Vital Signs
Height |
Weight |
Pulse (60-100) |
Respirations (12-20) |
Temperature (97.8-99.1) |
Blood Pressure (120-139/80-89) |
Pain (scale of 0-10) |
Integumentary
Inspect: color, moisture, hair, rashes, lesions, pallor, edema |
Palpate: temperature, turgor, lesions, edema, texture |
Scalp
Inspect: shape, symmetry |
Palpate: tenderness, deformity |
Nails
Inspect: shape, color |
Capillary refill (< 3 sec) |
Head
Inspect: symmetry, shape, size, uniformity |
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Neck
Inspect: symmetry, lesions, scars |
Palpate: tenderness, lymph nodes, thyroid gland, TMG |
Eyes
Inspect: interior and exterior, visual fields, acuity, reflexes |
Ears
Inspect: color, shape, symmetry, interior inspection |
Palpate: tenderness, deformity |
Nose
Inspect: shape, symmetry, interior inspection |
Palpate: frontal sinus, maxillary sinuses |
Mouth and Throat
Inspect: interior and exterior |
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Thorax and Lungs (anterior and posterior)
Inspection: respiration quality, symmetry, deformity, tracheal location |
Palpation: tenderness, fremitus, chest expansion |
Percussion: percussive tones, diaphragmatic excursion |
Auscultation: breath sounds and quality |
Heart and Great Vessels
Inspection: jugular venous pulse |
Palpate: pulses, PMI |
Auscultate: heart sounds (S1, S2) |
Peripheral Vascular System
Inspect: color, edema |
Palpate: temperature, edema |
Abdomen
Inspect: discomfort, uniformity, color, symmetry, scars, hernia, peristalsis, pulsations |
Auscultate: bowel sounds, bruits |
Percussion: four quadrants, liver, spleen, renal tenderness |
Palpation: light to deep, liver, spleen, aorta, rebound tenderness, fluid wave |
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Musculoskeletal
Inspection: asymmetry, deformity, atrophy |
Palpation: major joints, tenderness, deformity, ROM |
Neurological
Inspect: mental status, cranial nerves, coordination, movement, senses |
Palpate: motor strength, muscle tone, reflexes, senses |
Genitourinary
Inspect: general appearance, lesions, scars |
Palpate: breast exam, testicular exam, prostate exam, vaginal exam, pap smear |
Lymphatic
Palpate: assess lymph node locations |
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