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    Assessment by Body Systems

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    Pat McGarry
    The document provides an assessment of a patient's body systems by describing what should be examined for each system and what normal and abnormal findings may include. Key body systems addressed are neurologic, integumentary, cardiovascular, respiratory, gastrointestinal, genitourinary, and musculoskeletal. For each system, the assessment lists important physical exam components such as level of consciousness, motor response, pupil size and reaction, skin appearance and integrity, pulse rate and intensity, lung sounds, bowel sounds, urination characteristics, and range of motion. Mental and spiritual aspects are also noted as important to the overall psychosocial evaluation.

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    Assessment by Body Systems

    Uploaded by

    Pat McGarry
    61 views2 pages
    The document provides an assessment of a patient's body systems by describing what should be examined for each system and what normal and abnormal findings may include. Key body systems addressed are neurologic, integumentary, cardiovascular, respiratory, gastrointestinal, genitourinary, and musculoskeletal. For each system, the assessment lists important physical exam components such as level of consciousness, motor response, pupil size and reaction, skin appearance and integrity, pulse rate and intensity, lung sounds, bowel sounds, urination characteristics, and range of motion. Mental and spiritual aspects are also noted as important to the overall psychosocial evaluation.

    Original Description:

    Nursing assessment arranged by body system

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    The document provides an assessment of a patient's body systems by describing what should be examined for each system and what normal and abnormal findings may include. Key body systems addressed are neurologic, integumentary, cardiovascular, respiratory, gastrointestinal, genitourinary, and musculoskeletal. For each system, the assessment lists important physical exam components such as level of consciousness, motor response, pupil size and reaction, skin appearance and integrity, pulse rate and intensity, lung sounds, bowel sounds, urination characteristics, and range of motion. Mental and spiritual aspects are also noted as important to the overall psychosocial evaluation.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    61 views2 pages

    Assessment by Body Systems

    Uploaded by

    Pat McGarry
    The document provides an assessment of a patient's body systems by describing what should be examined for each system and what normal and abnormal findings may include. Key body systems addressed are neurologic, integumentary, cardiovascular, respiratory, gastrointestinal, genitourinary, and musculoskeletal. For each system, the assessment lists important physical exam components such as level of consciousness, motor response, pupil size and reaction, skin appearance and integrity, pulse rate and intensity, lung sounds, bowel sounds, urination characteristics, and range of motion. Mental and spiritual aspects are also noted as important to the overall psychosocial evaluation.

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    ASSESSMENT BY BODY SYSTEMS

    Neurologic
    LOC (level of consciousness)
    A/O X 3 (alert & orientated to name, time, & place)
    Verbal Response
    Clear
    Incoherent, ramblin, slurred, stuttering
    Dysphasia, aphasia
    Motor Response (<, = bilaterally, >)
    Grips (note strength)
    Obeys commands, localizes pain, withdrawal, flexion,
    extension, none.
    Assess Pupils
    Note shape
    Pupils equally round and react to light, and
    accommodate. (PERRLA)
    1 mm after surgery
    2-3 mm normal
    6-9 mm blown; if permanent, possible herniation
    Integumentary
    General Appearance
    Pale, flushed, cyanotic, discolored, freckled
    Moist, diaphoretic, clammy
    Hot, warm, cold
    Dry, scaly, oily
    Rash, abrasion, lacerations, incisions, broken, sores, lesions,
    scars, calloused, contusions.
    Tanned, glossy, tattoos
    Swollen, course or fine testure
    Turgor
    Normal loose tight tenting
    Integrity
    Intact - Impaired
    Mucous membranes
    Color - Condition
    Cardiovascular (normal pulse 60-100)
    Ap, B/P, Radial PP (present <, = bilaterally, >)
    Rate/rhythm
    Regular Irregular
    Strong
    Rapid
    Weak
    Absent
    Thready
    Intensity
    1,2 (hypo)
    3,4 (hyper or bounding)
    Doppler
    Skin
    pale, flushed, cyanotic, discolored, moist, cold,
    clammy
    Edema
    pitting nonpitting
    Capillary refill < 3 sec
    Homans sign + / -

    Respiratory (12-20 normal respirations)


    Breathing
    Dyspnea apnea deep/shallow
    SOB
    With which activities?
    Chest
    Excursion symmetrical/asymmetrical
    Lung Sounds (audible all lobes/bases)
    Rales crackles rhonchi wheezes
    Sputum
    Clear thin/thick tenacious note color
    Measure O2 Saturation
    Pulse Oximeter
    Gastrointestinal
    Abdomen
    Soft, firm, rigid, tender, sensitive to touch
    Enlarged, distended, flat, round
    Bowel sounds (listen all 4 quads 2 to 5 min)
    Normal, faint, hypo, absent, hyper
    BM size (sm, med, lg)
    N/V (nausea/vomiting) amount/color/frequency
    mL's, small, large
    blood tinged, fecal
    projectile
    Diarrhea (amt/color/freq)
    Appetite (tolerance to prescribed diet)
    Percentage
    Genitourinary (30 mL/hr normal output)
    Urination: independent, catheter, incontinent
    Amount
    Color yellow, amber, bloody, brown, dark red
    Appearance clean, cloudy, sediment
    Odor offensive, foul, musty, aromatic, ammonia like,
    odorless
    I/O (intake/output) all fluids should be balanced with
    output
    Bladder distention
    Check, feel, palpate
    Musculoskeletal
    ROM (range of motion)
    Gait
    Deformities
    Psychosocial
    Mental and spiritual
    Moods, affect, judgment, abilities, lifestyle, patterns, age

    Notes:

    NOTES:

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