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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:
__________________________________________
___
__________________________________________
_____________
__________________________________________
_____________
__________________________________________
_____________
HAIR
Color: ____________________ Normal
distrubution
Abnormal distribution
_________________________
Full Thinning Alopecia
__________________
Dry Oily Dandruff/foreign matter
Lesions:
__________________________________________
__________________________________________
_____________
__________________________________________
_____________
NAILS
Color normal Other
__________________________
Thick Thin Angle 160
Clubbing
Concave Convex Beaus lines
Paronychia Splinter hemorrhages

Patient: ________________________________
Patient: ________________________________
Date: ________________________________
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______________________
________
__________________________________________
______________
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

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Bleeding
__________________________________________
Teeth White Yellow Brown/Black
Caries Missing Uses dentures
____________
__________________________________________
______________
Breath Pleasant Fruity Halitosis
__________________________________________
______________
__________________________________________
______________
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
________________
__________________________________________
______________
__________________________________________
______________
CV
Apical pulse rate: _________ Regular
Irregular
Blood Pressure: _______________
S1 & S2 heard in all four locations
Abnormal sounds/exceptions
__________________
__________________________________________
______________
__________________________________________
______________
PV
Extremities Color normal for race
Cyanotic
Dry Diaphoretic Bilaterally

Patient: ________________________________
Patient: ________________________________
Date: ________________________________
Asymmetrical
_____________________________________
Nailbeds pink Cyanotic Clubbing
________
No JVD JVD Moves all
extremities
Exceptions
________________________________________
__________________________________________
______________
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
_____________________
__________________________________________
___________
__________________________________________
___________
Parestheisas
___________________________________
Pain
__________________________________________
__
CRT < 3 sec > 3 sec Temp
______________
MUSCULOSKELETAL
Obese Overweight Muscular
Lean
Thin Emaciated Petite
Posture Erect Stooped Kyphosis
Lordosis Scoliosis
Gait Smooth & Coordinated
Shuffling
Hesitancy Assistive devices
________________
__________________________________________
____________
Movement purposeful & controlled

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Tics/tremors Decreased muscle
tone
Immobility
_______________________________________
__________________________________________
_____________
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
________________________________
__________________________________________
______________
__________________________________________
______________
Joints Symmetrical Enlarged
Discolored
Heat Edema Tenderness Pain
Nodules Crepitus
_____________________________
__________________________________________
______________
__________________________________________
______________
ROM Full ROM: Shoulders
Elbows
Wrists Fingers Hips Knees
Ankles
Feet Toes
Limitations
__________________________________________

Patient: ________________________________
Patient: ________________________________
Date: ________________________________
__________________________________________
______________
__________________________________________
______________
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):
________
__________________________________________
______________
__________________________________________
______________
Cough Productive Nonproductive
Frequency/Sputum
________________________________
SaO2: ____________ Room Air Nasal
cannula
Other device ______________ Flow
rate _________
Mucous membranes moist Dry
Bleeding/Irritation
_____________________________
GU/GI
Abdomen Round Flat Convex
Incisions/scars
__________________________________
Bowel Sounds Present x4
Hyperactive >5-6

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Hypoactive (<5-6) Absent
___________________
Soft Firm Distended
Tenderness
Masses
__________________________________________
__
__________________________________________
______________
Urine Pale Yellow Amber
Tea-colored Red Clear
Cloudy/sediment
Frequency:
__________________________________________
Foley Catheter
___________________________________
__________________________________________
______________
Diet: ______________ Tolerance:
______________________
NG Tube: R / L Nare
Suction:
Low
Moderate Intermittent
Continuous
Drainage color/consistency:
_______________________
Feeding tube: Type
______________________________
Rate: ____________________ Place Val.
_________________
BM: Date of last _____________ Amt
___________________
Formed Loose Liquid
Color ________________ Abnormal odor
Frequency
__________________________________________
_
Flatus Present Not present

NEURO
LOC: Awake/alert Responds
appropriately
Lethargic Confused Stuporous
Comatose
Speech: Moderate tone & pace
Clear
Slurred Garbled Grunts/moans

Patient: ________________________________
Patient: ________________________________
Date: ________________________________
Aphasic No response
Mood: Cooperative/friendly Feelings
appropriate to situation Positive
feelings
Other
__________________________________________
____
__________________________________________
______________
__________________________________________
______________
Thought Processes: Full, free flowing
thoughts
Follows directions Realistic
perceptions
Makes sense Positive/healthy
thoughts
Suicidal thoughts Other
______________________
__________________________________________
______________
__________________________________________
______________
Oriented to Self Others Place
Time
__________________________________________
______________
__________________________________________
______________
Concentration With Without
Difficulty
(Backwards from 100, Alphabet
backwards)
__________________________________________
______________
__________________________________________
______________
__________________________________________
______________
Recent Memory With Without
Difficulty
(What did you have for breakfast?)
__________________________________________
______________
__________________________________________
__________________________________________
____________________________
Long-Term Memory President now
Previous

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Mothers maiden name Address
__________________________________________
______________
__________________________________________
______________
__________________________________________
______________
New Memory With Without difficulty
1 2 3 4 of 4 words
remembered
Words:
__________________________________________
_____
__________________________________________
______________
__________________________________________
______________
Abstract reasoning With Without
difficulty
(Apple/orange, Proverb)
___________________________
__________________________________________
______________
__________________________________________
______________
Judgement With Without difficulty
What would you do
if_______________________________
__________________________________________
______________
__________________________________________
______________
Sensory function: Correctly IDs dull &
sharp stimuli Paresthesias Pain
__________________________________________
______________
__________________________________________
______________
Motor Function Gag reflex intact
Absent
Swallows w/out difficulty W/
Difficulty
Involuntary movements/tremors
MAE on command
__________________________________________
______________
__________________________________________
______________

Patient: ________________________________
Patient: ________________________________
Date: ________________________________
Glascow Coma Scale TOTAL:
________________
Eye Opening: ___________
Spontaneous (4)
Verbal stimuli
(3)
To pain (2)
None (1)
Verbal Response: ___________
Oriented/talks (5)
Confused/talks
(4)
Inappropriate words (3)
Incomprehensible sounds (2) None
(1)
Motor Response: ____________
Obeys commands (6) Localizes pain
(5)
Flexion/withdraws (4)
Flexes abnormally (3) Extention to
pain (2)
None (1)
Special senses:
Smell Discharge Epistaxis
Snoring
Reddened mucous membranes Pain
Lesions
__________________________________________
__________________________________________
_____________
Correctly Incorrectly IDs scents
__________________________________________
_____________
Taste: Correctly Incorrectly IDs
tastes
__________________________________________
_____________
Vision: Reads print at 14 PERRLA
Exceptions
_______________________________________
Corrective lenses
________________________________
Drainage Pain Lesions
Redness
__________________________________________
_____________
Hearing: Hears whispered words
Hearing aids Drainage Redness
__________________________________________
_____________
Supplies checklist:

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Stethoscope
BP cuff
Tongue blade
Pen light

Patient: ________________________________
Patient: ________________________________
Date: ________________________________
Items to taste and smell