GOVT.

COLLEGE OFNURSING KOZHIKODE

MEDICAL SURGICAL NURSING

NURSING ASSESSMENT: HISTORY AND PHYSICAL EXAMINATION

Name: Sex: Marital Status: Hospital Ward/Bed

1. Male 1. Married Registration No.:
2. Female 2. Single No.:
Age: 3. Window
Address: Religion: Education (*): Admission Discharge
1. Hindu 1. Illiterate Date: Date:
2. Muslim 2. Primary
3. Christian 3. Secondary
4. Sikh 4. Graduate &
5. Any Other Above
Diagnosis: Operation:

Date of operation:
Occupation: Monthly Family Nursing Alert: Weight:
1. Unskilled Income (Rs.): 1. Sensitivity? ________in kgs.
2. Skilled 1. <1000 Allergy /
3. Professional 2. 1001 – 2500 Precaution Height:
4. Business 3. 2501 – 5000 _______ cm
5. Agriculture 4. >5000
6. Not working BMI:

Chief Complaints: with duration:

History of Present Illness:

Present surgical history

History of Past Illness:

Family History Health facility near home : Housing Type :

Type: Type: 1. Kuchcha
1. Hospital 2. Pucca
1. Joint 2. Health Centre
2. Nuclear 3. Any other: If any other (specify) Toilet :
4. Distance: _______________KMS. 1. Indian
2. Western
No. of members: 3. Temporary
4. Open
Electricity: 1. Yes 2. No
Any illness: Transportation facility :
Drinking Water (Source) :
1. Tuberculosis 1. Yes 1. TAP
2. DM 2. Well
3. Hypertension 2. No
3. Pond
4. Hereditary illness 4. River
5. Any Other: 5. Hand pump
 PERSONAL HISTORY

Personal hygiene:
Oral hygiene: Bath:
Diet: Veg Nonveg Egg
No. of meals per day:
Fluids:………Glasses/ day Tea/Coffee:………cups/day. Cola:……… glasses//day
Sleep and rest: ………… hours/day Uninterrupted Interrupted , explain :
Naps:……………….. Drugs used for sleeping: No Yes, Specify:
Elimination:
Bowels/day: Regular Irregular
Urine frequency: During day……….. During night:………….
Mobility and exercise:
Walking habits: No Yes, Regular Irregular
Exercise/activity: Sedentary Mild Moderate Heavy
Joints: Pain Discomfort Restriction, Specify:
Menstrual history: Regular Irregular If regular, Scanty Heavy cycle
LMP: Any other problem:
Sexual and marital history:
Spouse: General health: Good Fair Bad
Spouse occupation: Working Not working
Relationship: Satisfactory Unsatisfactory
Staying together: Yes No No. of children: General health:
Handicaps /Deficiencies/ impairment/Prosthesis/ Implants/ Fixtures/ Aids:
If any, Specify:
Hearing aids/Contact lenses and spectacles/ Dentures/ Pacemaker /Catheters and tubing.
Any other, Specify:
Substance use: Tobacco Drugs Alcohol Any other: Specify:
Addiction: Yes No

HEAD TO TOE ASSESSMENT

General appearance:
Sensorium: Alert Oriented Confused Disoriented Unconscious Coma
Emotional state:
Foul body odour: Yes No Foul breath: Yes No
Vital signs:
Temperature: Pulse: Respiration BP:
Skin colour: Normal Pale Flushed Cyanosed
Posture: Normal Kyphosis Lordosis Scoliosis
Gait: Normal Abnormal
Bleeding: Internal External Specify:
Discharge: No Yes, Specify:
Hair: Clean Unclean Pediculosis Dandruff
 Eye: Vision: Normal Impaired Discharge/Infection Specify:
Teeth and gums: No of teeth: Healthy Swollen Bleeding Caries
Any other, Specify:
Oral mucosa: Healthy Sore Lesions if any:
ENT:
Hearing: Normal Impaired Discharges Wax
Nasal deviation: Yes No Discharges Epistaxis
Neck: Thyroid enlargement: Yes No Carotid Pulse palpable: Yes No
Glands: Enlarged Not enlarged
If enlarged: Submandibular Cervical Clavicular Axillary Inguinal Any other:
Chest:
Shape of chest:
Chest movement:
Air entry: Equal Unequal Adequate Inadequate
Abdomen: Normal Distended Fluids
Shape: Abdominal girth: Scar:
Hernia: Pigmentation:
Limbs: Oedema Varicose veins Weakness Paralysis
Back: Curvatures: Normal Abnormal Pain Discomfort Tenderness
Skin: Hydrated Dry Intact Lesion Broken Lump Pigmentation Infestation
Wound
Dependency level of patient: Independent Partially dependent Fully dependent

I V Assessment
Type of line: Peripheral, site ___________________ Triple lumen CVL PICC
Tunnelled CVL Implanted port
Invertion site: WNL Redness Tenderness/pain Warmth Swelling Drainage
IV fluids: N/A IV fluids: ____________@ ______mls/hr Continous over _____hrs
IV pump Dial-a-flow Gravity
TPN/PPN: N/A TPN PPN @ __________mls/hr
Continous over _______hrs per _________ pump
 SYSTEM WISE ASSESSMENT

Neurological Assessment
Oriented to: Person Place Time

Communication / Speech: WNL Non-verbal Dysarthria

Aphasia: Expressive Receptive Global

Pupils: PERRLA
Equal: Yes No R larger L larger
Round: Yes No R abnormal shape L abnormal shape
Rractive to Light: Yes No
Reaction: Brisk Sluggish R no reaction L no reaction
Accommodation : R Yes No
L Yes No

GCS SCORE :
Sensation: WNL To pain No response to pain
Tremor : Present Absent

Right Left
Reflexes
Biceps
Triceps
Brachioradialis
Patellar
Achilles

Muscle tone: WNL Flaccid Spastic

Muscle strength : 5 4 3 2 1 0
Upper extremity
Right
Left
Lower extremity
Right
Left

(Muscle Strength: 5=WNL 4=75% normal 3=50% normal 2=25% normal 1=10% normal 0 complete paralysis)
Reflexes Tendon Reflexes: Grading
Grade DTR Response
4+ Very brisk, hyperactive, with clonus
3+ Brisker than average, slightly hyperreflexic
2+ Average, expected response; normal
1+ Somewhat diminished, low normal
0 No response absent
 Respiratory Assessment

Pulse ox: WNL (95-100%) WNL for this patient with oxygen at …………… %

Cough: None Non-productive, dry Productive Productive sounding, no sputum

Sputum: None
Consistnecy: Thick Thin Foamy
Color: White Other,

Oxygen: Room air ____ L/mt per face mask/ Cannula Mechanical ventilator

Respiratory rate: WNL Tachypnea/hyperventilation Bradypneic/bypoventilation

Respiratory effort: Relaxed and regular Pursed lip breathing Painful respiration Labored
Dyspnea at rest Dyspnea with minimal effort, talking , eating, repositioning in bed, etc.
Dyspnea with moderate exertion, dressing, walking =<20 feet,etc.
Dypnea when walking ______ feet or with exercise
Recovery time following dyspneia episode: _________ minutes
Respiratory rhythm: WNL Regular, tachypneic Regular, bradypneic Regular
with periods of apnea
Regular patrtern of increasing rate and depth, followed by decreasing rate and depth, followed by apnea (cheyne-
stokes)
Regular, abnormal, rapid and deep respiration (central neuroginic hyperventilation )
Regular, abnormal, prolonged inspiration with a pause or sigh with pweiods of apnea (apneustic)
Irregularly irregular pattern/depth (ataxic) Irregular with periods of apnea (cluster breathing)
Breath sounds (auscultate anterior & posterior, R & L upper, mid, lower chest):
Clear (vesicular) throughout
Decreased (atelectasis)
Crackles: Fine (sounds like hair rubbing) Coarse/moist
Gurgles/rhonci (low pitched, moaning, snoring sounds)
Wheezes: Inspiratory Expiratory
Friction rub (sounds like leather rubbing against leather)
Absent (pneumothorax?)
Palpation : Percussion :
Upper chest:Right ____________ Left __________ Upper chest: Right __________ Left __________
Mid chest: Right ___________ Left __________ Mid chest: Right _____________ Left __________
Lower chest:Right __________ Left _________ Lower chest: Right _________ Left _______
 Cardiovascular Assessment
Skin: Warm/dry Cool Clammy/diaphoretic Skin furgor: WNL Tenting
Weight:______kg
Capillary refill: WNL Delayed > 3seconds
Apical pulse rhythm: Regular Regularly irregular Irregularly irregular
Heart sounds:
Apical pulse rate: WNL . |(60-100) Normal S1 S2
Bradycardia Rate: S3 (gallop)
Tachycardiia Rate: Valve click [artifical heart valve]
Murmur:Pansystolic Midsystolic Diastolic
Apical /radial deficit: No Yes B/P: WNL Hypertension Hypotension

If yes, Rate: Lying Sitting Standing

Orthostatoc systolic drop < 20mm Hg = >20mm Hg

Peripheral pulses Edema

R radial Yes No R hand/arm No Non-pitting Pitting
R femoral Yes No R Knee to thigh No Non-pitting Pitting
R popleteal Yes No R ankle to Knee No Non-pitting Pitting
R post tibial Yes No R Foot/ankle No Non-pitting Pitting
R dorsalis Yes No
pedis
L radial Yes No R hand/arm No Non-pitting Pitting
L femoral Yes No RKnee to thigh No Non-pitting Pitting
L popleteal Yes No R ankle to Knee No Non-pitting Pitting
L post tibial Yes No R Foot/ankle No Non-pitting Pitting
L dorsalis Sacrum No Non-pitting Pitting
pedis
Other signuficant findings:
 Genitorurinary Assessment

Genitalia: WNL Abnormalities, describe:

_____________________________________________________
Assessment of urination: WNL Burning Frequency Urgency
Bladder distention Pelvic pain/discmfort Lower back/flank pain/discomfort
Contient: Yes Stress incontince with coughing/Straining Rarely incontient Regularly inconcent
Urine amount: WNL (over 30 mls/hr) Output apprpoximates intake
Less than 30mls /hr (dehydration? Post-op volume depletion? SIADH?)
Out put greatly exceeds intake (post-op diuresis? Diabetes insipidus?)
Urine coloor: Amber Yellow Orange Dark amber Pink Red tinged Grossly bloody
Urine characteristies: Clear Cloudy Sediment Abnormal odor
Urostomy: N/A Urostomy/ileal conduit Continence maintaining nipple value ostomy
Urinary stents: N/A R ureter L Ureter
Urinary catheter: N/A Foley, short term Foley, long term at home
Suprapublic catheter:- Insertion site: WNL S/S of inflection:

Pain Assessment
Location of pain: ________________________________Pain is: Acute Chronic Constant Intermittent
Pain is affecting: N/A Sleep Activity Exercises Relationships Emotions
Concentration Appetite Other:
Description of pain : Sharp Stabbing Throbbing Shooting Burning Electric-Shock like
Pain rating on a scalce of 0 to 10: ______ Acceptable level of pain for this client: ______________
What makes the pain worse? Activity Exercises Other:
What makes the pain decrease? Rest/Sleep Medication Heat Cold
Family presence Music Reading Distraction Meditation Guided imagery
Relaxation techniques Other:
Opiod medication): ____________________________________________________________ Route: _________ Last
dose: ______________
NSAIDS/Adjuvants: _____________________________________________________________ Route: _________
PCA: N/A Morphine Fentanyl via IV IM Epidural
Continuous dose: __________________/hr Demand dose: _______________ every ________minutes
Max dose per hour: _________
Doses the client have concern about overusing medications/ addicition? No yes,
 Gastrointestinal Assessment
Oral mucosa: Intact Moist Dry Pink Pale Ulcers:
Tongue: WNL Pink White Patches
Abdomen: WNL Distended Taut Ascites Abdominal incision Abdominal girth: ……….cm
Bowel movements: WNL Constipation Diarrhea Other____________

Last bowel movement: Today Yesterday Other:

Continent: Yes Rarely incontient Regularly incontinent
Nausa/vomiting: No Yes, describe: _____________________________________
Nutritional intake: Adequate Inadequate
Tubes: None Salem sump Nasogastric feeding tube Percutaneous Endoscopic Gastrostomy tube
Jejunostomy (J) tube pH of aspirate: ___
Insertion site: WNL Pressure areas Redness Purulent drainge Tenderns Warmth
Tube feeding: Type: ________________________
Amount: ________ml over_________ Hours Via Gravity Pump
Stoma: N/A Colostomy IIeostomy
Stoma status: Pink, Viable Red Deep red Dusky Dark Retracted below skin
S/S of infection:
Abdomen
Palpation:

Percussion:

Auscultation: Bowel sounds (all four quadrants): Active, WNL Hyperactive Hypoactive Absent
(listen for 5 full minutes)
Vascular sounds :
 Skin Integrity Assessment
Skin color: Normal Pale Jaundice Dusky Cyanotic
Skin is : Intact No If No, describe: Braden Scale Score:
Signs/symptoms of inflammation/infection: Redness Tenderness/pain Warmth Swelling
Location (s):
Contusion (s)/ Ecchymosis: Yes No
If yes, Size: Length ____________cm Width _______cm Depth ___________cm
Location(s): _______________________
Client’s Explanation of bruising: ______________________________________

Wounds

Type Size Tunnelling Undermining Surrounding Drainage

Tissue
Abrasion Length ___ cm None None WNL Color/
Avulsion Redness Characteristics:
Burn Present Present, Tenderness Serous
Laceration Width ____cm Pain Serosanguinous
Puncture Depth : Surrounding Warmth Bloody
Pressure ulcer, Depth ____cm _____Cm tissue is: Streaking Yellow
Stage ________ Dusky Excoriation Tan
Stasis |ulcer Soft Bruising Brown
Surgical incision Incision length Boggy Discoloured Green
Closed, edge are ___________cm Fluid-fill Dusky
Approximated Other, Purulent?
Surgical, describe: Wound edges No
Open areas Staples/Sutures WNL Yes
Total wound (circle one) Hyperkeratoric
dehiscence Odour?
__________________ No
Yes

Is client on a pressure reduction or relief surface: No Yes, type:

Cast / Extremity Assessment

Hot spots over cast? No Yes, describe:

Cast intact: Yes No, describe:
Drainage: None Yes, describe:
Extremity check
Color: WNL Pale
Temperature: Warm Cool
Sensation: : WNL Loss of sensation
Pain increasing? : No Yes, describe:
Swelling increasing : No Yes, describe