Nurses Physical Assessment Sheet - LTC by katali

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									                                          Physical Assessment                                              1
                                                  Long Term Care
Cognitive Review:
Level of Consciousness & Orientation:                     Communication: /_/Verbal /_/Other:

Memory Problems: /_/Short Term /_/Long Term

Hearing: /_/Adequate /_/Impaired /_/Hearing Aid           Vision: /_/Adequate /_/Impaired /_/Blind /_/Glasses

Respiratory Review:
Respiratory Rate/Depth:                    Breath Sounds:               O2 & Delivery Route:

Secretions:                                               Hx of Smoking: /_/Yes /_/No
Trach: /_/Yes /_/No                                       Last known date of tobacco use:
Genitourinary Review:
Incontinence?                Indicates Need to Void?      Catheter: /_/Yes /_/No   Catheter Size:
 /_/Yes /_/No                /_/Yes /_/No                 /_/Suprapubic /_/Urostomy
Gastrointestinal Review:
           G-Tube                    J-Tube                   N/G-Tube                 NPO
 /_/Yes          /_/No       /_/Yes      /_/No         /_/Yes       /_/No       /_/Yes /_/No
       Bowel Sounds                            Incontinent?                     Date of Last BM:
 /_/Yes          /_/No      /_/Bowel        /_/Ileo/Colostomy     /_/Bladder
Fluid Restrictions: /_/Yes /_/No                     Thickened Liquids: /_/Yes /_/No
Musculoskeletal Review:
Contractures: /_/Yes /_/No Paralysis: /_/Yes /_/No               Ambulation:          Bed Mobility:
Site:                       Site:                             /_/Walker /_/Cane       /_/Independent
                                                                                      /_/1 person
                                                                                      /_/2 person
Braces/Binders/Prosthesis:                                Weight Bearing:

Dental Status: /_/Own Teeth /_/Dentures /_/Edentulous

Any pain experienced now? /_/Yes /_/No       Location:                                Severity: (1 - 10)

Current Pain Meds:
                                            Physical Assessment                                                2
                                                     Long Term Care


 /_/Grimaces                  /_/Crying                   /_/Guarding
 /_/Restlessness              /_/Moaning                  /_/Other:

Integumentary Review:
Color:                        Turgor:                        Color:                        Dry: /_/Yes /_/No

Bruising (Note on Figure):                                   /_/Normal                     Moist:
                              /_/Fair                                                      /_/Yes /_/No

Wounds (Note on Figure):                                     /_/Pale

Incisions (Note on Figure):
Cardiovascular Review:
IV Access:                    Site:                          Peripheral Pulse Palpable: /_/Yes /_/No

Edema Present: /_/Yes /_/No                                  Pacemaker: /_/Yes /_/No
              /_/1+      /_/2+               /_/3+

Please # the wounds, bruises, rashes, etc. on the above figure. Indicate the location and describe below.
                                            Physical Assessment                                          3
                                                    Long Term Care

Use this space for narrative charting and description of abnormal findings from the front of the form.
Physical Assessment   4
     Long Term Care
        Physical Assessment   5
             Long Term Care


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