PHYSICAL EXAM
Vital Signs
Pain
Neuro
Temperature
Pulse/ Blood Pressure
Respiration/oxygen saturation
OLD CART
LOC/Orientation
Cranial Nerves
PERRLA/Cardinal Fields
Hearing/Vision
Memory
Gait
Musculoskeletal Grip/Arm strength
Leg strength
Muscle tone/ROM
Respiratory
Lung sounds
Cough (dry, moist, sputum)
Rate/Rhythm/Effort/Symmetry
Clubbing/Barrel Chest
Chest tube
Oxygen- check amt on flowmeter
Cardiovascular Heart sounds
Pedal pulses/Radial pulses
Edema
Cap Refill
GI
Abdomen shape/size
Soft/Firm
Bowel tones
BM (last? Color, amount, odor,
consistency)
Nausea
GI tubes/dains
GU
Urine (color, clarity, odor, amount)
GU tubes/drains
Integumentary
Color/Temp/Moisture
Turgor
Drain insertion sites
Skin/Tissue drains (drainage)
Incisions, rashes, wounds, lesions
Bruising
Pressure ulcers/Diabetic ulcers
Check coccyx & bony prominences
IV
Check IV site (warmth, redness,
drainage, swelling)
Location, type & gauge of IV
Check IVF/Drip type & rate
VS
Pain
Neuro
Musculo
Resp
Cardio
GI
GU
Integ
IV
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
PHYSICAL ASSESSMENT
Temp ____________°C
BP: ____________/______________
Pulse_____________ Bpm
Respiration: __________Breaths/min
Oxygen Saturation: _________________%
Onset ____________________________________
Location ____________________________________
Duration ____________________________________
Characteristics ____________________________________
Alleviating/aggravating factors __________________________________
Rating ____________________________________
Tx tried
LOC/Orientation ____________________________________
CN (I-XII) ____________________________________
PERRLA/Cardinal fields ____________________________________
Hearing/Vision____________________________________
Memory____________________________________
Gait____________________________________
Grip/Arm strength____________________________________
Leg strength____________________________________
Muscle tone/ROM____________________________________
Lung Sounds____________________________________
Cough (dry, moist, sputum) ____________________________________
Clubbing/Barrel Chest____________________________________
Chest Tube____________________________________
Oxygen –check amt on flowmeter ________________________________
Heart sounds (S1/S2) ____________________________________
Pedal Pulses/Radial pulses ____________________________________
Edema____________________________________
Cap Refill____________________________________
Abdomen shape/size____________________________________
Soft/firm____________________________________
Bowel tones (present in all 4 quads?) ____________________________________
BM (Last? color, amount, odor, consistency) ___________________________
Nausea____________________________________
GI tubes/drains____________________________________
Urine (color, clarity, odor, amount) ____________________________________
GU Tubes/drains____________________________________
Color/Temp/Moisture____________________________________
Turgor____________________________________
Drain insertion sites____________________________________
Skin/Tissue drains (drainage) ____________________________________
Incisions, rashes, wounds, lesions____________________________________
Bruising____________________________________
Pressure ulcers/Diabetic ulcers____________________________________
Check coccyx & Bony prominences ____________________________________
o Check IV site (warmth, redness, drainage, swelling) _______________
o Location/type/gauge of IV & IVF/drip _____________________