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15 Cards in this Set
- Front
- Back
|
Level of Consciousness (describe)
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Alert
Oriented Sleepy Lethargic Confused Stuporous Non-responsive |
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ORIENTED TO
RESPONSIVE TO |
Person
Place Time Verbal Pain Only Tactile Only Other:________________________ |
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EYES:
Pupils Reaction to Light |
Equal
Unequal Equal Brisk Sluggish Fixed Other:________________________ Unequal:______________________ |
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Grips/Release
Gait |
Equal
Unequal Steady Unsteady/Weak Unable to assess Partial weight bearing |
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Communication
|
English
Speak only Read only Write only Lip Read Sigh Other language________________ |
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Respirations
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R / L
Clear Crackles Coarse/Rhonchi Wheezes(ins - exp) Diminished Absent |
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Cough
Chest Expansion |
None
Productive Suptum col/amt___________ Nonproductive Symmetrical Non-symmetrical Oxygen therapy________________ |
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Heart Tones
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Regular
Irregular Dimished Murmur Other:________________________ |
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Skin Color
|
WNL
Jaundiced Cyanotic Flushed Pale Other:________________________ |
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Edema
Location |
Absent
Pitting Nonpitting Other:________________________ Pedal Sacral Scrotal Other:________________________ |
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Nail Beds
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Pink
Pale Cyanotic Other:________________________ Refill Brisk Refill Slow |
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Calf Tenderness
Pulses |
Absent
Right Left Apical________________________ Radial R__________ L__________ Pedal R__________ L__________ R=regular, I=irreg, D=doppler +3=bounding, +2=normal, +1=weak, 0=No pulse |
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Skin Condition
|
Warm
Cool hot Dry Moist Diaphoretic Other:________________________ ABNORMAL=do skin wound assess. |
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Abdomen
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Soft
Tender:_______________________ Rigid:________________________ Distended:____________________ Flat:_________________________ Tube present:_________________ Other:________________________ |
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Bowel Sounds
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Absent
Present Hyperactive:__________________ Hypoactive:___________________ |
