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Patrick Henry Community College

 NUR 111

Assessment Guide

Student Name:________________ Client Initials:_____________ Date:__________ 

General Appearance/Survey

Age: ________ Gait: _________  

Gender: ________ Posture: _________  Height: ________ Speech: _________  

Weight: ________ Affect: _________  

Other:________________________________________________________________________ 

 _________________________________________________________________ 

Vital Signs:T: _________ P:__________ R:_________ B/P:________  

O2 Sat: _________ 

Pain: Y or N

Onset-_________________________________ 

Location-_______________________________ Duration-_______________________________ 

Quality-________________________________ 

Intensity-_______________________________ 

 Past Medial History:

 _____________________________________________________________________________  _____________________________________________________________________________  ______________________________________________________________ 

Past Surgical History: _____________________________________________________________________________ 

 _____________________________________________________________________________ 

 __ 

Current Medications: (name, dose, route, frequency)

 _____________________________________________________________________________ 

 _____________________________________________________________________________  _____________________________________________________________________________ 

 _____________________________________________________________________________ 

 ____ 

Allergies: (medications, food, others & type of reaction)

 _____________________________________________________________________________  _____________________________________________________________________________ 

 __ 

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 _____________________________________________________________________________ 

 _ 

Integumentary

I. Skin: consistency__________ color____________ temperature_________ intact______________ turgor___________ edema(describe):_________________________________________ 

lesions(describe):_________________________________________ 

bruises(describe):_________________________________________ 

II. Hair: texture____________ amount____________ distribution___________ 

color ____________ balding____________ infestations___________ scalp ____________ 

III. Nails: texture___________ color_____________ condition_____________ 

evidence of infection (describe):______________________________ capillary refill:____________ 

The Head

I. Skull: shape ___________ masses____________ tenderness______________ 

Describe abnormal findings:__________________________________________________________ 

__________________________________________________________ 

II. Face: symmetry___________ edema (describe)___________________ 

eyelids______________ exopthalmus___________ 

III. Eyes: Pupil Size ________ Response____________ Color___________ 

Visual Acuity: L_______ R________ B__________ 

Glasses _________ Contacts___________ 

Lesions_________ Pstosis ___________ Redness_________ Drainage_________ Conjunctiva _______ Sclera __________ 

EOM: _____________________________________________ 

IV. Ears / Hearing: Auricle _________Level of Ear_________ Aides __________ 

External Auditory Meatus:_____________________________ 

Tympanic Membrane:________________________________ Weber __________ Rhine__________ Whisper __________ 

V. Nose/Sinuses: Mucosa___________ Color_________ Edema_____________ 

Discharge _________ Smell _________ Patency____________ Septum ___________ Sinuses : Frontal & Maxillary ________ 

VI. Mouth & Oropharynx: Lips: Color __________ Condition_______________ Oral mucosa ________________ Buccal Mucosa___________________ 

Tongue_____________ Gum____________ 

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Uvula __________ Hard Palate __________ Soft Palate____________ 

Teeth_______ Dentures________ Gag Reflex ________ 

 Neck 

I. Muscles: ROM __________ (flexion, extension, hyperextension)II. Trachea: midline or deviated

III. Lymph Nodes: ____________________________________________________ 

IV. Carotids:______________________ Jugulars:___________________________ V. Thyroid Gland:____________________________________________________ 

Thorax & Lungs

I. Chest: Shape__________ AP to Transverse ___________________ 

Chest Excursion________________ Tactile Fremitus_______________ 

II. Respirations: Rate_______ Depth________ Rhythm________ Symmetry________ III. Lung Sounds: Anterior _______________ Posterior ________________ 

Heart- Vascular- Breast-Lymphatics

I. Heart: PMI_______ AP Rate__________ Sounds___________ Heaves__________ Thrills ______________ 

II. Central Vessels: Carotids _______________ Jugulars_______________ CVP______ 

III. Peripheral Vascular: B/P: R_______ L________ Standing___________ 

Edema ____________ (1+ 2+ 3+ 4+) Location_____________ 

Carotid _____Brachial _____Radial _____ Femoral_______ 

Popliteal_____Dorsalis Pedis_______ Posterior Tibal _____ Amplitude: absent 0; thready/weak +1; normal +2; increased +3; bounding +4

IV. Breast & Axillary Lymphatics:Inspection: ________________________________ (lumps, lesions, discharge,

discoloration, dimpling, other)

Self Exam:___________________ Mammogram:___________________ Axillary Lymph Nodes:________________________________________ 

Abdomen

I. Inspection: contour ______________ size_____________ symmetry__________ 

lesions _______________ scars____________ distention__________ 

abdominal girth_______________ II. Auscultation: bowel sounds: ____________________________ 

III. Percussion: __________________________________________ 

IV. Palpation: __________________________________ (tender/nontender)

Musculoskeletal

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Posture:_______________ Tremors: ______________ (intention/resting)Strength:______________ Gait:______________ Coordination:________________ 

Contractures:__________ Symmetry:___________ ROM: ____________________ 

Joint Tenderness:___________ Nodules:________________ Creptius:___________ 

 Neurological

I. Mental Status: language__________ orientation____________ STM:___________ LTM:_________ Attention:_____________ Calculation:_________ 

II. Glasgow Coma Scale: Eye Opening _______ Motor ________ Verbal__________ 

III. Cranial Nerves: I_____ II_____ III______ IV______ V_____ VI______ VII_____ 

VIII _____ IX_____ X_____ XI ______ XII______ IV. Reflexes: Biceps________ Patellar________Achilles________Babinski_________ 

V. Motor Function: Proprioception__________________ Romberg________________ 

VI. Sensory Function: Touch __________ Pain___________ Temperature___________ Tactile Discrimination:

2-Point Discrimination____________ 

Stereognosis____________________ 

Extinction Phenomena____________ 

Genitals

I. Female: Inspection____________ Inguinal Pulses:__________ Pap Test:__________ Menarche_________ LMP__________ Menopause ________ 

II. Male: Inspection______________ Hernias____________ Rectal Exam___________ 

III. Urination: color_________ odor____________ amount_____________ 

frequency__________ urgency___________ dysuria ____________ IV. Rectum: hemorrhoids __________ pain w/ defecation___________ bleeding_______ 

Occult Blood _________ 

Additional Notes:

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