NURSING SYSTEM REVIEW CHART

Name: Marjun Dallito Date:

Pulse Rate: 70bpm Bp: 90/60 Temp: 37.4C
Respiratory Rate: 40cpm Weight:
EENT:
[ ] impaired vision [ ] blind
[X] pain [ X ] reddened [ ] drainage
[ ] gums [ ] hard of hearing [ ] deaf
[ ] burning [ ] edema [ ] lesion [ ] teeth
Assess eyes, ears, nose,
throat for abnormality [ ] No problem
RESP:
[ ] asymmetric [ X ] tachypnea
[ ] apnea [ ] rales [ X ] cough [ ] barrel chest
[ ] bradypnea [ ] shallow [ ] rhonchi
[ X ] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing
[ X ] pain [ ] cyanotic
Assess resp. rate, rhythm, depth, pattern,
breath sounds, comfort [ ] no problem
CARDIOVASCULAR:
[ ] arrhythmia [ ] tachycardia [ ] numbness
[ ] diminished pulses [ ] edema [ X ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate rhythm, pulse, blood
Pressure, circ., fluid retention, comfort
[ ] no problem
GASTROINTESTINAL TRACT:
[ ] obese [ X ] distention [ ] mass
[ ] dysphagia [ ] rigidty [ ] pain
Assess abdomen, bowel habits, swallowing,
Bowel sounds, comfort [ ] no problem
GENITO – URINARY AND GYNE:
[ ] pain [ ] urine color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] noctoria
Assess urine freq., control, color, odor,
Comfort / Gyn-bleeding, discharge
[ X ] No problem
NEURO:
[ ] paralysis [ ] stuporous [ ] unsteady
[ ] seizure [ ] lethargic [ ] comatose [ ] vertigo
[ ] tremors [ ] confused [ ] vision [ ] grip
Assess motor function, sensation, LOC, strength
Grip, gait, coordination, orientation, speech
[ X ] no problem
MUSCULOSKELETAL and SKIN:
[ ] appliance [ ] stiffness [ ] itching [ ] petechie
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [ ] poor turgor [ ] cool [ ] deformity
[ X ] wound [ ] rash [ ] skin color [ ] flushed
[ ] atrophy [ ] pain [ ] ecchymosis
[ X ] diaphoretic [ ] Moist
Assess mobility, motion gait, alignment, joint function/
Skin color, texture, turgor, integrity [ ] no problem