Physical assessment form

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Physical assessment form

  1. 1. Health Assessment John Knowles 20F HEALTH HISTORY – Biographical data, reason for care, health history, family history, special considerations. MENTAL STATUS – Appearance, behavior, LOC, cognition, though processes. GENERAL SURVEY – Mobility, physical appearance, body structure. VITALS Height/Weight O2 Sat. TPR B/P Current Pain Target Pain / % / / / /10 /10 HEAD NECK  Skin/Symmetry of facial features  Skin  Hair/Scalp  Trachea  CN 7 – motor/CN 5 – sensory  Mastoid Process  Temporal pulses  Carotid Pulses  Eyes – PERRLA/FOV  Carotid Bruits  Ear  ROM  Nose  Oral/Dental ANTERIOR THORAX POSTERIOR THORAX  Skin  Skin  Even chest expansion - visual  Even chest expansion - palpation  Turgor  10 point breath sounds  8 point breath sounds  Breath rate/rhythm/quality  Breath rate/rhythm/quality  Aortic/Pulmonic/Erbs/Tricuspid  60 second Apical heart rate  Heart rate/rhythm/quality ARMS/HANDS ABDOMEN  Skin  Skin  Radial pulses  4 Quadrant bowel sounds  Nails  4 Quadrant palpation  Capillary refill  Questions: last bowel  Strength/Resistance movement/diarrhea/constipation/  ROM pain/tenderness GENITOURINARY LEGS/FEET  Skin  Skin/Edema  Palpate bladder  Pedal pulses  Questions: pain/urinary problems  Nails  Capillary refill  Strength/Resistance  ROM

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