________________________________________________________
____________________________________________________________________________________________________________
Quality:
What does it feel like?(sharp/dull/stabbing/burning/crushing)________________________________________________________________________________________________
___
______________________________________________________________________________________________________________________________________
_____________

Severity/Intensity: = (0/1/2/3/4/5/6/7/8/9/10)

What is the best it gets?

________________________________________________________________________________________________________________________________
What is the worst it gets?
_______________________________________________________________________________________________________________________________
One hour after nursing intervention?
_______________________________________________________________________________________________________________________

Onset and duration:

Time pain started?
____________________________________________________________________________________________________________________________________
How long did it last?
___________________________________________________________________________________________________________________________________
What causes pain?
____________________________________________________________________________________________________________________________________
What makes it better?
__________________________________________________________________________________________________________________________________
Worse?
______________________________________________________________________________________________________________________________________
_______
Any associated symptoms?
_____________________________________________________________________________________________________________________________

Also:
Bowels sounds
___________________________________________________________________________________________
Heart sounds ___________________________________________________________________________________________
Lung sounds ___________________________________________________________________________________________
Skin turgor
___________________________________________________________________________________________
Capillary refill ___________________________________________________________________________________________
Skin condition
___________________________________________________________________________________________
Foley catheter ___________________________________________________________________________________________
IV
___________________________________________________________________________________________
IV fluids
__________________________________________________________________________________________
NG tube
___________________________________________________________________________________________
Nutrition
___________________________________________________________________________________________

Gastrostomy tube
___________________________________________________________________________________________

Neurological
Orientation :( Alert and oriented x3)

(confused/sedated/restless/lethargic/comatose)___________________________________________
LOC: Glasgow Coma Scale (15) (>7=
coma)___________________________________________________________
1
2
Eyes
Does not open eyes
response to pain
Verbal
no sounds
Incomprehensible
Motor
no movements
Extension/ decerebrate
commands

3
4
in response to voice
spontaneously
inappropriate words
Confused
AN flexion/decorticate Flexion/Withdrawal

5
N/A
Oriented
Localizes

6
N/A
N/A
Obeys

Language: Responds to questions and commands easily. Speech is clear and understandable. Pitch, rate, and
volume/understandable, moderate pace; clear tone) (not understandable/fast/slow/slurred/aphasia)
IF DIFFICULTY ask client to:
Name common objects pointe to
(Y/N)___________________________________________________________________________________
Match written words/ pictures to spoken words
(Y/N)____________________________________________________________________
Respond to simple commands
(Y/N)_____________________________________________________________________________________

Memory:

IF DIFFICULTY:
Immediate: repeat 3 digits, then add 1 at a time until failure to repeat ( 5-8)
#______________________________________________
Same as above but reversed order (4-6) #
____________________________________________________________________
Recent:
Able to recall recent events of day (Y/N)
Remote:
Able to recall 3 items- book/light/fan (Y/N)
Able to describe past surgery/tx (Y/N)

Attention Span:

Attention: Able to recite alphabet/count to 100 (Y/N)

Calculation: serial 7s (100/93/86/79/72/65/58/51/44/37/30/23/16/9/2 90 seconds/3 mistakes)
Cranial Nerves: -already assessed

Reflexes: (0: no response/ +1: hypoactive/+2: normal/+3: more than normal/+4: hyperactive)

Plantar/ Babinski: (negative Babinski/may be absent in adults)(positive Babinski/absent in >2 yrs.)

Deep tendon :( +2 bilaterally)
Brachioradialis L_____R_____/Biceps L______R_____/Triceps L______R_____/Patella L______R_____/Achilles L______R_______
Gross Motor: (USE ROMBERG PLUS 1 OTHER)
Romberg Test:(negative Romberg/may sway slightly but is able to maintain upright posture and foot stance)
(positive Romberg/cannot maintain foot stance/moves the feet apart to maintain stance)
Walking Gait: already assessed
Standing on one foot w/eyes closed:(maintains stance >5 seconds)(<5 seconds)
Heel-Toe walking:(maintains heel-toe walking in a straight line)(assumes a wider foot gait to stay upright)
Toe or Heel walking:(able to walk several steps on toes/heels)(cannot maintain balance on toes/heels)
Fine Motor: (eyes open then closed/ document what it was)
Finger-to-nose:(repeatedly and rhythmically touches the nose)(misses the nose/slow response)
Supination/Pronation: (can alternately supinate and pronate hands at rapid pace) (performs with slow, clumsy
movements/irregular timing/difficulty alternating from supination to pronation)
Finger to nose/nurses finger:(performs with coordination and rapidity)(misses/moves slowly)
Fingers to fingers: (performs with coordination and rapidity)(misses/moves slowly)
Fingers to thumb(same hand):(rapidly touches each finger to thumb with each hand)(cannot coordinate this fine
discrete movement with one hand/both hands)
Heel down opposite chin:(demonstrates bilateral equal coordination)(has tremors/is awkward/heel moves off shin on
one/both)
Toe/ball of foot to nurses finger:(moves smoothly with coordination)(misses finger/cannot coordinate movement)
Light Touch Sensation: (COMPARE SYMMETRICALY)
(able to vocalize ,with eyes closed, when being lightly touched with a wisp of cotton on forehead, check, hand, lower
arm, abdomen, foot, an lower leg)(anesthesia/hyperesthesia/hypoesthesia/paresthesia/MAP OUT)
Pain Sensation: (COMPARE SYMMETRICALY)
(able to discriminate sharp and dull sensations on hand, lower arm, abdomen, foot, an lower leg)
(anesthesia/hyperesthesia/hypoesthesia/paresthesia/MAP OUT)
Position/Kinesthetic: (COMPARE SYMMETRICALY)(can readily determine the position of fingers and toes) (unable)
Middle finger R_______________________ L_____________________/Big toe R______________________ L_________________________
Tactile Discrimination :) One and Two point discrimination (Y/N) Stereognosis (Y/N) Extinction Phenomenon (Y/N)

INTEGUMINTARY
Skin:
Skin color: (varies) (pallor/jaundice/cyanosis/erythema)
Uniformity :( generally uniform except areas exposed to sun/areas of lighter pigmentation on palm/soles/nail beds/lips
of darker skinned pt) (hypermigmentation/hypopigmentation/vitiligo/albinism)
Edema :( no edema) (pitting/nonpitting) (1+ 2mm/ 2+ 4mm/ 3+ 6mm/ 4+ 8mm)
(measure_________mm/location_____________
Color__________________________temperature_____________________shape________________________________________________
__
Skin lesions: (nevi/freckles/striae/birthmarks;no other abrasions or lesions)
(abrasioncontusion/laceration/burn/ecchymosis/petchia/macule/ atrophy/ patch/ erosion/ nodule/ lichenification/ tumor/
scales/ papule/ crust/ pustule/ fissure/ plaque/scar/vesicle/ keloid/ wheal/ excoriation/ bulla/ cyst

(size______cmx________cm/type_______________description_____________________/location_________________________________
_
Pressure ulcer_________________lengthx________________widthx___________________depth_______________stage (1/2/3/4)
Location in reference to bony
prominence_______________________________________________________________________________
_______________________________________________________________________________________________________________________
_
Palpation of skin moisture: (moisture in skin folds /axillae/absent) (excessive moisture/excessive dryness)
Temperature/Texture: (uniform; within normal range/smooth) ( rough/war/cool/clammy)
Turgor: (>3 seconds) R Hand:_______________ L Hand:___________________ R Foot:_______________ L
Foot:__________________

Breast and Axillae

Size/Shape/Symmetry: (females: rounded; slightly unequal in size and generally symmetric/ males: even with the
chest wall unless obese/ both)(asymmetric/recent change in size/ swelling/ marked asymmetry)
Skin: (skin uniform in color, smooth, and intact)

(hyperpigmentation/ hypopigmentation/ retraction/ dimpling/ localized hypervascularization/ edema/pig skin or orange

peel)
Areola: (round /oval and equal bilaterally; possible Montgomerys tubercles)(any asymmetry/ mass/lesion)
Nipple: (round, everted, and equal in size; similar in color; both nipples point down/out; no discharge; inversion
present from puberty)(asymmetrical size or color/ discharge/ crust/ fissures/ recent inversion)
Lymph nodes: (no tenderness, masses, or nodules)( tenderness, masses, or nodules)
Breast: (no tenderness, masses, nodules, or nipple discharge) (tenderness/ masses/ nodules/ discharge)
MASSES: location____________________and distance from nipple________________________cm
Size _____________cm X__________cm X_______________cm Does it have discrete edges?_____________________________
Shape (round/oval/lobulated/indistinct/irregular)
Consistency (hard/ soft)
Mobility (fixed/movable)
Skin over lump (reddened/ dimpled/ retracted/ unaffected)
Nipple (displaced/ retracted/ unaffected)
Tender
(Y/N)
Nipple/Areola palpation: (no tenderness, masses, nodules, or nipple discharge)( no tenderness, masses, nodules, or
discharge)

4 breast quadrants: upper outer/ upper inner/ lower outer/ lower inner (Most masses found in upper outer
and in tail of spense)
Hair:
a) Distribution-:(evenly distributed)

(sparse/thinning/alopecia)________________________________________________________________
b) Thickness/Thinness: (thick)
(thin)_______________________________________________________________________________________
c) Texture/Oiliness: (silky, resilient) (brittle/dry/excessively
oily)_____________________________________________________________
d) Infection/Infestation: (no infection/infestation)
(pediculosis/flaking)__________________________________________________________

e)
Color________________________________________________________________________________________________________________
f) Body Hair: ( vairiable)
(hirsutism/absent)________________________________________________________________________________

__________________________________________________________________________________________
Nails:
Texture: (smooth) (thin/thick/grooves/furrows/Beaus lines/discolored/detached)
Color: (highly vascular and pink LT skinned/brown or black pigmentation DK skinned) (pallor/cyanotic/erythema)
Surrounding tissue: (intact epidermis) (hangnails/paronychia

HEENT
HEAD:
Skull: (normocephalic and symmetric with frontal, parietal, and occipital prominence; skull smooth and nontender on palpation)
(X large/X small/ lacks symmetry/tender/longer mandible/more prominent nose and forehead)
Scalp: ( intact free from lesions, infestations, dandruff)(sparse/thinning/alopecia)
Facial features :-( symmetric/slightly asymmetric facial features, palpebral fissures equal in size; symmetric nasolabial folds)
(increased facial hair/low hair line/thinning[absent] eyebrows/asymmetric features/myxedema facies/moon face/
periorbital edema/sunken eyes)
*CN VII (Facial): Motor = elevate/lower eyebrows, frown/smile, close eyes tightly, puff checks, show teeth
(Symmetric facial movements)
( tics/tremors)
*CN V (Trigeminal): Motor

(Masseter and temporalis muscles equally strong on palpation sensation to light touch and pain, intact bilaterally; intact cornea reflex)
EARS:

Auricles: (auricles color of surrounding skin, symmetrical, and aligned with outer canthus of eye about 10 degrees
from vertical)
(cyanotic/jaundice/pallor/erythema/asymmetric/low-set ears)
Palpation of auricles: (auricles mobile, firm, and non-tender; pinna recoils after it is folded) (tender/loss of
elasticity)
External ear canal:(distal 1/3 contains hair follicles; small amount of gray/tan/brown cerumen)
(erythema/discharge/excessive cerumen)

HEARING
*CN VIII (Gross hearing intact: RinneAC>BC, Weber negative)
Voice: (normal voice tones audible) (not audible/ asks to repeat/talks load)

R:_________________

L:__________________

Whisper test/watch tick test: (able to hear) (not able to hear)

R:_________________

L:__________________
Weber Test (Weber negative =perceives sound equally in both ears)
L:__________________
Better in impaired ear=bone-conductive/Better in unimpaired ear=sensorineural

R:_________________

Rinne Test (positive Rinne AC > BC)

R:_________________
hearing loss

L:__________________ (BC > AC) or (BC = AC) both indicate conductive

EYES:

(myopia/hyperopia)(glasses/
contacts)___________________________________________________________________________________
Eyebrows: (hair evenly distributed; skin intact) (alopecia/scaling/flaking)
Eyelashes: (evenly distributed, curled slightly outward) (turned inward)

Lids: (skin intact; no discharge/discoloration, lids close symmetrically, 15-20 bpm; no sclera visible above cornea, upper /lower borders of cornea
slightly covered) (close asymmetrically/incompletely/painfully, rapid/monocular/absent
blinking/ptosis/ectropion/entropion /rim of sclera visible between lid and iris)
Lachrymal Apparatus: (no enlargement, swelling, or redness, small amount of exudates, minimal tearing) (sty/dacryocystitis/tearing)
Conjunctiva in bulbar: (transparent with small blood vessels, no swelling, exudates, foreign bodies, or lesions.)
(pallor/ erythema/ jaundice/ sty/ hordeloum/ conjunctivitis/ lesions/ nodules)
Sclera: (white with small superficial vessels, no exudates, lesions or foreign bodies).
Cornea: (transparent, shiny, and smooth; no discharge, cloudiness, opacities or irregularities).
(opaque/ not smooth/cataracts/irregular/astigmatism/arcus senilis>40)
Anterior Chamber: (even distribution of light in anterior chamber)
Iris: (flat and round with even color distribution) (buldging of iris torwards cornea)
Pupil: (deep black, round with smooth borders, equal in diameter (3-7mm.)(mydriatics/ myotics/anisocoria)

Reaction to light: (constrict briskly to direct and consensual light.)

*CN III (Occulomotor) (no

constriction/unequal/sluggish)
Accommodation :(constrict when looking at near object and dilate when looking at far object; converge when object moved toward nose)
(dont constrict/dont dilate/dont converge)
Pupils equal, round; briskly react to light and accommodationPERRLA
VISION
*CN II (Optic)______________________________________________________________________________
Visual fields: (able to see the stimulus at about 90 temporal, 60 nasally, 50 superiority, and 70 inferiority)
R:_____ temporal_____nasally_____superiority_____ inferiority
inferiority

Cardinal fields of gaze (EOM): CN

L:_____temporal_____nasally_____superiority_____

III ___________CN IV__________CN VI____________

(both eyes move symmetrically in each of the six fields of gaze, converge on held object toward the nose, no
nystagmus) (not coordinated/ not parallel/ strabismus/ nystagmus)
Corneal light reflex (Hirschberg Test): (light reflex seen symmetrical in both pupils at ______oclock ) (light falls
off center in one eye)
Cover Test: (uncovered eye does not move) (when dominant eye covered, opposite eye moves to focus)
Near vision: (able to read newsprint at a distance of 14 inches) (unable/difficult)

( Snellen type chart at 20ft.) (Denominator of >40/ able to read 50% or more of line on chart)
L:_________________________
R:___________________________
Color vision: (able to identify primary colors found in the examining room)
_______________________________________________________
Visual acuity: 20/20

Functional Vision if <20/200:

of 1 ft.

R:________L/P______H/M_____C/F L:________L/P_______H/M________C/F at a distance

NOSE/ PARANASAL SINUSES

External nose: (symmetric and midline, non-tender on palpation; no lesions, discharge, or nasal flaring; uniform
color)
(asymmetric/ discharge from
nares/tender/)_____________________________________________________________________________
Patency: (patent bilaterally) (restricted air
movement)______________________________________________________________________
Internal nose: (nasal septum intact and at midline; pink mucosa lining no lesions; small amount of clear watery
discharge)
(septum deviated to R/L side/mucosa red/abnormal or excessive discharge)
Frontal and Maxillary sinuses: (nontender) (tender)
*CN II (Olfactory) (Able to distinguish various odors)

Throat (neck)
Neck Muscles:(muscles equal in size; head centered) (unilateral swelling/tilted to one side/muscle weakness)
Head Movements: (coordinated, smooth movements with no discomfort) (muscle/tremor/spasm/stiffness)

Chin to chest/sternocleidomastoid :head flexes

45_______________________________________________________________________
Chin up/trapezius: head hyperextends
60________________________________________________________________________________
Ear to shoulder/ sternocleidomastoid: head laterally flexes
40____________________________________________________________
Turn head/ sternocleidomastoid: head laterally rotates
70________________________________________________________________
Muscle Strength CN XI (Accessory): (against resistance with smooth, strong, and symmetrical movement;
equal strength) (unequal)
Turn to side against resistance/
sternocleidomastoid:____________________________________________________________________
Shrug shoulders against resistance/
sternocleidomastoid:_________________________________________________________________
Lymph Nodes: (not palpable) (enlarge/palpable/tender)
Face client and bend head slightly forward:
Submental and submandibular nodes :place fingertips under the mandible on side nearest palpating hand and pull tissue laterally
Supraclavicular nodes: have client bend head forward and relax shoulders so they drop, use hand nearest side to be examined, hook
index and middle finger over the clavicle lateral to sternocleidomastoid muscle
Anterior and posterior nodes: move fingertips slowly in a forward circular motion against the sternocleidomastoid and trapezius
muscle
Deep cervical lymph nodes: bend or hook fingers around the sternocleidomastoid muscle

Cardiovascular
Heart/ Circulation
60-100 (strong (2+), regular, and equal bilaterally at all sites)
Rate-(tachycardia/bradycardia)
Rhythm-(regular/irregular/arrhythmia/dysrhthmia)
Symmetry
(bilateral/unilateral)
Strength -(0 absent/1+ weak/ 2+ strong/ 3+ full/ 4+ bounding)
Pulse:

Pulse location:
Temporal
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Carotid
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Brachial
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+)
____________________________
Radial
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Apical
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Femoral
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+)
____________________________
Popliteal
R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Posterior tibial R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________
Dorsalis pedis) R:______________ (0/1+/2+/3+/4+) L:______________ (0/1+/2+/3+/4+) ____________________________

Blood Pressure:

120/80 / 140/90 MAX

Pressure-(hypotension/hypertension 140+/90+/prehypertension 120-139/80-89/orthostatic hypotension)

Location- (L arm___________/R arm__________/ L thigh__________/R thigh______________)
(auscultated/palpated/cuff/doppler)
Position-(Fowlers/ semi-Fowlers/supine/standing)
Orthostatic-(a difference of 20mmHg diastolic or 10mHg systolic OR MORE)
5 minutes between
positions=(supine_________________________/Fowlers_____________________/standing____________________)

Precordium : (no visible lift on left lateral sternal border; no lifts, heaves, or pulsations in aortic, pulmonic, tricuspid,
or mitral areas; pulsations palpable/unpalpable at (PMI) 5th ICS MCL)(lifts/heaves/pulsations)
PMI location: (5th ICS MCL/medial to MCL)(lateral to MCL >2cm/__________)
Epigastric area: (possible aortic pulsations)(bounding pulsations)
Auscultation: (S1 and S2 auscultated in aortic, pulmonic, tricuspid, and mitral areas; S1 slightly loader/equal than
S2 in tricuspid and mitral areas; S2 slightly louder/equal than S1 in aortic and pulmonic areas; regular rhythm)
(increased or decreased intensity than normal/S3=lub-dub-dee in older adults/S4= dee-lub
dub/arrhythmia/dysrhythmia/ejection clicks/pericardial rub)
LOUDEST= aortic S1/S2/=____________ pulmonic S1/S2/=___________ tricuspid S1/S2/=_________ mitral
S1/S2/=________
position________________
_______________________________________________________________________________________
Carotids: (strong (2+), regular, and equal bilaterally; no audible bruits)( -(0/1+/ 2+ strong/ 3+/
4+/absent/unequal/bruit/thrill)
JVD: (no JVD)(JVD then measure JVP-jugular venous Pressure__________________________cm)(unilateral/bilateral)>3-4cm

Peripheral Vascular System

Palpate peripheral pulses: (full (grade) pulse volumes, equal bilaterally) (asymmetric volumes/ absent

pulsations/ increased or decreased volume)

Peripheral veins: (distention may be present in dependent position and veins collapse when limb is elevated)
(tortuous or distended except older adults/ distended in thigh/lower leg/ posterolateral part of calf)
Signs of phlebitis: (symmetric in size; limbs non tender; no muscle tension, edema; negative Homans sign)
(edema/ tenderness/ positive Homans sign/ warmth or redness over vein/ muscle tension)
Peripheral Perfusion: (skin color,MM ________ and uniform in pigmentation; skin temperature slightly__________to
touch; no edema; skin texture is resilient and moist)(cyanotic/pallor/ dependent rubor/ brown pigmentation around
ankles/ skin cool/ edema/skin shiny or waxy/ ulceration/ absent hairgrowth)

Blanch test: (>2 seconds)

__________R hand__________L hand__________R foot_____________L foot

RESPIRATORY
Thorax and Lungs
12-20 (eupnic, regular, silent, unlabored, and equal bilaterally)
__________________________________________________________________________________________
Respirations:

Type-(Costal[thoracic]/diaphragmatic[abdominal])
Rate*- (eupnea*/ apnea/ bradypnea/ tachypnea)
Depth*-(Nonexaggerated and effortless.)(shallow/deep/hyperventilation/ hypoventilation)
Rhythm (Regular and even in rhythm)- (regular/irregular)
Quality-(Respirations heard few centimeters from clients nose by unaided ear) (silent/noisy/labored/unlabored) (sputum/coughing)
Symmetry (Thorax rises and falls in unison, no paradoxical movement )- (unilateral/bilateral)
Effectiveness (ABG/O2 95%-100%__________________)________________________________
Chest
movement________________________________________________________________________________________________________

Chest: (Ratio of anterior posterior diameter to the transverse diameter is 12; thorax slightly elliptical in shape.)

(barrel/funnel)(pectus excavatum/pigeon(pectus carinatum)

Trachea: (central placement at midline of neck) (deviated)
Thyroid Gland: (not visible/descends during swallowing) (visible/enlarged/not fully movable with swallowing)
Spine: (vertically aligned, shoulders and scapula at same height bilaterally) (kyphosis/lordosis/scoliosis)
Palpation: (no masses or crepitus palpated; non tender).(crepitus/masses/tender)
Thorax expansion: (Thumb separates 4/ ___________cm. from spinal column and remains in the same plane of the
10th/________ spinous vertebra; full symmetric excursion, thumbs separate______cm)
Tactile fremitus: (fremitus (buzzing on ulnar aspect of hand) at 2nd/_______ ICS anteriorly and T1/______ and
T2/______ posteriorly and at the trachea and less palpable in the periphery of the lungs) (decreased/absent)
Percussion: (Resonant sounds over lung tissue, dull sounds over diaphragm and cardiac silhouette, flat over the
ribs)
Diaphragmatic excursion :( On inspiration level of diaphragm at T12/_____ and T10/_______on expiration)
Auscultation:( bronchovesicular sounds auscultated between the scapulae posteriorly and at the 1st/_____and
2nd/______ICS anteriorly, equal bilaterally ; vesicular sounds auscultated in peripheral lung fields anteriorly and
posteriorly, equal bilaterally ; bronchial and tubular sounds auscultated over trachea; no adventitious breath sounds
noted) (wheeze/crackle/rales/ronchi)
Breathing pattern: (respiration 12-2-_________per minute; regular and even in rhythm; quiet, nonexaggerated and
effortless; inhales and exhales through nose; thorax rises and falls in unison, no paradoxical movement)
Intercostal spaces: (No retractions or bulging)
Muscles of respiration: (Using no accessory muscles.)(suprasternal/substernal/intercostal retractions)
Costal angle: (Less than 90 degrees during exhalation at rest, widens slightly during inhalation)
Angle of the ribs: (Ribs articulate at 45 degrees with sternum)

Curvature nail plate angle: (convex curvature; angle of nail plate approximately 160 degree angle) (spoon
nail/clubbing)

GI
MOUTH
LIPS:(uniform pink/darker bluish hue; soft, moist, smooth texture; contour symmetrical; able to purse lips )

(pallor/cyanosis/edema/fissures/crusts/scales/dry/asymmetrical/unable to purse lips)

Inner lips/Buccal mucosa: (uniform in color/freckled in DK skinned; moist, smooth, soft, glistening, and elastic
texture)
( dry/ pallor/ leukoplakia/bleeding/edema/mucosal cysts/irritation from dentures/abrasions/ulcerations/nodules/tender)

Teeth/Gums:

(32 adult teeth; smooth white, shiny, tooth enamel; no visible dental caries or tartar; pink/ bluish/ brown, moist, firm
gums with no retraction)
(missing teeth/discolored enamel)( spongy/bleeding/receding/atrophied/tender gums)
Dentures: (smooth intact dentures) (ill-fitting/broken/absent dent)(periodontal dz/tartar/gingivitis/glossitis/sordes/
halitosis)
Salivary Glands:(submaxillary/ sublingual/ parotid)(edema/parotitis)
Tongue: (midline; slightly rough w/ a thin white coat; dorsum pink with raised papillae, moist, ventral portion with
prominent blood vessels, no lesions present; moves freely nontender.)(deviated from center(CN XII)/smooth
tongue/red tongue/furry coating/restricted mobility/swelling)
*CN XII: (Tongue in midline of the mouth symmetrical and moves freely)
Breath: (minimal/absent)(foul/ammonia/sweet/acetone)
Palate: (Hard and soft palate concave and pink; hard palate slightly lighter than soft palate and more irregular in
texture; no lesions or malformations noted)(pallor/cyanotic/jaundice/exostoses)
Uvula: (Soft palate and uvula rises symmetrically when client says Ah, uvula midline (CN X/Vagus ))(deviation to
one side/immobility)
Oropharynx: (pink and smooth posterior wall) (edematous/erythema/lesions/plaques/drainage)

Tonsils: (pink and smooth no discharge; grade 1 OR not visible) (inflamed/discharge/removed)

(swollen grade: 2 = between pillars and uvula/ 3=touch uvula/4=one or both extend to midline of oropharynx)
*CN VII:( Sensory component -identifies sweet, sour, salty, and bitter tastes accurately)
*CN IX/ CN X (Gag reflex present, speech clear, no hoarseness or nasal quality, swallows water easily)

Abdomen
Skin: (uniform in color; unblemished; free of lesions/ possible scars/ striae)(rash/ lesions/purple striae/ tense,

glistening skin)
Contour: (flat/ convex/ scaphoid or concave with symmetrical contour; no evidence of spleen or liver enlargement)
(distended/ bulges/ asymmetric/ localized protrusion around umbilicus)

Abdominal movements: (no visible peristalsis or aortic pulsations unless very lean; abdomen rises with inspiration
and falls with expiration) (any asymmetry/ mass/lesion/ marked aortic pulsations/ visible peristalsis)
Vascular pattern: (no visible vascular pattern) (visible venous pattern)
Bowel Sounds:-diagphragm(bowel sounds present x4 quadrants ) (normo 5-20/min, hypoactive <1/min,
hyperactive>3/sec. absent
How long since last eaten?
______________________________________________________________________________________________
Vascular Sounds:-bell (absence of arterial bruits) (bruit over/aortic area/ renal/ iliac/ femoral artery)
Peritoneal Friction Rubs:spleen/liver (absence of friction rub)( friction
rub)_____________________________________________________
Percussion: (tympany over the stomach, slightly lower tympany over intestines; dullness over spleen and liver)
(large dull areas/ increased tympany)
___________________________________________________________________________________
Percussion of Liver: (7-10 cm)(more than 2cm above normal/ less than 2cm below normal)
Light Palpation: (no tenderness; relaxed abdomen with smooth, consistent tension) (tenderness/ hypersensitivity/
masses/ increases tension)

Anus
Rectal exam=L lateral or R lateral
Anal Mucosa: (deeply pigmented, coarse, moist, and hairless; no lesions, inflammation, rash, masses, or additional
openings; anal opening closed; no leakage of feces or mucus; no tissue profusion ) (fissures/ ulcers/ excoriations/
hemorrhoids/ fistula openings/ rectal prolapse) DESCRIBE: oclock with client head being 12 oclock
-ask to bear down to assess for hemorrhoids, -finger for tone

Palpation of Bladder: (not palpable) (palpable)

GU

Female Genitals/Inguinal Area

Pubic Hair: (wide variations: generally kinky before menopause then straighter; distributed in the shape of an
inverse triangle) (scant/extends over abdomen)

Stage 1: preadolescence; no hair

Stage 2:(11-12) sparse, long, slightly pigmented
Stage 3:(12-13) darker, curlier, develops over pubic symphysis
Stage 4: (13-14) like an adult but thinner; not on
thighs
Stage 5: sexual maturity-adult appearance and appears on inner aspect of the upper thighs
Skin: (pubic skin intact, no lesions; skin of vulva area slightly darker than surrounding skin; labia round, full, and
relatively symmetric; no evidence of infestations) ( lice/lesions/scars/fissures/edema/erythema/excoriations/
varicosities/leukoplakia)
Clitoris/Urethral orifice/Vaginal orifice: (clitoris does NOT exceed 1 cm in width and 2 cm in length; free of
lesions, swelling, inflammation
and discharge) (lesions/swelling/inflammation/discharge)
Lymph nodes: (inguinal lymph nodes not palpable and nontender) (palpable/tender)

Male Genitals/Inguinal Area

Pubic Hair: (triangular distribution, often spreading up the abdomen) (scant/absence)

Tanner Stages of male pubic hair and genital development (12-16 Years)
Stage 1: no hair; size of penis, scrotum, and testes relative to body as in childhood
Stage 2: sparse, long, slightly pigmented hair at base; slight enlargement of penis, scrotum, and testes
Stage 3: darker, curlier, develops over pubic symphysis; elongation of penis; testes and scrotum continue to enlarge
Stage 4: continues to darken and thicken; penis increases in breadth/width; testes and scrotum continue to
enlarge/darken
Stage 5: adult distribution of hair extends to inner thighs, umbilicus, and anus; adult appearance of testes and scrotum
Penile shaft/Glans: (penile skin intact, no lesions; foreskin easily retractable from the glans; small amount of thick
white smegma )
( lice/lesions/scars/fissures/edema/erythema/excoriations/foreskin not retractable/discharge/malodorous)

Urethral meatus: (pink and slit-like appearance positioned at top of penis)

(lesions/swelling/inflammation/discharge/ hypospadias/ epispadias)

Scrotum: (scrotal skin is darker than surrounding skin and is loose; scrotum appears asymmetric [left usually lower] )
(marked asymmetry )
Inguinal Area: (no swelling or bulges) (swelling/bulge)

Musculoskeletal
Muscle size: (equal bilaterally)(atrophy/

hyperatrophy)____________________________________________________________________
Contractures: (no contractures)( contractures)
____________________________________________________________________________
Tremors: (no tremors) (resting tremor/ intention tremor/ tic/
fasciculation)________________________________________________
Muscle strength: (equal strength on both sides)(25% or less of normal
strength)______________________________________________
0: 0% complete paralysis
3: 50% full movement against gravity
1: 10% no movement with visible/palpable muscle contraction 4: 75% full movement against gravity and minimal
resistance
2: 25% full movement against gravity with support
5: 100% full movement against gravity and full resistance
Sternocleidomastoid turns head to one side against resistance of yours hand
L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Trapeziusshrugs shoulders against resistance of your hand
L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Deltoid-holds arms up and resists while you try to push down
L: (0/1/2/3/4/5) R: (0/1/2/3/4/5)
Biceps-fully extends each arm + tries to flex while you try to hold in extension
L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Triceps- fully flexes each arm + tries to extend while you try to hold in flexion
L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Wrist/Finger spreads the fingers and resists as you try to push them together
L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Grip Strength grasps index and middle fingers while you try to pull fingers out
L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Hip while supine, both legs extended, raises one leg at a time while you push down
L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Hip abduction-supine, both legs extended, pushes out w/ your hand on lateral side of knee L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Hip adduction-supine, both legs extended, pushes in w/your hand on medial side of knee
L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Hamstrings-supine w/both knees bent, resists as you try to straighten legs
L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Quadriceps supine w/knees partially extended, resists as you try to flex the knee
L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Ankles/Feet resists while you try to dorsiflex the foot then flex the foot
L: (0/1/2/3/4/5) R:
(0/1/2/3/4/5)
Skeletal structure: (no deformities)(bones
misaligned)_____________________________________________________________________
Palpate bones: (no tenderness or edema) (tenderness/ edema)
___________________________________________________________
Joints: (no edema, tenderness, crepitation, or nodules)(edema/ tenderness/
crepitation/nodules)________________________________
Joint movement: (joints move freely)(limited ROM)
________________________________________________________________________

PAIN
*Pain (reports no pain)
Location:____________________________________________________________________________________________________
____________________________________________________________________________________________________________
Quality:
What does it feel like?(sharp/dull/stabbing/burning/crushing)________________________________________________________________________________________________
___
______________________________________________________________________________________________________________________________________
_____________

Severity/Intensity: = (0/1/2/3/4/5/6/7/8/9/10)
What is the best it gets?
________________________________________________________________________________________________________________________________
What is the worst it gets?
_______________________________________________________________________________________________________________________________
One hour after nursing intervention?
_______________________________________________________________________________________________________________________

Onset and duration:

Time pain started?
____________________________________________________________________________________________________________________________________
How long did it last?
___________________________________________________________________________________________________________________________________
What causes pain?
____________________________________________________________________________________________________________________________________
What makes it better?
__________________________________________________________________________________________________________________________________
Worse?
______________________________________________________________________________________________________________________________________
_______
Any associated symptoms?
_____________________________________________________________________________________________________________________________

Psychosocial
LOVE and BELONGING/Self Esteem/spirituality/ Cognitive/Saftey