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Date
Patient Initials
Gender
Rm #
Allergies
Age
BRAZOSPORT
COLLEGE
Associate Degree
Nursing Program
Clinical Nursing
RNSG 1360
Student (Print)
Time
T° ____ Pulse
____
(Apical/Radial)
RR ___ B/P
______(Left/Right)
Other
Time
T° ____ Pulse
____
(Apical/Radial)
RR ___ B/P
______(Left/Right)
Other
Primary Dx
History
ASSESSMENT
Neurological/Eyes Responsive to verbal stimuli,
alert, oriented x3, B/L grips present and equal
Speech clear, responds to
questions appropriately to
setting
(B/L)
PERRL Pupils _____ mm
Sclera: white, Conjunctiva pink & moist
DTRs intact and equal (patellar, radial,
brachial, Achilles)
ENT
Neck supple, full ROM, no visible
lesions, lumps or bumps
Ears symmetrical, B/L canals patent,
no visible lesions or drainage
B/L nares patent, no visible lesions or
drainage
√ / *
Septum
midline
fasciculation
Tongue midline w/o
Pharynx without visible erythema or
swelling; denies dysphagia
Natural dentition w/o visible signs of
decay or dentures present U/L adequate fit
Oral mucous membranes pink &
moist without lesions
Cardiovascular:
Apical/radial pulses equal &
regular Apical pulse =
S1,S2 present no murmur
heard
PMI 4th-5th ICS @ left
midclavicular line
B/L temporal, carotid,
brachial, femoral, DP & PT pulses 2+ - 3+/4+
B/L fingernail and toenail
beds pink, CRT < 3 secs
Respiratory:
expansion
Symmetrical chest
Respiratory rate even &
unlabored, No accessory muscle use
Lungs are CTA @ anterior,
posterior, axillary, apices
Gastrointestinal:
Abdomen soft, denies
tenderness with palpation
Bowel sounds present x 4
quads
Last BM =
patient
describes as: “normal, soft, hard, adequate, usual
or
“
Genitourinary:
Voids clear, yellow/amber
urine, reports no difficulty or pain
Extremities:
strong
B/L hand grips equal &
(Active/Passive)Upper
ROM Intact (Active/Passive) Lower ROM intact
B/L Homan’s sign
negative
command
Integumentary:
present
MAE active & on
Full AROM noted of all joints
Skin warm & dry, intact, turgor
No visible cyanosis, no visible
jaundice
(Safety)
ID
band_____________ Allergy band_____________
Other__________________
Bed: locked and in low
position Call bell within reach Denies
discomfort
Patient/Family Verbalized
understanding to call immediately if any SOB or
discomfort
Room in good order, supplies
present and need anticipated
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