Nursing Physical Assessment Sheet

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PV

Extremities ❑ Color normal for race ❑ Cyanotic

❑ Dry ❑ Diaphoretic ❑ Bilaterally

❑ Asymmetrical _____________________________________

❑ Nailbeds pink ❑ Cyanotic ❑ Clubbing ________

❑ No JVD ❑ JVD ❑ Moves all extremities

❑ Exceptions ________________________________________

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❑ Edema ___________________________________________

❑ Non-Pitting ❑ Pitting ❑ 1+ ❑ 2+ ❑ 3+ ❑ 4+

PV, CONT.

Peripheral Pulses ❑ All palpated

Pulse quality ↑ Extr ❑ 0 ❑ 1+ ❑ 2+ ❑ 3+ ❑ 4+

↓ Extremities ❑ 0 ❑ 1+ ❑ 2+ ❑ 3+ ❑ 4+

❑ Bilaterally ❑ Exceptions _____________________

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❑ Parestheisas ___________________________________

❑ Pain ____________________________________________

❑ CRT ❑ > 3 sec ❑ Temp ______________

MUSCULOSKELETAL

❑ Obese ❑ Overweight ❑ Muscular ❑ Lean

❑ Thin ❑ Emaciated ❑ Petite

Posture ❑ Erect ❑ Stooped ❑ Kyphosis

❑ Lordosis ❑ Scoliosis

Gait ❑ Smooth & Coordinated ❑ Shuffling

❑ Hesitancy ❑ Assistive devices ________________

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❑ Movement purposeful & controlled

❑ Tics/tremors ❑ Decreased muscle tone

❑ Immobility _______________________________________

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❑ Balance intact ❑ Abnormalities ________________

❑ Deformities _______________________________________

Extremities ❑ Aligned & symmetrical

❑ Muscle grps symmetrical ❑ Toned ❑ Atrophy

❑ Masses ____________________________________________

❑ Exceptions ________________________________________

Strength (0-5): Upper arms ______ Forearms ______

Wrists: ______ Fingers: ______ Hips: _______

Hamstrings: ______ Quads: ______ Ankles: _______

Toes: ______ Feet: ______ ❑ Grip strength equal

❑ Exceptions/other ________________________________

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Joints ❑ Symmetrical ❑ Enlarged ❑ Discolored

❑ Heat ❑ Edema ❑ Tenderness ❑ Pain

❑ Nodules ❑ Crepitus _____________________________

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ROM ☑ Full ROM: ❑ Shoulders ❑ Elbows

❑ Wrists ❑ Fingers ❑ Hips ❑ Knees ❑ Ankles

❑ Feet ❑ Toes

Limitations __________________________________________

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RESPIRATORY

Per Patient:

❑ Difficulty breathing ❑ Cough ❑ Productive

Frequency ___________________________________________

❑ Sputum color/amount __________________________

❑ Alert ❑ ↓LOC ___________________________________

❑ Cyanosis __________________________________________

❑ Chest symmetrical ❑ Barrel chested

Rate: ____________ ❑ Regular ❑ Irregular

❑ Deep ❑ Moderate ❑ Shallow

❑ Use of accessory muscles ❑ SOB

❑ Normal lung sounds in all fields

❑ Adventitious sounds (type & location): ________

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❑ Cough ❑ Productive ❑ Non-productive

Frequency/Sputum ________________________________

SaO2: ____________ ❑ Room Air ❑ Nasal cannula

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