BULACAN STATE UNIVERSITY

COLLEGE OF NURSING
City of Malolos, Bulacan

PHYSICAL ASSESSMENT FORM (ADULT)

Name of Student: _________________________ Area of Assignment: ________________________

Name of Clinical Instructor:________________ Inclusive Dates:_____________________________

I. CLIENTS PROFILE & CENTRAL CORE

Clients Initials: ______________________Age :_______

Gender:_________Religion:____________
Civil Status:
______________Allergies:____________________________________________________ Diet:
_________________________ Height: ____________________Weight: _____________________
Date & time of Admission:_____________________ Mode of Admission:
_______________________
Impression/Diagnosis:________________________________________________________________
__
Reason for seeking health care:
_________________________________________________________
Vital Signs: T:_________ PR:________ RR:________ BP: _________ Pain
score:___________________
General Physical
Description:__________________________________________________________________________
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General Behavior
exhibited:_____________________________________________________________________________
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Physician in-charge:_________________________________
Nurse-on-Duty: _____________________________________

II. STRESSORS & REACTIONS TO STRESSORS

A. Clients Complaints Upon Admission
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Stressors as perceived by the client and SOs:

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B. Identification and Reactions to Stressors by person

variables/subsystems:
1. Intrapersonal
a. Physiological (Head to Toe)
Past medical history:

Illnesses:____________________________________________________________________________
Surgery:____________________________________________________________________________
History of chronic
disease_____________________________________________________________
Immunization History: (specify the number of doses received)
_____ BCG _____ DPT _____ OPV _____ AMV
_____ MMR _____ HepB _____ TT _____ HiB
_____ MMV _____ Rubella Vaccine _____ Others(specify)

Smoking:
_____ pcks/day
_____ pck/year
Alcoholic Beverages:
______________Type ______________ Amount
______________ Frequency of Use ______________ Date of Last
Drink
Illicit drugs:
______________Type ______________ Amount
______________ Frequency of Use ______________ Date of Last Use
Medication (prescription/OTC)
Medicin Dose Frequency Last Dose Indication
e

Allergies: ______________ Foods ______________ Drugs

Perception of health: _____ good _____ fair _____ poor
Dietary Preferences:
_________________________________________________________________

Physical Assessment:
Central Nervous System
Level of Consciousness:
_____alert _____lethargic _____drowsy
_____Obtunded _____Stuporous _____Comatose
Mood (subjective):
_____ pleasant _____irritable _____calm
_____happy _____euphoric _____ anxious
_____ fearful _____ others(specify)
Affect (objective):
_____surprise _____anger _____sadness
_____joy _____disgust _____fear
_____flat _____blunted _____full
Orientation Level:
_____person _____place _____time
Memory:
_____ recent _____Intermediate _____Remote
Pupils: Right Left
_____size _____Reaction _____size _____Reaction
Reflexes:
_____ grade (describe)
Grasps: Right Left
 _____Strong _____Weak _____Strong _____Weak
Others:
_____Numbness _____Tingling _____Restless _____ Mannerism
Pain: None: _____
Provoking/Precipitating
factors:________________________________________________

Quality/Location:______________________________________________________________
Radiating or non-
radiating:_____________________________________________________
Severity/intensity:
_____________________________________________________________

Timing:_______________________________________________________________________
Visual Acuity:
_____Normal _____glasses _____ contacts
_____blind (R/L) _____Prosthesis: (artificial eye) R/L

Hearing:
_____Normal _____impaired (R/L) _____deaf(R/L)
_____hearing aid _____tinnitus _____drainage from ears
Touch:
_____Normal _____abnormal (specify)
Smell:
_____normal _____abnormal
Communication:
_____ Brocas Aphasia _____ Wernickes Aphasia
_____ Global Aphasia

Cardiovascular System
Pulse Rate and Characteristics:
_____regular _____irregular _____strong _____weak
_____ Right Upper Extremity _____ Left Upper Extremity
_____ Right Lower Extremity _____ Left Lower Extremity
Heart Sounds: _____ S1 _____S2 _____Others (specify)
Blood Pressure: _____ standing _____lying _____sitting
Extremities: Temperature:
Upper Extremities _____cool _____warm
Lower Extremities _____cool _____warm
Capillary Refill Time: _____ second/s
Homan's Sign: _____ Negative _____Positive
Claudication: _____ Negative _____Positive
Nails: _____Normal _____Thickened
_____Clubbing _____Other (specify)

Respiratory System
Chest: _____ symmetrical _____ asymmetrical (specify)
Respirations: _____ rate
_____ depth (shallow/deep, abdominal/diaphragmatic)
_____ regular _____ irregular (specify)
_____ periods of apnea
_____ dyspnea at rest
_____ orthopnea
_____ dyspnea on exertion
_____others(specify)
Cough: _____ absent _____ present (specify)
_____ dry
_____soft
_____ productive
_____ nonproductive
_____ whooping
_____ Sputum: _____odor
_____color
_____consistency
Breath Sounds:
_____ Normal _____ Adventitious (specify location)
_____ absent
_____ crackles
 _____ rhonchi
_____ friction rub
_____ wheezing
Respiratory devices:
_____ CTT:______________________________________________________________
_____ Tracheostomy:
____________________________________________________
_____ ETT:______________________________________________________________
_____Oxygen Therapy:
__________________________________________________

Gastrointestinal System
Prescribed Diet: _________________________________________________________________
Appetite: _____Normal _____Abnormal (specify)
Gag Reflex: _____ Present _____ Absent
GIT problems: _____ Nausea _____Vomiting
_____ Dysphagia _____ Constipation
_____ Diarrhea _____Incontinence
_____ hemorrhoids _____ Others (specify)
Feeding Ability: _____ Able _____ Unable (specify)
Mouth: _____pink _____inflammed
_____moist _____dry
_____lesions/ulcerations _____ Others(specify)
Oral Prosthesis: _________________________________________________________________
Defecation Pattern: _____ Consistency _____ Color
_____ Amount _____ Frequency
Abdomen: _____symmetry _____ flat
_____rounded _____obese
_____Ascites _____Soft
_____Firm _____ Tender
_____ Distended
Bowel sounds: _____Hypoactive _____ Hyperactive
_____Normoactive _____Absent
Bowel Diversions: _____ Ostomies (specify)

Integumentary System

____ color: pallor, ashen, pink, jaundice, cyanotic, ruddy

____ temperature: warm, cool
____dry, moist, clammy, diaphoretic
____Skin integrity: intact, impaired (specify)
____turgor: good, poor
____edema:pitting/non-pitting, dependent, bipedal, periorbital, anasarca
____pruritus
____bruises/lesions
____decubitus ulcer(describe)

Urinary System

Bladder Patterns: _____ color _____ Amount

_____ Turbidity _____ Frequency
Urinary problems: _____Dysuria _____Nocturia
_____Urgency _____Hematuria
_____Retention _____Burning
_____Hesitancy _____ Incontinence
Elimination Assistive Devices:
_____ catheterization (specify)

Musculoskeletal System

Self-Care Ability: (0=Independent 1=Assistive device 2=Assistance from others 3=Assistance

from person and equipment 4=Dependent/Unable)
Self 0 1 2 3 4 Self care 0 1 2 3 4
care
Feeding Transferrin
g
Bathing Ambulatin
 g
Dressin Toileting
g
Bed
Mobility

Problems: _____ tremors _____ atrophy _____ swelling

Assistive Devices: _____none _____crutches _____Commode
_____Walker _____cane _____splint/brace
_____wheelchair _____others (specify)
Gait:
_____normal _____abnormaI (specify)
Range of Motion:
_____normal _____limited (specify)
Posture:
_____normal _____Kyphosis
_____Lordosis _____Scoliosis
Deformities: _____None _____Yes (specify)
Amputation: _____None _____ Yes (specify)

Reproductive System
Sexual
concerns:_____________________________________________________________________
_____________________________________________________________________________________
Female: _____LMP _____GPTPAL Score
_____Menopause (specify)
Family Planning: _____No _____Yes (type)
Vaginal bleeding: _____No _____Yes (describe)
History of sexually transmitted disease _____None _____Yes(specify)
Last Pap Smear: _________
Male:
Prostate problems _____No _____Yes (type)
Penile discharges: _____No _____Yes (type
Last prostate exam:_______
Congenital Problems:
_____hypospadia _____epispadia
History of sexually transmitted disease _____None _____Yes(specify)

b. Psychological

Overt signs of stress: (crying, wringing of hands, clenched fists)

Coping Strategies:__________________________________________________-
_________________
Impact of Hospitalization/Illness (financial, self-care, role performance):
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Recent Major loss:
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Living Arrangement:
_____ Alone _____Nuclear _____ Extended
Number of Children: __________________
Occupation:_________________________________________________________________________
Employment Status:
_____employed _____ unemployed

Social activities:
_____active _____limited _____none

c. Spiritual

Religion: _____Protestant _____Catholic _____Jewish

_____Muslim _____Buddhist _____others(specify)
Religious Practices/Restrictions:
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 Concerns related to spiritual or religious customs?
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d. Developmental

Psychosocial tasks:
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Psychosexual task:

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Cognitive level:

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Moral Development:

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2. Interpersonal (between persons) and Extrapersonal (within the

community)
a. Socio-cultural
Community participation:
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Health cultural beliefs:
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Political Affiliations:
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Stressors as perceived by the nurse:
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III. NURSING DIAGNOSES (in priority)

Classification Nursing Problems (at least 5)
Physiological

Psychological

Socio-cultural
Spiritual

Developmental

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Name/Signature of Student