Student Name: __________________________
Client information
Client code:
Rm no: Age:
Date of admission:
Reason for admission:
Hx (health challenges):
T P R BP
baseline
T P R BP
Time:
T P R BP
Time:
Neurological Assessment Nutrition:
Diet:
Amount of Meals consumed %
B: L: S:
___________________________________
Intake & Output totals:
___________________________________
Elimination:
Cardiovascular Assessment Respiratory Assessment Musculoskeletal Assessment
Abdominal Assessment
Subjective Inquiry:
OPQRSTUV presenting problem:
______________________________________________
______________________________________________
appetite/dysphagia/food intolerance/abdominal
pain/nausea/vomiting/bowel habits/abdominal
hx/medications/nutritional assessment
Inquire about last BM (date) ____________________
Inspection:
Contour ________________________________
Symmetry ______________________________
Umbilicus ______________________________
Skin pigmentation & colour__________________
Pulsations/movement _____________________
Hair distribution _________________________
Demeanor ______________________________
Striae/scars (note location, description)
_______________________________________
Auscultation (note difference in sequence):
Bowel sounds ____________________________
How many BS should you hear / min? ________
How long do you listen to determine absence of
bowel sounds?) ________________________
Vascular sounds (using bell of stethoscope listen for
bruits in renal, aorta, iliac & femoral arteries)
__________________________________________
Percussion:
Genitourinary Assessment Integumentary Assessment
