Nursing Physical Assessment Sheet

INTEGUMENTARY - SKIN

❑ Color normal for race  ❑ pale  ❑ cyanotic

❑ Jaundice  ❑ erythema  ________________________

Texture ❑ Dry  ❑ diaphoretic  

Temp ❑ Warm  ❑ hot  ❑ cool   ❑ cold

Turgor  ❑ Elastic ❑ ↓ elasticity ❑ Tenting

❑ Edema: _________________________________________

Pitting ❑ 1+   ❑ 2+   ❑ 3+

❑ Vascularity: ____________________________________

❑ Skin clean, no odor  ❑ Odor  ❑ Dirty

❑ Thick  ❑ Moderate ❑ Thin

Lesions: _____________________________________________

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HAIR

Color: ____________________ ❑ Normal distrubution

❑ Abnormal distribution _________________________

❑ Full  ❑ Thinning  ❑ Alopecia __________________

❑ Dry  ❑ Oily  ❑Dandruff/foreign matter

❑ Lesions: __________________________________________

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NAILS

❑ Color normal ❑ Other __________________________

❑ Thick  ❑ Thin  ❑ Angle 160° ❑ Clubbing

❑ Concave  ❑ Convex  ❑Beau’s lines

❑ Paronychia  ❑ Splinter hemorrhages

❑ Brittle  ❑ CRT < 3 sec  ❑ > 3 sec _______________

Other ________________________________________________

HEAD

Facial expression  ❑ Pleasant/smiling  ❑ Tearful

❑ Blank stare/mask-like  ❑ Sleepy  ❑ Startled

❑  Head symmetrical ❑ Asymmetrical

❑ Round  ❑Ptosis ❑ Other ________________________

EYE

❑ Sclera white  ❑ jaundiced

❑ Bulbar conjuct. clear  ❑ Pink ❑ Vascularity

❑ Palpebral conjunct pink  ❑ Red ❑ Jaundiced

❑ Discharge/Drainage______________________________

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NOSE

❑ Drainage/discharge ______________________________

❑ Lesions ____________________________________________

MOUTH

Mucous membrane  ❑ Moist  ❑ Dry  ❑ Pink

❑ Red  ❑ Lesions ___________________________________

Tongue ❑ At midline  ❑ Deviates _________________

❑ Tremors  ❑ Pink  ❑ Red  ❑ White  ❑ Black

❑ Fissures  ❑ Lesions/other ______________________

Lips ❑ Pink  ❑ Pale  ❑ Moist  ❑ Dry  ❑ Intact

❑  Lesions/other ____________________________________

Gums ❑ Pink  ❑ Pale  ❑ Red  ❑ Swelling

❑ Bleeding __________________________________________

Teeth ❑ White  ❑ Yellow  ❑ Brown/Black

❑ Caries  ❑ Missing  ❑ Uses dentures ____________

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Breath  ❑ Pleasant  ❑ Fruity  ❑ Halitosis

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NECK & THROAT

Blood vessels ❑ No distention  ❑ JVD

Carotid pulse ❑ Equal ❑ Unequal  ❑ Weak  

❑ Absent  ❑  Bruit  _________________________________

Thyroid ❑ not enlarged  ❑ Enlarged

❑ Trachea at midline ❑ Deviation

Throat ❑ Lesions/inflamm ________________________

Difficulty swallowing? ❑ No  ❑ Yes

Lymph nodes ❑ Not palpable  ❑ Palpable

❑ Hard  ❑ Soft  ❑ Size & Location ________________

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CV

Apical pulse rate: _________ ❑ Regular ❑ Irregular

Blood Pressure: _______________

❑ S1 & S2 heard in all four locations

❑ Abnormal sounds/exceptions __________________