Nursing Vital Signs And Systems Assessment Template

Vital Signs

The patient's temperature is mildly elevated at 37.8 °C, with a tachycardic pulse of 104 bpm and an elevated respiratory rate of 22 breaths/min. Blood pressure is stable within normal limits at 134/82 mmHg, though oxygen saturation is concerningly low at 91% on room air, improving to 96% on 2 L/min via nasal prongs. The patient is alert and oriented to person, place, and time (GCS 15), and reports a pleuritic chest pain score of 4/10 on movement.

HEENT (Head, Eyes, Ears, Nose, Throat)

The head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light at 3 mm bilaterally, and the conjunctivae are pink and moist. The tympanic membranes are pearly grey with no effusion, and the nasal passages are patent with mild clear rhinorrhoea. The oral mucosa is dry, and the pharynx shows mild erythema without tonsillar exudate or enlargement.

Respiratory

Respiratory effort is mildly increased with a regular rhythm at 22 breaths/min and no accessory muscle use. Chest expansion is symmetrical, though air entry is reduced at the right base. Auscultation reveals coarse crackles and bronchial breath sounds in the right lower lobe, with clear vesicular breath sounds throughout the left lung field. The patient exhibits a frequent cough productive of mucopurulent sputum and mild dyspnoea on exertion.

Cardiac

The heart rate is elevated at 104 bpm with a regular rhythm. Dual heart sounds (S1 and S2) are audible with no murmurs, gallops, or rubs detected. Peripheral pulses are strong and equal (2+) radially and dorsalis pedis bilaterally, with a brisk capillary refill time of less than 2 seconds. There is no peripheral oedema, cyanosis, or pallor observed.

Abdominal

The abdomen is soft, non-distended, and symmetrical with a well-healed right lower quadrant appendicectomy scar. Bowel sounds are normoactive across all four quadrants. There is no tenderness, guarding, or rebound on palpation, and no hepatosplenomegaly or palpable masses are detected.

Musculoskeletal

Upper and lower extremities are symmetrical with no gross deformities, joint swelling, or tenderness. The patient demonstrates full active and passive range of motion and 5/5 muscle strength in all limbs. Gait is steady and balanced, and the patient mobilises independently without aids.

Skin

The skin is warm, flushed, and dry with mildly reduced turgor. Skin integrity is generally intact with all pressure areas, including the sacrum and heels, free from breakdown or erythema. Minor senile ecchymosis is noted on the bilateral forearms, and a superficial 1.5 cm x 0.5 cm healing abrasion is present on the anterior left shin, which is clean, dry, and free of erythema, exudate, or other signs of infection.