Faculty of Nursing

PHYSICAL EXAMINATION
&
HEALTH ASSESSMENT
Log Book

2021- 2022
1
 Student's Data

Student's name:

Student's No:

Age:

Sex:

Level:

Group:

Address:

Telephone No:

2
 Physical examination- Nur 120204

Evaluation Sheet

Student's Name:

Evaluation Item Marks Student's Marks

Checklist 10

Quizzes 5

Case study and Videos 5

Grooming 5

Attendance 5

Total marks 30

Clinical instructor: Student's signature:

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 Physical examination- Nur 120204
Mid arm circumference measurement (MAC)

Student's name: Date:

Task Score Yes No Remarks

1. Prepare the equipment. 1
2. Wash your hands following the hand 1
washing technique.
3. Explain the procedure to the patient 1
4. Measure the midpoint of the non- dominant 2
arm between the top of the acromion process
of the scabula and the alcranon process of
the ulna with the forearm flexed at 90°.
5. Mark the midpoint with a felt-tipped pen. 2
6. Draw the tape around the midpoint of upper 2
arm gently without compressing the skin
7. Record the reading. 1

Total marks /10

Instructor's signature: Student's signature:

4
 Physical examination- Nur 120204
Skin, hair and nails checklist

Student's name: Date:

Task Score Yes No Remarks

Hand washing 0.5
Prepare needed equipment 0.5
Explain procedure to patient 0.5
History taking 0.5
1. Inspect and palpate the skin
• Color 0.5
• Temperature 0.5
• Moisture 0.5
• Texture 0.5
• Mobility and turgor 1
• Edema 1
• Lesion 0.5
(4.5)
2. Inspect and palpate the hair
• Color 0.5
• Texture 0.5
• Lesion 0.5
• Distribution 0.5
(2)
3. Inspect and palpate the nails
• Shape and contour 0.5
• Consistency 0.5
• Color 0.5
(1.5)
Total marks /10

Instructor's signature: Student's signature:

5
 Physical examination- Nur 120204

Weight and Height Measurements Checklist

Student’s name:

Steps Student's Experience

Yes No
1-Balance the scale before standing 1

2-Place a clean paper on the scale 0.5

3-Assist the patient onto the scale with only a gown on, with feet firmly on 1
scale and hands at site.

4-Adjust the weights until the balance pointer is again in the middle of the 1
balance area.
5-Records immediately and accurately the patient‟s weight in 0.5
kilograms and grams.
6-Bring back the metal weight after finishing. 1
7-Raise the measuring rod above the patient‟s head. 1
8-Ask the patient to turn so that his back is against the measuring 0.5
rod.
9-Bring the measuring rod down so that it rests on the top of the patient „s 0.5
head.
10-Note the height and write it down so that you don‟t forget it. 1

11-Bring the measuring rod back. 0.5

12-Record the patient‟s weight and height in the record at in early appropriate 0.5
time.
13- Calculate B.M.I, Ideal Body Weight, and Percentage of Weight 6
Change, using the specified formulas

Total marks /15

Instructor's signature: Student's signature:

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 Physical examination- Nur 120204

Head, Neck and Cervical lymph nodes Checklist

Student's name:----------------

Steps Done Done

complete Incomplete Not done

`Inspection
1. Head
0.5
a. position, shape ,size
2.Face
.a.symmtery
b.facial expression 0.5
c. facial features &appropriateness to age
3.Neck
a.position in relation to head
b.ROM 1
c.position of trachea
d.Thyriod gland
Palpation
1.Scalp for lesions, masses, 0.5
2.Sinuses:
1
a.frontal, ethmoid, maxillary
3.Temporal artery pulsation 0.5
4. Tracheaposition , any deviation
1
5. palpate carotid artery
6.Tempo.mandibular joint (TMJ) 0.5
7.Thyroid gland
a.anterior approach 0.5
b.posterior approach
8. Cervical lymph nodes:
• Size, shape, consistency, tenderness
• Preauricular
• Posterior auricular
• Occipital: base of the skull
• Submental
1
• Submandibular
• Tonsilar
• Superficial cervical
• Deep cervical
• Posterior cervical
• Supraclavicular
Scores:-

Instructor name -----------

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 PHYSICAL EXAMINATION- NUR 120204
Eye Examination Checklist

Student's name: Date:

Task Score Yes No Remarks
Hand washing 0.5
Prepare needed equipment 0.5
Explain procedure to patient 0.5
History taking 0.5
1. Inspect and palpate external ocular structures:

• Eyebrow: movement and symmetry 0.5

• Eyelid and lashes: redness, swelling, 0.5
discharge or lesions
• Lacrimal apparatus: enlargement or 0.5
obstruction
• Sclera: color 0.5
• Conjunctiva: color, inflammation, or lesion 0.5
• Cornea: abrasion 0.5
• Pupil :
▪ Pupillary light reflex 1
▪ Test for accommodation 1
(5)
2. Extra ocular muscle movement 1
3. Visual acuity
• Fare vision 0.5
• Near vision 0.5
(1)
4. Examine Visual field 1
Total marks /10

Instructor's signature: Student's signature:

8
 PHYSICAL EXAMINATION- NUR 120204
Ear Examination Checklist

Student's name: Date:

Task Score Yes No Remarks

Hand washing 0.5
Prepare needed equipment 0.5
Explain procedure to patient 0.5
History taking 0.5
Inspect External Ear:
• Size and shape 0.5
• Skin conditions: edema, inflammation, 0.5
lesions
• Position 0.5
• External Auditory Meatus: drainage or 0.5
Atresia
(2)
Palpation:
• Pinna for tenderness 0.5
• Mastoid process for tenderness 0.5
)1)
Hearing acuity
• Whisper test 1
• Weber test 2
• Rinne test 2
) 5)
Total marks /10

Instructor's signature: Student's signature:

9
 PHYSICAL EXAMINATION- NUR 120204
Nose Examination Checklist

Student's name: Date:

Task Score Yes No Remarks

Hand washing 0.5
Prepare needed equipment 0.5
Explain procedure to patient 0.5
History taking 0.5
Inspect & palpate external nose:
• Skin: Color, Consistency 0.5
• Shape: Symmetrical 0.5
• Naris: Symmetry, change in nares with 0.5
respiration, crust, septum midline
• Tenderness 0.5
(2)
Inspect internal nose:
• Color of mucosa 0.5
• Moist 0.5
• Lesions, polyp 0.5
• Visible Turbinates: Symmetrical, same color 0.5
as mucosa, moist, no lesion
• Function of nose for patency: Air is felt 1
being exhaled through opposite naris,
noiseless
(3)
Para nasal sinuses:
• Palpate Frontal, ethmoid & maxillary 1
sinuses for tenderness
1
• Percuss Frontal & maxillary sinuses for
resonance
• Transllumination for Frontal & maxillary 1
sinuses
(3)
Total marks /10

Instructor's signature: Student's signature:

10
 PHYSICAL EXAMINATION- NUR 120204

Mouth and Throat Examination Checklist

Student's name: Date:

Task Score Yes No Remarks

Hand washing 0.5
Prepare needed equipment 0.5
Explain procedure to patient 0.5
History taking 0.5
Inspect open & closed mouth: Symmetrical lips, 0.5
No lesion, swelling, drooping
Inspect & palpate lips: Color, Consistency, lesions 0.5

Inspect Buccal Mucosa: Color, Consistency, 1

lesions
Inspect & palpate Gum: Color, lesions 1
Inspect & palpate teeth: Color, number, position, 1
condition,
Inspect & palpate tongue: Color, Symmetry, 1
texture, Movement, lesions
Ventral surface: color, condition of blood vessels,
lesions
Inspect & palpate hard and soft palate: Color, 1
consistency
Inspect Oropharynx (throat): color 1
Uvula: position, rises and fall on phonation

Inspect tonsils: color, swelling 1

Total marks /10

Instructor's signature: Student's signature:

11
 PHYSICAL EXAMINATION- NUR 120204
Thorax and Lung EXAMINATION Checklist

Student's name: Date:

Task Score Yes No Remarks

Inspect anterior, lateral and posterior thorax
with the patient in sitting position for
• Chest symmetry 0.5
• Respiration pattern 0.5
• Antero-posterior to lateral diameter 0.5
0.5
• Skin color
(2)
Palpate anterior and posterior thorax for
• Tenderness 1
• Tactile fremitus as patient says “99” 1
• Thoracic expansion 1
(3)
Percuss the anterior and posterior thorax
correctly moving from side to side starting at
apices for:
• Resonance over lung periphery 1
• Diaphragmatic excursion (back only) 1.5
(2.5)
Auscultate breath sounds over anterior and
posterior lung periphery for:
• Normal breath sounds 1
• Bronchophony while patient says “99” 0.5
• Egophony while patient say “ee” 0.5
• Whispered pectoriloquy while patient 0.5
whispers “one two three”
(2.5)
Total marks /10

Instructor's signature: Student's signature:

12
 PHYSICAL EXAMINATION- NUR 120204
Heart and Neck Assessment Checklist

Student's name: Date:

Task Scoring Yes No Remarks

A- History Taking 2
B- Neck
1- Carotid Artery(Right& left)
• Inspection: pulsation 0.5
• Auscultation 0.5
• Palpation 0.5
2- Observe the jugular venous 0.5
(2)
C- Heart
• Inspect pulsations 1
• Palpation: Palpate the apical impulse 1
• Percussion 0.5
• Auscultation:
✓ Auscultate heart rate and rhythm 1
✓ Auscultate S1 and S2. 1

• Auscultate extra heart sound:

S3 0.5
S4 0.5
Murmurs. 0.5
(6)

Total marks /10

Instructor's signature: Student's signature:

13
 Physical Examination- Nur 120204
Abdominal Examination Checklist

Student's name: Date:

Task Score Yes No remarks

History taken 1
1. Inspection
• Contour (rounded, flat, scaphoid) 0.5
• Skin (color, Striae, Stoma, scare, lesion, 0.5
Prominent veins)
• Symmetry 0.5

• Umbilicus (position, shape, inflammation) 0.5

• Pulsation 0.5

• Peristalsis 0.5

• Respiratory movement 0.5

• hair distribution 0.5

(4)
2. Auscultation
• Bowel sound 0.5
• Vascular sound 0.5
(1)
3. Palpation
• Light palpation 0.5
• Deep palpation 0.5
• Liver 0.5
• Spleen 0.5
• Kidney 0.5
• Aortic pulsation 0.5
(3)
4. Percussion
• General tympany 0.5
• Spleen and liver dullness 0.5
(1)
Total marks /10
Instructor's signature: Student's signature:

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 Physical Examination- Nur 120204
Musculoskeletal Examination Checklist

Student's name: Date:

Task Score Yes No remarks

1. Assesses posture, body alignment, and symmetry. o.5
3. Assesses spinal curvature:
a. Standing erect. 0.25
b. Bending forward at waist, arms hanging free at sides. 0.25
(0.5)
4. assesses knees Alignment 0.25
5. Examines gait by observing client walking; notes:
a. Base of support (distance between the feet). 0.25
b. Stride length (distance between each step). 0.25
c. Phases of the gait. 0.25
(0.75)
9. Measures arm length from acromion process to the tip 0.25
of the middle finger.
10. Measures leg length from the anterior superior iliac 0.25
crest to the medial malleolus.
11. Measures circumference of arms, and thighs 1
12. Inspects symmetry and shape of muscles and joints. 1
13. Assesses joints for swelling, heat, redness, stiffness, 0.5
tenderness, limitation of movement, deformity, and
notes surgical scars.
14. Tests active ROM by asking client to move each of 1
the following joints: temporomandibular, neck, thoracic
and lumbar spine; shoulder, upper arm and elbow; wrist,
hands, and fingers; hip, knee, ankles, and feet.
a. Temporomandibular. Able to open and close, move 0.25
side-to-side.
b. Neck Flexes, extends, hyperextends, bends laterally, 0.25
and rotates side-to-side.
c. Thoracic and lumbar spine. Able to bend at the waist, 0.25
stand upright, hyperextend (bend backward), bend
laterally, and rotate side-to-side.
d. Shoulder. Able to move the arm circumduction, 0.25
abduct, adduct, and rotate, internally and externally.
e. Upper arm and elbow. Able to bend, extend, supinate, 0.25
and pronate the elbow.
f. Wrist Flexes, extends, hyperextends, and moves side- 0.25
to-side.

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g. Hands and fingers. Able to spread the fingers 0.25
(abduct), bring them together (adduct), make a fist
(flex), extend the hand (extend), bend fingers back
(hyperextend), and bring thumb to index finger
(opposition and reposition).
h. Hip. Able to extend the leg straight, flex the knee to 0.25
the chest, abduct and adduct the leg, rotate the hip
internally and externally and hyperextend the leg.
i. Knee. Able to flex and extend the knee. 0.25
j. Ankles and feet. Able to dorsiflex, plantar flex, evert, 0.25
invert, abduct, and adduct the feet and ankles.
16. Assesses muscle strength by having the client 0.5
perform ROM against resistance.
17. Grading Muscle Strength: 1
0: 0% of normal strength; complete paralysis
1: 10% of normal strength; no movement, contraction of
muscle is palpable or visible
2: 25% of normal strength; full muscle movement
against gravity, with support
3: 50% of normal strength; normal movement against
gravity
4: 75% of normal strength; normal full movement
against gravity and against minimal resistance
5: 100% of normal strength; normal full movement
against gravity and against full resistance

Total marks /10

Instructor's signature: Student's signature:

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 Physical examination- Nur 120204
Neurological examination checklist

Student's name: Date:

Task Score Yes No Remarks

This student correctly use inspection and palpation for examining the following:
1. Mental status:
• Consciousness/alertness (using GCS): 0.5
▪ Eye opening 0.5
▪ Motor response 0.5
▪ Verbal response (1.5)
2. Cranial nerves
• I 0.25
• II 0.25
• III,IV,VI 0.25
• V 0.25
• VII 0.25
• VIII 0.25
• IX,X 0. 5
• XI 0.25
0.25
• XII
(2. 5)
3. Motor function (muscle strength, size, fine motor
1
movement)
1. Sensory function
• Light touch identification 0. 5
• Sharp, dull identification 0. 5
• Kinesthesia 0. 5
(1.5)
2. Cerebellar function:
• Heel-Toe walking (tandem walk): 0.5
• Finger to nose test 0.5
• Romberg‟s test for balance 0.5
• Observation of rapid alternating action 0.5
movements.
• Finger-thumb test 0.5
(2.5)
3. Reflexes :
• Planter(Babinski) 1
Total marks /10
Instructor's signature: Student's signature:

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 Physical examination- Nur 120204
Head- to toe Examination
Student's Name: Date:
Task Score Yes No Remarks
Head and Neck:
• Scalp and hair 1
• Ear 1/2
o Rinne test 1
o Weber test 1
• Nose 1/2
• Eye (No fundoscopic examination) 1/2
• Extra ocular movement 1
• Direct pupil response 1/2
• Mouth 1
• Temporomandibular joint 1
• Lymph nodes 1
(9)
Thorax:
• Inspection 1
• Palpation 1
• Auscultation 1
o Bronchophony (“99”) 1
o Egophony (“ee”) 1
o Whispered petriloquy (“1 2 3”) 1
• Percussion 1
o Diaphragmatic excursion 1
o Correct landmarks 1
• Breasts 1
(10)
Cardiovascular System:
• Anatomical landmarks 1
• Auscultation 1
• Carotid arteries 1
o Jugular veins 1
• Peripheral pulses 1
• Allen test 1
(6)
Skin and Nails:
• Skin 1
• Nails:
o Color 1/2
o Shape 1/2
(2)
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Abdomen:
• Inspection 1
• Auscultation
o Bowel sounds 1/2
o Vascular sounds 1/2
• Percussion 1
• Light palpation 1/2
• Deep palpation 1/2
• Liver span 1
(5)
Musculoskeletal:
• Inspection 1
• Palpation 1
• Passive range of movement 1
(3)
Neurological:
• Level of consciousness:
o Appearance 1
o Thought process and 1
perceptions 1
o Cognitive abilities 1
• Deep tendon reflexes 1
• General sequence (5)
Total Marks /40
Instructor's signature: Student's signature:

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 Physical examination- Nur 120204
Head-to-Toe Assessment Sheet

Student’s Name:
Date of Submission:
Total Grade:
1. Biographic Data

a) Name
b) Age
c) Gender
d) Marital Status
e) Occupation
2. Present Illness

a) Main reason for seeking care now

b) Symptoms analysis

Symptom Analysis
P Provocate/Palliative:
Q Quality/Quantity:
R Region/Radiation:
S Severity Scale:
T Timing:

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 Health Assessment
I- General Survey
a) Physical Appearance
❖ Age
❖ Sex
❖ Level of consciousness
❖ Skin color
❖ Facial features
b) Body Structure
❖ Stature.
❖ Nutrition
❖ Symmetry
❖ Posture
❖ Position
❖ Body build, contour
c) Mobility
❖ Gait
❖ Range of motion
d) Behavior
❖ Facial expression
❖ Mood and affect
❖ Speech
❖ Dress
❖ Personal hygiene
e) Measurement
❖ Wight Height BMI
❖ Vital Signs: Pulse Temp BP Resp
Documentation (SOAP)
…………………………………………………………………………………………
…………………………………………………………………………………………
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II- Review of Systems & Physical Examination
1. HEENT
A- Subjective Data
Headache

Head injury

Dizziness

Neck pain

Lumps or swelling
History of head or neck surgeries _

Vision Changes:

Use Glasses:
Blurred Vision:

Hearing changes:

Ear problems:

Balance:
Ear discharge

Tinnitus

Vertigo

Pain Mouth or Tongue:

Nose Bleeding:

Changes in Smelling or Taste:

Sore Throat:

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B- Objective Data (Assessment Techniques)
Items of Physical Examinations Techniques Findings
Skull size , shape, symmetry
Hair &scalp
Auscultate for carotid bruit
Clenched jaws, puff cheeks,
Palpate TMJ
Use cotton swab for facial sensations
Palpate sinuses
Inspect and palpate teeth and gums
Test rise of uvula
Test gag reflex
Test sense of smell and taste
Inspect ROM neck
Shrug shoulders
Palpate all cervical lymph nodes
Palpate trachea for symmetry, palpate
thyroid gland
Conjunctiva
Corneal light reflex,
Use ophthalmoscope and otoscope
Near vision test
Confrontation test
Diagnostic position test
Ear drainage, color
Mouth
Weber and Rinne test
C- Documentation (SOAP)
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
…………………………………………………………………………...………….

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 2. Upper extremities
A- Subjective Data
Pain Skin changes
Swelling Changes in nails
B- Objective Data (Assessment Techniques)
Items of Physical Examinations Techniques Findings
Inspect skin
Blanche fingernails
Palpate peripheral pulses
Muscle strength
Assess ROM
Phalen's sign
Tinel's test
Allen test
Epitrochlear lymph nodes
Reflexes
Biceps
Triceps
Brachioradialis
6p's of circulatory check
Pain
Pallor
Pulslessness
Paresthesia
Poikilothermia
Paralysis

C- Documentation (SOAP)
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………

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 3. Posterior thorax

A- Subjective Data
Pain Stiffness
Swelling Trauma
B- Objective Data (Assessment Techniques)
Items of Physical Examinations Techniques Findings
Inspect spine for alignment
Identify respiratory land marks
Assess anteroposterior to lateral diameter
Assess thoracic expansion
Palpate tactile fremitus
Thoracic expansion
Percuss lung field
Diaphragmatic excursion
Auscultate breath sounds

C- Documentation (SOAP)
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………

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4. Anterior Thorax ( heart, lung and breast &lymph nodes)
A- Subjective Data
Breathing Changes:

− Dyspnea:

− Orthopnea:

− Chest Pain:

− Cough:

− Sputum: Color

− Fatigue:

− Smoking history :

− Nipple discharge breast pain, swelling:

− BSE:

B- Objective Data (Assessment Techniques)

Items of Physical Examinations Techniques Findings
Observe respirations. Pattern
auscultate breath sounds
Identify and inspect cardiac land marks
Palpate apical pulse
Palpate pericardium
auscultate heart sounds
Listen for murmur
inspect jugular veins
Measure CVP
Auscultate carotid
Inspect general breast app
Palpate breast
Palpate breast and axillaries lymph nodes
C- Documentation (SOAP)
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
…………………………………………………………………………………………
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 5. Abdomen

A- Subjective Data
Appetite:
Dysphagia:
Food intolerance:
Abdominal pain:
Nausea\ vomiting:
Bowel habits:
Nutritional assessment:
B- Objective Data (Assessment Techniques)
Items of Physical Examinations Techniques Findings
Auscultate for bowel sounds
Inspect
light and deep palpation
percuss for masses and tenderness
percuss the liver
blunt percussion over CVA (posterior thorax)
for tenderness
Percuss spleen
Special tests
• Murphy‟s sign
• Rebound tenderness
• Iliopsoas muscle test

C- Documentation (SOAP)
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
…………………………………………………………………………...…………

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 6. Lower Extremities

A- Subjective Data
Leg pain or cramp:
Skin changes:
Swelling:
B- Objective Data (Assessment Techniques)
Items of Physical Examinations Techniques Findings
Inspect skin
palpate peripheral pulses
Palpate inguinal lymph nodes
assess for Homan‟s sign
inspect and palpate joints for swelling
assess ROM
Bulge signs
Ballottement of the patella
6p's of circulatory check
Pain
Pallor
Pulslessness
Paresthesia
Poikilothermia
Paralysis
Color change test
assess for pedal and ankle edema
Reflexes
Quadriceps
Achilles

C- Documentation (SOAP)
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
…………………………………………………………………………...…………

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 7. Neurological
A- Subjective Data
Tremors
Seizures
In-coordination
Numbness or tingling
B- Objective Data (Assessment Techniques)
Items of Physical Examinations Techniques Findings
inspect gait and balance
assess recent and remote memory
Romberg test
Coordination and skilled movement
• Rapid alternating movement
• Finger to finger test
• Finger to nose test
• Heal to chin test
Sensory test
• Pain
• Temperature
• Light touch
• Vibration
• Kinesthesia
• Tactile discrimination
• Stereognosis
• Graphesthesia
• Extinction
• Point location
test the Babinski reflex

C- Documentation (SOAP)
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
…………………………………………………………………………...………
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 CASE STUDY
Patient Assessment Guide

Patient‟s Name:..........................................Age:..............Sex: F □ M□
Religion:............................Nationality:...................Education:....................
Occupation:...................................Place ofresidence:.................................
Marital status: M□ S □ W□ D□
Date ofadmission:........................................................................................
Current ambulatory condition: Ambulating □ Stretch□ Wheelchair □
Medical Diagnosis:.......................................................................................
Reason of admission:.....................................................................................................
.........................................................................................................................................
......................................................................................................................................
History of current illness:.....................................................................................
.........................................................................................................................................
......................................................................................................................................
Past medical history:.....................................................................................................
........................................................................................................................................
Past surgicalhistory....................................................................................................
....................................................................................................................................
Allergies: Food □ Drugs □ Others:..............................
General Appearance:
Eyes:
- Vision: Clear□ Dam □ Blurred □ Double vision □
- Sclera: Clear □ Yellow □
- Discharge (characteristic if present): Yes □ No □
- Use of aids: Yes □ No □
- Other complains:.................................................................................
Mouth:
- Mucous membranes: Moist □ Dry □

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 - Teeth: Number:....... Color:.............Surface characteristics:............
- Use of dentures: Yes □ No □
Hearing:
- Ability:
- Discharge (characteristic if present): Yes □ No □
- Use of aids: Yes □ No □
Cardiovascular:
- Apical pulse:........................................................................................
- Peripheral pulses palpable: Yes □ No □
- B.P.: Sitting:......................Supine:....................Standing:...................
- Edema yes □ No □ location:……………………….
- Types of edema: pitting □ Non-pitting □
- Face color: pink □ pale □ cyanotic □
Others (describe) :……………………………………..
- Face skin: warm □ cool □ dry □ moist □
- Extremities: warm □ cool □ color (describe): ………
Oxygenation:
- Respiration: Shallow □ Deep □ Regular □ Irregular □
- Cough: Dry □ Productive □
- Sputum: Color......................................Odor................................
- Any breathing difficulties: yes □ ( ) □ No
- Respiratory Aids: yes □ ( ) □ No
- History of smoking: No□ yes/ No. of years ....... No. of cigarettes /
day:..........
- Chest sound: clear □ Abnormal (describe) □
Skin integrity:
- Color: Normal □ Pale □ Cyanosis □ Jaundice □
- Intact: Yes □ No □
- Temperature (touch): Warm □ Cold □ Hot □
- Moisture: Moist □ Dry □
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 - Describe alteration of skin integrity if present: Smooth without lesions □
Rashes □ Bruises □ Petechia □ Ecchymosis □
Arching □ Abrasion □ Edema □ Wound □
Surgical incision/scar □ Bed sores □
Nutrition:
- Weight: ...........................Height:.................... BMI.............
- Eating patterns:..........................................................................
- No. of daily meals: ................... ................... ................... ........
- Special diet (types ifpresent):...................................................
- Food preference / intolerance:...................................................
- Food allergies: Yes □ No □
- Caffeine intake: Yes □ No □
- Any problems or discomforts associated with eating:…………………
- Any changes with normal eating pattern : Appetite changes □
NGT □ TPN □ Ostomies □
Bowel elimination:
- Usual time:......................................... - Frequency/day:................................
- Color:................................- Consistency:.......................................................
- Any bowel regulating aids: Laxatives □ Suppositories □ enemas □
- Any problems associated with bowel elimination :…………………..................
- Intestinal sound:..................................................................................
- Describe alteration of bowel elimination during hospitalization (if any):
.....................................................................................................................
Bladder elimination:
- Usual frequency / day:....................................................................
- Any problems associated with bladder elimination:………………………….
- Assistant devices: Catheters □ Drains □ Ostomies □ Diversions □
- Describe alteration of bladder elimination during hospitalization (if any):
..............................................................................................

30
Cerebral:
- Level of consciousness:………………………………………………
- Pupils: Reactive □ Round □ Regular □
- Eye opening:......................................................................................
- Best verbalresponse:...........................................................................
- Best motorresponse:...........................................................................
- Oriented to : Time □ Place □ Persons □
- Memory: Intact □ Recent □ Remote only □
Safety:
- Risk for fall: Yes □ No □
- Specify contributing factors:..............................................................
- Use of safety devices: Side rails □ Restrains □
Activity:
- Exercise habits:...............................................................................................
- History of physicaldisability:.........................................................................
- Limitation in ambulation:...............................................................................
- Pattern: Dependent □ Independent □ Need assistant □
- Use of assistants device: Cane □ Crutches □ Walker □
- Verbal report of fatigue /weakness: Yes □ No □
Self-care "activities of daily livings":
Patient‟s ability for:
- Feeding: Dependent □ With Assistant □ Independent □
- Bathing: Dependent □ With Assistant □ Independent □
- Toileting: Dependent □ With Assistant □ Independent □
- Dressing: Dependent □ With Assistant □ Independent □
Comfort:
Sleep:
- Hours of sleep / night:.......................- Hours of day naps:..............................
- Sleeping aids (specify):...................................................................................
- Factors contributing to sleep alteration during hospitalization (if any):
.....................................................................................................
31
Pain:
- Onset:...........................................................Duration: ................................... ..-
Location:.......................................................
- Frequency: …………………………………
- Severity: mild □ moderate □ sever □
- Radiation:.....................................................................
- Quality: Stabbing □ Aching □ Burning □
Bricking □ Throbbing □ others………………..
- Alleviating / aggravating factors:.....................................................................
Communication:
- Ability to : Read □ Write □ Understand the language □
- Barriers of communication : verbal □ non-verbal □
- Describe:.........................................................................................
Support systems:
- Who lives with patient:(specify)……………………………………………….
- The main financial supporter in the family: :(specify)…………………………
- Financial (income): Enough □ Not enough □

Emotional status:
- Recent stressful life events:.................................................................
- Fear □ Anxiety □ Grieving □
- Physical manifestation:........................................................................

32
 Physical examination- Nur 120204
Health assessment checklist for Elderly client
Environmental assessment:
Room Condition:
Cleanliness:
Dust : yes ( ) No: ( )
Wastes: yes ( ) No: ( )
Insects: yes ( ) No: ( )
Ventilation: Suitable yes ( ) No: ( )
Lighting: Suitable yes ( ) No: ( )
Furniture: Arranged yes ( ) No: ( )
Assisting Facilities:
Side rails yes ( ) No: ( )
Near side phone: yes ( ) No: ( )
Near side light: yes ( ) No: ( )
Near side ring: yes ( ) No: ( )
Floor:
Slippery: yes ( ) No: ( )
Stairs:
Steps: yes ( ) No: ( )
Elevator: yes ( ) No: ( )
Bathroom:
Toilets: Suitable: yes ( ) No: ( )
Client's assessment:
Visual Impairment:
Burning Eyes: yes ( ) No: ( )
Discharge: yes ( ) No: ( )
Use of glasses: yes ( ) No: ( )
Itching: yes ( ) No: ( )
Glaucoma: yes ( ) No: ( )

33
 Cataract: yes ( ) No: ( )
Ears:
Discharge: yes ( ) No: ( )
Hearing impairment: yes ( ) No: ( )
Use of hearing aid: yes ( ) No: ( )
Mouth & throat:
Dentures: yes ( ) No: ( )
Dry mouth: yes ( ) No: ( )
Bleeding gum: yes ( ) No: ( )
Tooth decay: yes ( ) No: ( )
Loss of teeth: yes ( ) No: ( )
Ability to swallow: yes ( ) No: ( )
Mouth infection: yes ( ) No: ( )
Integumentary:
Dryness: yes ( ) No: ( )
Lesions: yes ( ) No: ( )
Itching: yes ( ) No: ( )
Bleeding: yes ( ) No: ( )
Bruises: yes ( ) No: ( )
Hair loss: yes ( ) No: ( )
Thickened nails: yes ( ) No: ( )
Thinning: yes ( ) No: ( )
Sores: yes ( ) No: ( )
Respiration:
Rate: -----------------
Shortness of breath: yes ( ) No: ( )
Cough: yes ( ) No: ( )
Frequent cold: yes ( ) No: ( )
Asthma: yes ( ) No: ( )

34
Cardiovascular:
Pulse Rate: -----------------
Palpitation: yes ( ) No: ( )
Fatigue: yes ( ) No: ( )
Chest pain: yes ( ) No: ( )
Edema: yes ( ) No: ( )
Hypertension: yes ( ) No: ( )
Orthostatic hypotension: yes ( ) No: ( )
Varicosities: yes ( ) No: ( )
Gastrointestinal:
Constipation: yes ( ) No: ( )
Heartburn: yes ( ) No: ( )
Incontinence: yes ( ) No: ( )
Rectal bleeding: yes ( ) No: ( )
Dysphasia: yes ( ) No: ( )
Abdominal pain: yes ( ) No: ( )
Weight loss: yes ( ) No: ( )
Impaired ability to chew: yes ( ) No: ( )
Musculoskeletal:
Joint swelling: yes ( ) No: ( )
Pain: yes ( ) No: ( )
Tremor: yes ( ) No: ( )
Kyphosis: yes ( ) No: ( )
History of fracture: yes ( ) No: ( )
Muscle weakness: yes ( ) No: ( )
Use of cane of devices: yes ( ) No: ( )
Neurological:
Numbness: yes ( ) No: ( )
Diminished sense of smell: yes ( ) No: ( )
Diminished sense of touch: yes ( ) No: ( )
35
 Diminished sense of touch: yes ( ) No: ( )
Urinary:
Frequency: yes ( ) No: ( )
Incontinence: yes ( ) No: ( )
Urgency: yes ( ) No: ( )
Nocturia: yes ( ) No: ( )
Urinary retention: yes ( ) No: ( )
Reproductive:
Onset of menopause: yes ( ) No: ( )
Breast self examination: yes ( ) No: ( )
Vaginal discharge: yes ( ) No: ( )
Psychological assessment:
Feels lonely: yes ( ) No: ( ) Evidence:

Confusion: yes ( ) No: ( ) Evidence:

Forgetfulness: yes ( ) No: ( ) Evidence:

Depression: yes ( ) No: ( )

Evidence:
Dementia: yes ( ) No: ( )
Evidence:
Anxiety: yes ( ) No: ( )
Evidence:
Always live in the past: yes ( ) No: ( )
Evidence:
Adjust to social life: yes ( ) No: ( )
Evidence:

36
Daily Living Activities:
Sleeping: Normal: Disrupted:
Number of hours: Naps:
Nutrition: Normal: Special:
Bathing: Frequency:
Dressing:
Combing Done: Not done:
Exercise: Done: Not done:
Drinking tea: yes ( ) No: ( )
Numbers of cup/day:
Drinking coffee: yes ( ) No: ( )
Numbers of cup/day:
Entertainment:
T.V Present: not present:
Garden: Present: not present:
Planned Program rituals and social activities:
Present: not present:
Newspaper and magazines:
Present: not present
Emergency Services:
Present Complaints:
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------
Chronic Illness:
Hypertension: yes ( ) No: ( )
Diabetes: yes ( ) No: ( )
Heart diseases: yes ( ) No: ( )
Kidney disease: yes ( ) No: ( )
Asthma: yes ( ) No: ( )
37
 Liver Diseases: yes ( ) No: ( )
Cancer: yes ( ) No: ( )
Psychiatric illness: yes ( ) No: ( )
Medication:
1- ------------------------------------------------------------------------------------------
2- ------------------------------------------------------------------------------------------
3- ------------------------------------------------------------------------------------------
4- ------------------------------------------------------------------------------------------
5- ------------------------------------------------------------------------------------------

Student's name: Student's signature:

Instructor's name: Instructor's signature:

38
 Physical examination- Nur 120204

Mini Lab Case Scenario (Quiz I)

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 Physical examination- Nur 120204

Mini Lab Case Scenario (Quiz II)

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