8/16/2019 NUR310&NRS103 Head to Toe Health Assessment

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 NUR310/310L & NRS103/NRS103L Health Assessment

Template for Physical Assessment Documentation

Student:___________________________ Date:______________________________ 

**Use appropriate abbreviations throughout

Patient Profile:

Clients !nitials" Age" Ra#e"

$arital Status" Religion" Se%"'u#ation" (##upation" )irthpla#e"

Chief Complaint (can be made up, if your client has no complaints at this time, or state well

health checkup:

!istory of Present "llness (if applicable, #$A if %well check up&:

Past !ealth !istory:

Allergies"

!mmuniations +,'ap- H).- inluena- pneumonia- i #hil' in#lu'e va##ine s#he'ule"

(ther illnesses/inuries"

(perations"

Current $e'i#ations"

Current nutritional pattern +2hr re#all"

Current %er#ise pattern +t4pe an' re5uen#4"

Current sleep pattern +a'e5ua#4 an' amount"

So#ial habits" Caeine" Ni#otine +#al#ulate pa#6 4ears i appli#able"

Al#ohol"7rugs"

8/16/2019 NUR310&NRS103 Head to Toe Health Assessment

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'amily !ealth !istory (CAD, !T#, Ca, CA, D), *besity, +A, T, !", Aller-ies, kidney

disease, sei.ure disorder, alcoholism, mental illness, etc/ Attach a -eno-ram, only need

back to -randparents

+*S (+e0iew of Systems$history of each system:

P1 (Physical 12am:

)89999999999999999999 8"999999999999999999999RR"999999999999999998ain"

 Neurologi#"

(rientation"

:lasgo; Coma S#ale" Spee#h"4e opening"

$otor response"

4es/8upils"

,ou#h sensation"

Car'iovas#ular"

Heart rate/8$!"!s heart rate normal or age- ;hat is the normal rate or age<

Heart soun's"

8ulses"Capillar4 Reill"

'ema"

All e%tremities pin6 an' ;arm<

8/16/2019 NUR310&NRS103 Head to Toe Health Assessment

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Respirator4"

!s respirator4 rate normal or age<

Lung soun's"=or6 o breathing +use o a##essor4 mus#les or retra#tions<

Cough<

Anatomi#al air;a4 patent- mi'line an' inta#t<

:astrointestinal

)o;el soun's in all 5ua'rants"Ab'omen palpation"

Ab'ominal #ontour"

,en'erness<

8t able to pass stool regularl4 ;ithout assistan#e< Nutritional status an' 2 hr 'iet re#all"

:enitourinar4

.oi'ing on o;n ;ithout assistan#e +su#h as a ole4 #atheter<Urine #olor"

)la''er 'istention<An4 #omplaints o urgen#4- re5uen#4- burning or it#hing<

$us#ulos6eletal,one in all e%tremities"

Strength in all e%tremities"

:ait"

R($ in all e%tremities"

S6in"

An4 s6in lesions- rashes- #uts/abrasions<$u#ous membranes inta#t- pin6 an' moist

S6in temperature"

lasti#it4/tone<S6in #olor +appropriate or ethni#it4<"