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8 Cards in this Set
- Front
- Back
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Cardiovascular |
Telemetry? Pulse and refill? Edema? Skin tone? Heart sounds-apical, murmur, rate and rhythm |
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Respiratory |
Lung sounds (deep breaths through mouth) Rate and rhythm Symmetry Depth (shallow, deep, wnl) Effort (labored, unlabored, accessory muscles) Cough? Oxygen? Smoker? |
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Gastrointestinal |
Otomy? Appetite Number of meals per day Last meal Weight loss or gain Symptoms of (nausea, vomiting, diarrhea, constipation, reflux, dysphagia) Mucous membranes, mouth and tongue (moist, pink, no lesions) Dental status Dentures Bowel sounds Palpate (soft, firm, distended, tender) Bowel movement Flatus |
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Genitourinary |
Foley History of UTI, kidney infection, kidney stones? Difficulty with (incontinence, difficulty starting flow, discharge, blood, odor, frequency urging, burning, pain during urination or in lower back/flank) Assess urine |
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Muskuloskeletal |
Gait (steady, unsteady, limp) Ambulation Assistive devices Spine (kyphosis, lordosis, scoliosis) Range of motion Sit down Strength (wnl, weakness, paralysis) Assess joints (redness, swelling, stiffness) Activity tolerance (weakness or dizziness, trouble lifting or back pain, shortness of breath or tires easily, any other pain, history of fractures) |
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Neurological /sensory-perceptual |
Already assessed grasp Already asked about weakness or dizziness (any history of head injury, seizures, numbness or tingling) LOC (alert, sedated, comatose) Oriented to (person, place, time, situation) Speech (clear, garbled, aphasiac) Nasal drainage? Hearing (HOH, deafness, hearing aids) Glasses or contacts Extraocular movement (normal, animal, unable to perform) Clear of drainage Pupils equal Sclera (white, red, jaundiced) Conjunctiva (pink, pale, jaundiced, inflamed) Pupil size (wnl, dilated, pinpoint) Pupil reaction (brisk, sluggish, fixed) |
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Integumentary |
Noticed moles Any changes or other skin conditions? Sunscreen? History of bad sunburn? Self assessment or dermatologist? Any lesions, rashes, bruising, cuts, scars, redness, varicose veins, incisions? Tattoos or piercings? Skin color (appropriate, flushed, cyanotic, pale, jaundiced) Turgor (good, poor) Temperature (hot, warm, cool) Moisture (dry, diaphoretic) Skin integrity (intact?) |
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Miscellaneous |
Falls? Bed rails Call light Seizures precautions Bed alarm Isolation Restraints Pain (location, scale, relief) Any questions? |
