Thanks to visit codestin.com
Credit goes to www.scribd.com

Scribd
Upload
981 views4 pages

Nursing Systems Review Chart

This document contains an assessment of multiple body systems including eyes, ears, nose, throat, respiratory, cardiovascular, gastrointestinal, genitourinary, neurological, musculoskeletal, skin, and coping mechanisms. Impairments were noted including impaired vision, hearing loss, reddened eyes, dental issues, respiratory distress, irregular heart rhythms, abdominal distention, urinary issues, unsteady gait, skin lesions, and pain. The patient's ability to manage their health and activities of daily living were also assessed.

Uploaded by

manilyn_cute888
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
981 views4 pages

Nursing Systems Review Chart

This document contains an assessment of multiple body systems including eyes, ears, nose, throat, respiratory, cardiovascular, gastrointestinal, genitourinary, neurological, musculoskeletal, skin, and coping mechanisms. Impairments were noted including impaired vision, hearing loss, reddened eyes, dental issues, respiratory distress, irregular heart rhythms, abdominal distention, urinary issues, unsteady gait, skin lesions, and pain. The patient's ability to manage their health and activities of daily living were also assessed.

Uploaded by

manilyn_cute888
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 4

EENT

_ Impaired Vision __Blind __Pain


__Reddened __Drainage __Gums
_ Hard of hearing __Edema __Lesions
__Teeth none
Comments:

Respiratory
__Asymmetric __tachypnea __apnea
__rales _cough __Barrel Chest __Shallow
__bronchi sputum __Diminished
__dyspnea __Orthopnea __labored
__wheezing __Pain __Cyanotic _/None
Comments:

Cardiovascular
__arrhythmia __tachycardia __Numbness
_Diminished pulses Edema __ Fatigue
__Irregular __bradycardia __murmur
__Tingling __Absent pulses __Pain
None
Comments:

Gastrointestinal Tract
__Obese __Distention __mass
__Dysphagia __rigid pain None
Comments:

Genitourinary
_Pain __Urine Color __Vaginal
__Bleeding __Hematuria __Discharge
__nocturia None
Comments:.

Neuro Musculoskeletal and Skin


__Paralysis __Stuporous Unsteady __appliance __Stiffness _Itching __petichiae
__Seizures Lethargic __comatose __ hot __Drainage __Prosthesis __Swelling
__vertigo __Tremors __Confused Vision __Lesions _Poor Turgor __Cool __Deformity
__Grip __None __wound __rash Skin color _Flushed
Comments __Atrophy __pain __ecchymosis _diaphoretic
__moist
Comments:

NURSING SYSTEMS REVIEW CHART


HEAD TO TOE ASSESSMENT
V. NURSING ASSESSMENT

SUBJECTIVE OBJECTIVE
COMMUNICATION ( ) glasses ( ) languages
( ) Hearing loss ( ) contact lenses ( ) hearing aide
( ) Visual changes ( ) speech difficulties
( ) Denied Pupil size:
Comments
Reaction:

Oxygenation: Respiration: ( /)regular ( )irregular


( ) Dyspnea Describe:
( ) Smoking History Right:
( ) Cough Left:
( ) Sputum
( ) Denied
Comments:

CIRCULATION Heart rhythm. ( /) regular ( ) irregular


( ) chest pain ( ) Ankle edema:
( ) leg pain Pulse: CAR. RAD. DP. FEM.
( ) numbness of extremities R:
( ) denied L:
Comments:
Comment:

NUTRITION ( ) Dentures ( ) none


Diet: Full partial with patient
Character: Upper:
( ) Recent change in weight, Appetite Lower:
( ) Swallowing difficulty
( ) Denied
Comments:
ELIMINATION Bowel sounds:
Usual bowel pattern ( ) yes
Urinary frequency: ( ) no
Date of last BM: Urine ( color, consistency, odor )
( ) diarrhea character:
( ) urgency ( ) incontinence
( ) dysuria ( ) polyuria Comments:
( ) hematuria ( ) Foley catheter in
in place
( ) denied

Comments:

MGT OF HEALTH & ILLNES Briefly describe the patient ability to follow
( ) alcohol ( amount, frequency ) treatment ( diet, meds, etc. ) for chronic health
problems ( if present )
( ) denied
( ) BSE
Last pap smear LMP:

SKIN INTEGRITY ( ) Dry ( ) cold ( /) pale


( ) Dry ( /) Flushed ( ) warm ( ) moist
( ) Itching ( ) cyanotic
( ) Other:
( ) Denied
Comments:

ACTIVITY / SLEEP ( ) LOC and orientation


( ) Convulsion
( ) Dizziness Gait: ( ) walker ( ) cane ( )other
( ) Limited motion of joints ( ) steady ( ) unsteady
( ) Limitation in ability to ( ) sensory & motor losses in face or other
( ) Ambulates extremities
( ) Bathe self ( ) ROM Limitation
( ) Other Comment:
( ) Denied
Comments:

COMPORT / SLEEP / AWAKE ( ) facial grimaces


( )Pain ( ) Guarding
( ) Location- right inguinal ( ) Other signs of pain:
Frequency- upon touch ( ) side rails release from signed ( 60+ years )
( )N/A
( ) Nocturnal
( ) Sleep difficulties
( ) Denied
Comments:

COPING
Occupation:
Members of household:
Most supportive person:

You might also like