med surg revised database and physical assessment tool

8/12/2019 Med Surg Revised DataBase and Physical Assessment Tool

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DataBase / Physical Assessment Tool with Lab Values

Student Name: _Donna Joanne Bennett/ A. Bruner, instructor Date: 1/31/13

DATABASE and PHYS!A" ASSESS#ENT T$$"

Client Initials ________ Room # _______ Admitted On ________ A%%er&ies____________________________

edical D! ________________________________________________________________________________

Chie" Comlaint ____________________________________________________________________________

__________________________________________________________________________________________

$isto%y o" P%esent Illness _____________________________________________________________________

__________________________________________________________________________________________

Past edical $isto%y ________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Past &u%'ical $isto%y __________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

(amily $isto%y _____________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Alcohol )se ________________ Tobacco )se _________________ Rec%eational D%u' )se _______________

Neuro%o&ic Awa*e Letha%'ic &tuo%ous Comatose$riented to: Pe%son Place Time

Con"used (ollows Commands Resonds a%o%iately

Pu'i% si(e: R _____ L _____ %ound %eacti+e

S'eec): Clea% umbled ,a%bled Ahasic

Othe% Ob-ecti+e Data.__________________________________________________________________

&ub-ecti+e Data.______________________________________________________________________

*ita% Si&ns

BP_____ Lyin' &ittin' &tandin' BP_____ Lyin' &ittin' &tandin'

Tem'_____ O%al A!illa%y Tymanic Tem'_____ O%al A!illa%y Tymanic

Pu%se_____ Radial Aical Re'ula% I%%e'ula% Pu%se_____ Radial Aical Re'ula% I%%e'ula%

Telemet%y # _____ Rhythm __________ Telemet%y # _____ Rhythm __________

+es'irations___ Re'ula% I%%e'ula% &hallow Labo%ed ,ua%din' +es'irations___ Re'ula% I%%e'ula% &hallow Labo%ed ,ua%din'Pain rated___scale 01203 Location ___________________________ Pain rated___scale 01203 Location___________________________Hei&)t_____ ei&)t_____ &ou%ce ________________________ Hei&)t_____ei&)t_____&ou%ce ________________________


&ub-ecti+e Data.______________________________________________________________________


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nte&ument S-in Tur&or: Tentin' 4 5 sec 6 5 sec

#ucous memranes: oist D%y Pin* Pale 7ellow

S-in: 8a%m Cool D%y oist &mooth Rou'h Lesions location3 ________

!o%or: Pin* A%o%iate "o% Race Ashen Dus*y 9aundiced

Scars location and o%i'in3 _________________________________________

Othe% Ob-ecti+e Data.__________________________________________________________________&ub-ecti+e Data.______________________________________________________________________

Head and Nec- Contacts ,lasses

Dentures: )e% Lowe% Teet): Clean Poo% issin'

$O$ $ea%in' Aid Resonds a%o%iately to +oice o% noise : "t away

Ears: &ymmet%ic !ana%sA''earance:_______________________________


&ub-ecti+e Data.______________________________________________________________________

T)ora/"un&s/Heart "un& sounds: L ; R Clea% Rales Rhonchi 8hee3 ________


&ub-ecti+e Data.______________________________________________________________________

Breast and Ai%%a A''earance: Dimlin' Ret%action C%ustin' D%aina'eLast ammo'%am _______________ =e!t ammo'%am ________________


&ub-ecti+e Data.______________________________________________________________________

Adomen A''earance: (lat Rounded Distended

Boe% Sounds: $yoacti+e $ye%acti+e I II III IV ?uad%ants noted

2mi%icus: idline Othe%

NT: &i


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Peri')era% 4ascu%ar Edema: @2 @: @5 @ Location ________________

*aricose *eins: R L Peda% Pu%seL _____ R _____

!o%or. R _________ L _________Tem'erature. R _________ L _________

Othe% Ob-ecti+e Data.__________________________________________________________________&ub-ecti+e Data.______________________________________________________________________

enitourinar5 Continent Incontinent

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med surg revised database and physical assessment tool

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