Physical Assessment Student Name: ______________________________ Initials: ____________ Date: ___________________

T _______ P ________ R _______ BP Lying ________Sit/Stand _________ Pain ____________ Intake _____________Output _______________

POx _______ RA/O2@_____ BGM _____ @ _______

% Eaten ________ Weight ____________ LBM ____________

SYSTEM (circle applicable normal findings) ABNORMAL ASSESSMENT FINDINGS: (Include scores from other assessment tools if applicable)

NEUROLOGICAL / SENSORY Alert and oriented to person, place and time. Behavior appropriate to situation. Pupils equal, round and react briskly to light. Hand grasps strong, equal. Verbalization clear and understandable. Swallowing without coughing or choking on liquids and solids. Memory intact. Hearing & vision intact.

CARDIOVASCULAR Regular apical. Distinct S1,S2, Neck veins flat at 45 degrees. Capillary refill time less than 3 seconds. Peripheral pulses strong, equal, palpable. No edema. No calf tenderness. No chest discomfort.

PERIPHERAL NEUROVASCULAR (CMS CHECK) Compare bilateral extremities: Pink, warm, pulses present, no edema, ROM equal, Sensation intact without numbness and tingling. No pain.

RESPIRATORY Respirations quiet and regular. Breath sounds clear all lung fields with no adventitious sounds. Symmetrical movement without use of accessory muscles. Sputum clear. Nailbeds and mucous membranes pink. No shortness of breath.

MUSCULOSKELETAL Active ROM of all extremities with symmetry of strength. Steady gait, upright posture, and tolerance of activity.

INTEGUMENTARY Skin color within patients norm. Skin warm, dry and intact. Mucous membranes moist. No rashes or ulcerations. Hair supple and intact. Nail surface smooth, intact. Pressure ulcer risk score:______ Wound/incision/ tube insertion site (if applicable) Dressing dry, intact. Appliance intact No redness, edema, increased temperature, tenderness of surrounding tissue. Sutures/staples intact. Incision line approximated. Wound bed pink & moist COCA ____________________________ REEDA ______________________

GASTROINTESTINAL Abdomen soft & without distension. Bowel sounds active (5 34/min) Able to pass flatus. No pain with palpation. No nausea or vomiting. BMs within own normal pattern and consistency _______ x day. Last BM ______ COCA _________

GENITO-URINARY Able to empty bladder without c/o dysuria or retention. Bladder not distended after voiding. Urine clear and yellow to amber. No complaints of urgency, frequency, nocturia. Absence of G.U. discharge.

NUTRITION & FLUID BALANCE Tolerates diet without c/o, No > or < 10% of ideal body weight. Skin turgor <3 sec., Mucous membranes moist. Daily weights show no> or < 2 pound increase.

PAIN & SLEEP Pain at acceptable level of _____. Feels rested.

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