RESPIRATORY SYSTEM ASSESSMENT
NAME
AGE
GENDER
RELIGION
MARITAL STATUS
EDUCATION
OCCUPTION
ADDRESS
HOSPITAL NO
WARD
UNIT
BED.NO
DIAGNOSIS
CONSULTANT DOCTOR NAME
DATE OF ADMISSION
DATE OF DISCHARGE
CHIEF COMPLAINT
1.
2.
3.
4.
5.
HISTORY OF PRESENT ILLNESS
1.ONSET
SUDDEN .. GRADUAL .
DURATION ; DAYS WEEKS ..MONTHS ..YEARS ..............
FREQUENCY ;INTERMITTENT CONTINUOUS .
2.DYSPNEA
ONSET ;SUDDEN .GRADUAL..
TYPE ;ACUTE ..CHRONICPROGRESSIVE
RECURRENT ;..
AGGRAVATING FACTORS ;WALKING.. EXERCISE ..OTHERS .
CLIMBING STAITRS
ASSOCIATED FACTORS ;COUGH.PALPITATION.OTHERS.
RELIEVIBG FACTORS ;SITTING..USING PILLOWS .REST..
3.COUGH
ONSET ; SUDDEN ..GRADUAL ..
TYPE OF COUGH ;DRY COUGH..PRODUVTIVE ..
IF PRODUCTIVE
SPUTUM CHARACTER ;WATERY.THIN MUCUS STRINGY.
TENACIOUS .. FROTHY .THICK .
ODOR ;PRESENT .ABSENT..
COLOR;WHITE .GREEN RUSTY.YELLOW
BLOODY..
TIME OF COUGH ;
EARLY MORNING LATE AFTERNOON
NIGHT TIME.
4. HEMOPTYSIS
ONSET ;SUDDEN GRADUAL ..
FREQUENCY ;INTERMITTEENT CONTINUOUS ..
SOURCE OF BLOOD ;LUNGS..NOSE.. STOMACH .
COLOUR ;BRIGHT RED DARK RED..BROWN.
AMOUNT ;TEASPOON TABLESPOONCUP..
5.WHEEZING
PRESENTABSENT.
CHEST TIGHTNESS; PRESENT.ABSENT .
STRIDOR;PRESENT . ABSENT..
CHANGE IN VOICE CHARACTER; PRESENT .. ABSENT.
6. CHEST PAIN
ONSET ;SUDDEN .GRADUAL.
LOCATION; RIGHT SIDE.. LEFT SIDE
TYPE ; DULL ..HEAVY PRESSURE.BURNING
CRUSHING CONSTRUITING .. SQUEEZING
TIGHTNESS
DURATION; DAYS.. WEEKS.. MONTHS.
YEARS..
FREQUENCY; INTERMITTENT CONTINUOUS..
INTENSITY; MILD. MODERATE .. SEVERE .
LOCATION ;RIGHT SIDE LEFT SIDE
RADIATING; SHOULDER. NECK. ARM
BACK
AGGRAVATING FACTORS; ACTIVITY COUGHING ..
STRAINING..
PAST MEDICAL HISTORY ;
PREVIOUS HEALTH STATUS ; HEALTHY YES NO
IF NO SPECIFY THE REASON
PREVIOUS HOSPITALIZATION; NO YES ..
IF YES SPECIFY REASON
TREATMENT ;REGULAR IRREGULAR.
OUT COME ..
HISTORY OF SURGERIES; YES NO..
IF YES SPECIFY
TYPE OF SURGERY
INDICATION..
RECOVERY .
FOLLOW UP
IMMUNIZATION ;IMMUNIZED . NOT IMMUNIZED.
HISTORY OF ADULT HOOD DISEASES; YES.. NO ..
IF YES SPECIFY
TYPE OF SURGERY
INDICATION ..
RECOVERY ..
FOLLOW UP ..
HISTORY OF TRAUMATIC INJURIES ; YES . NO
IF YES SPECIFY TREATMENT TAKEN
.
HISTORY OF ALLERGY; PRESENT ABSENT ..
IF PRESENT SPECIFY --- TYPE OF ALLERGY ..
DUST . POLLEN . FUR ..
OCCUPATIONAL ALLERGY ..
TREATMENT TAKEN ------- YES . NO
DRUGS
DURATION
MENSTRUAL HISTORY ;
AGE AT MENARCHE
CYCLE ; REGULAR IRREGULAR
FREQUENCY;
DURATION ;1-3 DAYS.35 DAYS.57 DAYS
MORE THAN 7 DAYS.
AMOUNT;
FAMILY HISTORY;
MARITAL STATUS;
MARRIED.UNMARRIED.WIDOW
SINGLE.DIVORCED.
CONSANGUINEOUS MARRIAGE ; YESNO.
TYPE OF FAMILY ;NUCLEAR.JOINT
POSITION IN THE FAMILY..
NUMBER OF ADULTS.
NUMBER OF CHILDREN
HISTORY OF FAMILIAL ILLNESS; DIABETES
MELLITUS.HYPERTENSION
HEART DISEASESEPILEPSY.
ASTHMAANY OTHER ILLNESS..
ANY RECENT DEATH OCCURRED; YES..NO..
IF YES CAUSES
FAMILY TREE;
SOCIOECONOMIC HISTORY;
HOUSING; KUTCHAPUCCA.
LIGHTING; ADEQUATE..INADEQUATE
VENTILATION; ADEQUATEINADEQUATE..
DRAINAGE; OPENCLOSE..
OCCUPATIONAL HISTORY;
TYPE OF INCOME; DAILY WAGEWEEKLY WAGE.
MONTHLY WAGE..YEARLY
TYPES OF WORK;
SEDENTARY.MODERATE
HEAVY WORK RETIRED..
PERSONAL HISTORY;
BRUSHING; NO.OF TIMESTYPES OF DENTRIFICE
BATH; DAILYNO OF TIMES/DAYS..\
BOWEL MOVEMENTS; REGULAR.IRREGULAR.
IF IRREGULAR SPECIFY THE CAUSE
BLADDER FUNCTION.
MICTURITION ;FREE ..STRAINFUL.STRESS.
Incontinence.dribbling.
If retention specify
SLEEP;
USUAL BEDTIME.TIME OF AWAKENING
USE OF DRUGS ;. YES. NO..
IF YES SPECIFT THE REASON ..
ACTIVITIES OF DAILY LIVING; DEPENDENT IN DEPENDENT
DIETARY HISTORY; VEGETARIAN .. NON VEGETARIAN.
COFFEE; YES. NO
IF YES NO OF TIMES / DAY . AMOUNT ;
SMOKING; YES NO
IF YES NO OF CIGRATEES PERT DAY . FREQUENCY .. OCCATIONALLY
SOMETIMES..
PAN CHEWING; YES NO..
IF YES NO OF PACKETS PER DAY
FREQUENCY .. OCCATIONALLY .
SOMETIMES VERY OFTEN.
PHYSICAL EXAMINATION
GENERAL APPEARANCE
NOURISHMENT ; WELL NOURISHED . UNDER NOURISHED
.
BODY
BULIT ; MODERATE . THIN . OBESE .
ACTIVITY ; ACTIVE . DULL .. RESTLESS ..
PERSONAL HYGIENE; ABLE TO DO SELF NEEDS ASSISTANCE
.. DEPENDENT .
1. MENTAL STATUS;
CONSCIOUSNSS. UN CONSCIOUSNESS ..
.. DELIRIOUS STUPOR
COMA..
2. SPEECH ; CLEAR .. SLURRED . FLUENT
MURMURING . COHERENT .
3.ORIENTATION TO ; TIME .. PLACE ..PERSON
....
4. MOOD ; LOOKS RELAXED . TENSED ANGER.
AGITATED IRRITATED..
5. ATTITUDE ; COPERATIVE . NEGATIVE..
HOSTILE. POSTURE ; RELAXED ERECT
POSTURE.. CORDINATED MOVEMENTS .. UNCORDINATED
MOVEMENTS BENT POSTURE . BODY CURVES
. NORMAL LODOSIS . KYPHOSIS
SCOLISIS
MOVEMENTS ; NORMAL .. ANY LIMP
VITAL SIGNS ;
TEMPERATURE
PULSE RATE RHYTHM . VOLUME
RESPIRATION ; RATE RHYTHM DEPTH
BLOOD PRESSURE;
HEIGHT AND WEIGHT ;
HEIGHT . Cm/ FEET .
WEIGHTS Kg /POUNDS .
HEAD TO FOOT EXAMINATION
SKIN ;
COLOUR ; NORMAL .. PALLOR .. ICTERUS . CYANOSIS
.. ERYTHEMA..
TEXTURE ; NORMAL DRY FLAKY
WRINKLED.. EXCESSIVE MOISTURE
TEMPERTURE ; NORMAL COLD AND CLAMMY .. FEBRILE
..
TURGOR ; NORMAL . TENTED .
LESIONS ;
MACULES ; ABSENT . PRESENT ..
PAPULES ; ABSENT . PRESENT..
VESICLES ; ABSENT .. PRESENT
WOUNDS ; ABSENT PRESENT
EDEMA ;ABSENT PRESENT ..
HEAD;
SKULL ;SYMMETRY .. ASYMMETRY
SCALP ; CLEAN . DIRTY DANDRUFF .
PEDICULI. NITS .
HAIR
COLOUR ; BLACK BROWN . GREY
TEXTURE ; THICK .. THIN SILKY
DISTRIBUTION ; EVEN . UNEVEN . ALOPECIA .
FACE ;
SHAPE ; SYMMETRY .. ASYMMETRY
MOON FACE . PUFFINESS
FACIAL HAIR ; ABSENT PRESENT .
COLOUR ; NORMAL .. PALLOR .. ICETERUS
CYANOSIS .. FLUSHED..
EYES
SHAPE ; SYMMETRY ASYMMETRY.
EYEBROWS; NORMAL EQUAL ALIGNMENT .. UNEQUAL
ALIGNMENT .
EYE LASHES ; NORMAL TURNED INWARD..
EYELIDS ; NORMAL REDNESS SWELLING .
CRUSTING.. DISCHARGE STY
CONJUNCTIVA ; NORMAL .. RED
PALE.. PURULENT..
SCLERA ; NORMAL JAUNDICED.
PUPILS ; REACTING TO LIGHT . DILATED. CONSTRICTED..
LENS ; NORMAL . OPAQUE
VISION ; NORMAL . MYOPIA.. HYPEROPIA .
EARS ;
EXTERNAL EARS;
DISCHARGES ; ABSENT PRESENT
CERUMEN ODSTRUCTING ; ABSENT . PRESENT .
TYMPANIC MEMBRANE ; NORMAL LESIONS
HEARING ; NORMAL DIFFICULTY
NOSE
SHAPE ; SYMMETRY ASYMMETRY .
LESIONS ; NONE . YES .
POPLYS ; NONE .. YES ..
COLOUR ; NORMAL . PALE .. FLARING .. CYANOSED
SEWELLING ; NONE . YES .
DISCHARGE ; ABSENT .. EXUDATES.. BLEDDING ..
SPUTUM ; INTACT .. DEVIATED . PERFORATED..
SINUSES
FRONTAL SINUS ; NORMAL . TENDER ..
MAXILLARY SINUS ; NORMAL .. TENDER
MOUTH
LIPS AND BUCCAL MUCOSA ; NORMAL .. PALLOR .
ULCERATED . CRACKED . BLEDDING ..
ANGULAR STOMATITIS.
MOIST . DRY ..
TEETH ; 32 ADULT TEETH MISSING TEETH .. DISCOLORATION
GUMS ; NORMAL GINGIVITIS .. GUM BLEEDING
TONGUE ; NORMAL PALE .. ULCERATED.
COATED. CYANOSED .
UVULA ; NORMAL . DISCOLORED .. SWOLLEN
NECK ;
MOVEMENT ; NORMAL . TREMOR.. STIFFNESS..
LYMPH NODES ; NORMAL . ENLARGED .
THYROID GLAND ; NORMAL . ENLARGED ..
TRACHEA ; MIDLINE DEVIATED .
CHEST
SIZE ; SYMMETRY . ASYMMETRY
SHAPE ; NORMAL .. BARREL CHEST . PIGEON CHEST
. FUNNEL CHEST . KYPHOSCOLIOSIS
BREATHING MOVEMENT ; NORMAL .. USE OF ACCESSORY MUSCLES
.. INTERCOASTAL RETRACTIONS . SUBSTERNAL RETRACTION
...................
POSITION OF COMFORT ; SUPINE . LATERAL ..
ORTHOPNEIC.. TRIPOD . PARADOXICAL MOVEMENT ..
RESPIRATION ;EUPNOCEA . BRADYPNEA
TACHYPNEA. HYPERNOEA APNEA.
TENDERNESS ; NONE YES
MASSESS ; NONE .. YES.
LESIONS ; NONE YES
BREAST ; SYMMETRY ASYMMETRY .
TENDERNESS MASS. DISCHARGE.
RESPIRATORY EXCURSION
ANTERIOR CHEST ; SYMMETRY .. ASYMMETRY .
if asymmetry description ,
POSTERIOR CHEST ;SYMMETRY .. ASYMMETRY .
If asymmetry description,
TACTILE FREMITUS
VIBRATION ; NORMAL . ABSENT INCREASED
.. DECREASED
BILATERAL SYMMETRY; PRESENT .. ABSENT ..
PRECUSSION SOUNDS
AREA
ANTERIOR
THORAX
RIGHT UPPER
LOBE
LEFT UPPER
LOBE
RIGHT
MIDDLELOBE
RIGH LOWER
LOBE
LEFT LOWER
LOBE
LATERAL
THORAX
RIGHT UPPER
LOBE
LEFT UPPER
LOBE
RIGHT MIDDLE
LOBE
RIGHT LOWER
LOBE
LEFT LOWER
LOBE
POSTERIOR
THORAX
RIGHT UPPER
LOBE
LEFT UPPER
LOBE
RESONANT
DULL
FLAT
HYPERRESONANT TYMPANY
RIGHT LOWER
LOBE
LEFT LOWER
LOBE
DIAPHRAGMATIC EXCURSION;..cm
BREATH SOUNDS
AREA
ANTERIOR
THORAX
RIGHT UPPER
LOBE
LEFT UPPER
LOBE
RIGHT MIDDLE
LOBE
RIGHT LOWER
LOBE
LEFT LOWER
LOBE
LATERAL
THORAX
RIGHT UPPER
LOBE
LEFT UPPER
LOBE
RIGHT MIDDLE
LOBE
RIGHT LOWER
LOBE
LEFT LOWER
LOBE
POSTERIOR
THORAX
RIGHT UPPER
LOBE
LEFT UPPER
CLEAR
WHEEZE
CRACKLES
RHONCI
PLEURAL
FRICTION RUB
LOBE
RIGHT LOWER
LOBE
LEFT LOWER
LOBE
VOICE SOUNDS
;NORMALBRONCHOPHONY.EGOPHONY
WHISPERED PECTORILOQUY
HEART SOUNDS;S1S2MURMURS..
GALLOP SOUNDS.
ABDOMEN
SIZE:SYMMETRY.ASYMMETRY..
SHAPE: NORMAL.DISTENDED.
COLOUR:NORMALDISCOLOURATION.SCARS
STRIAE..CULLENS SIGN .TURNER SIGN
BOWEL SOUNDS:NORMAL.INCREASED
DICREASED.ABSENT
LIVER:NORMALENLARGEDTENDERNESS
EXTREMITIES:
HANDS: SYMMETRY.ASYMMETRY
DEFORMITYTENDERNESS.SWELLING
TREMORSCONTRACTURES.
NAILS:
NORMALSPOONSHAPEDPARONYCHIA
CYANOSISEARLY CLUBBING.
.LATE CLUBBINGCAPILLARY REFILL TIME< 3sec.>3sec.
Legs: symmetry.ASYMMETRY.
BOW LEGS..TALIPES EQUINOVARUS..
TALIPES EQUINOVALGUSCONTRACTURES
HIP DISLOCATIONVARICOSE VENIS.
DIGNOSTIC INVESTIGATIONS
DATE
NAME OF THE TEST
PATIENT FINDINGS
NORMAL VALUES
NURSING DIAGNOSIS:
1.
2.
3.
4.
5.
6.
7.
.
..
.
