DataBase / Physical Assessment Tool with Lab Values

Student Name: _Donna Joanne Bennett/ A. Bruner, instructor

Date: 1/31/13

DATABASE and PHYSICAL ASSESSMENT TOOL

Client Initials ________ Room # _______ Admitted On ________ Allergies ____________________________
Medical Dx ________________________________________________________________________________
Chief Complaint ____________________________________________________________________________
__________________________________________________________________________________________
History of Present Illness _____________________________________________________________________
__________________________________________________________________________________________
Past Medical History ________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Past Surgical History ________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Family History _____________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Alcohol Use ________________ Tobacco Use _________________ Recreational Drug Use _______________
Neurologic

Awake Lethargic Stuporous Comatose

Oriented to: Person Place Time
Confused Follows Commands Responds appropriately
Pupil size: R _____ L _____ round reactive
Speech: Clear Mumbled Garbled Aphasic
Other Objective Data:__________________________________________________________________
Subjective Data:______________________________________________________________________
Vital Signs
BP

_____ Lying

Temp

Sitting Standing

_____ Oral

Axillary Tympanic

BP _____ Lying

Sitting Standing

Temp _____ Oral

Axillary Tympanic

_____ Radial Apical Regular Irregular

Telemetry # _____ Rhythm __________
Respirations ___ Regular Irregular Shallow Labored Guarding
Pain rated ___(scale 0-10) Location ___________________________

_____ Radial Apical Regular Irregular

Telemetry # _____ Rhythm __________
Respirations ___ Regular Irregular Shallow Labored Guarding
Pain rated ___(scale 0-10) Location___________________________

Height _____ Weight

Height _____Weight

Pulse

_____ Source ________________________

Pulse

_____Source ________________________

Other Objective Data:__________________________________________________________________

Subjective Data:______________________________________________________________________

DataBase / Physical Assessment Tool with Lab Values

Integument

Skin Turgor: Tenting < 3 sec > 3 sec

Mucous membranes: Moist Dry Pink Pale Yellow
Skin: Warm Cool Dry Moist Smooth Rough Lesions (location) ________
Color: Pink Appropriate for Race Ashen Dusky Jaundiced
Scars (location and origin) _________________________________________
Other Objective Data:__________________________________________________________________
Subjective Data:______________________________________________________________________
Head and Neck

Contacts Glasses
Dentures: Upper Lower Teeth: Clean Poor
Missing
HOH
Hearing Aid
Responds appropriately to voice or noise 2 ft away
Ears: Symmetric Canals Appearance: _______________________________
Other Objective Data:__________________________________________________________________
Subjective Data:______________________________________________________________________
Thorax/Lungs/Heart

Lung sounds: L & R Clear Rales Rhonchi Wheeze Rub

Diminished (location) ____________________________
Symmetrical movement Y or N
Cough: Productive Nonproductive Characteristics: Thin Frothy Thick
O2: Room air NC Mask L/min _____
Heart sounds: S1 S2 extra sounds (what?) ________
Other Objective Data:__________________________________________________________________
Subjective Data:______________________________________________________________________
Breast and Axilla

Appearance: Dimpling Retraction Crusting Drainage

Last Mammogram _______________ Next Mammogram ________________
Other Objective Data:__________________________________________________________________
Subjective Data:______________________________________________________________________
Abdomen

Appearance: Flat Rounded Distended

Bowel Sounds: Hypoactive Hyperactive I II III IV quadrants noted
Umbilicus: Midline Other
NGT: Size _____ Nare _____ Suction _____ Fluid _____
PEG: Name of Formula _______________ Continuous Bolus
Placement Checked _____ Residual Amount _____ Color _____________

BM: Date __________ Characteristics ___________ Normal for patient _____

Vomiting/Emesis: Amount __________ Characteristics __________
Diarrhea: Amount __________ Frequency __________ Appearance _________
Other Objective Data:__________________________________________________________________
Subjective Data:______________________________________________________________________

DataBase / Physical Assessment Tool with Lab Values

Peripheral vascular

Edema: +1 +2 +3 +4 Location ________________

Varicose Veins: R L
Pedal Pulse L _____ R _____
Color: R _________ L _________Temperature: R _________ L _________
Other Objective Data:__________________________________________________________________
Subjective Data:______________________________________________________________________
Genitourinary

Continent Incontinent
Foley Size _____
Urine: Color __________ Odor __________ Characteristics _______________
Other Objective Data:__________________________________________________________________
Subjective Data:______________________________________________________________________
Musculoskeletal

Full ROM Limited __________ Paralysis __________

Contractures __________ Amputation __________ Splint __________

Prosthesis _______________
Muscle Strength: Equal Strong Dominant: L R
Other Objective Data:__________________________________________________________________
Subjective Data:______________________________________________________________________
IV site

Location __________ Size _____ Type: Continuous or Heplock

Site: Redness Edema Normal
IVF __________ Rate __________ Expiration Date __________
Other Objective Data:__________________________________________________________________
Subjective Data:______________________________________________________________________
List all problems that you note and the system associated with each:
__________________________________________________________________________________________
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List six (6) nursing diagnoses in order of high to low priority: