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9 Cards in this Set

  • Front
  • Back

Neuro

Alert and orientated


Pain


Confused

Cardio

Chest pain


Peripheries temp


Febrile or afebrile

Vitals

HR


BP


Resps


O2


Temp

Meds

Given as charted


How did they take them?


Refusals?

Resps

Distress?


Saturating on RA?


Assistance


Coughing or noises

GIT/METABOLIC

Diet (soft, minced, blend)


Where they ate their meals


Tolerated? Size?


Independent? Setup required?


Gastric distress


Bowels?

Genitourinary

Continent, uses toilet, pad or IDC


Difficulty or discomfort?


Pad change time

Skin

Mobility


In bed/walking/able to reposition


New concerns, breaks or wounds?


Skin check - dry and intact


Dx - location and condition

Psychosocial

Visits


Carers as in care plan


Level of assist for cares


Bed height


Buzzer


Polite an cooperative with staff (attitude)