Student: Patient Initials: ______ Unit: _____ Room: _____ Date/Time: __________Med DX: __________________________________________Surgery __________________________________________Time: VS T _____ P _____ R _____ BP _____ Ht. _____ ID BAND Y NTime: VS T _____ P _____ R _____ BP _____ Wt _____ ALLERGY BAND Y N

NEUROLOGIC ASSESSMENT

A & O x ______ to Person Place Time Situation LOC: Awake Alert Lethargic Obtunded Stuporous Comatose

Memory: Immediate Past Abstract Reasoning Appropriate Expression of Words

Behavior: Cooperative Follow Commands Appropriate Agitated Combative Hostile Lethargic Unresponsive

Speech: Clear Understandable Appropriate Slurred Aphasic Incomprehensible

Sensory System: Identifies: Light touch Dull Sharp Direction of movement Objects

Cranial Nerves: I - olfactory, II - optic, III - oculomotor, IV - trochlear, V - trigeminal, VI - abducens, VII - facial, VIII - acoustic, IX - glossopharyngeal, X - vagus, XI - spinal accessory, XII hypoglossal

Coordination: Rapid finger to nose movement: Y N Heel straight down shin: Y N

Reflexes: Bicep brachioradialis triceps patellar achilles planter ankle clonus

PAIN ASSESSMENT: Location Duration Intensity on Pain Scale of 0 to 10 _______

Describe: sharp dull stab throb ache ; localized radiates

EYES, EARS, NOSE, THROAT ASSESSMENT

EYES: PERLA Sluggish R L Nonreactive R L Pupil Size R L Glasses Contacts Artificial eye

Eyelids: Able to close Unable to close Redness Swelling Discharge Lesions R L

Eyeballs: Symmetrically aligned Exophthalmos Sunken Conjunctiva: Pink Moist Redness Dryness Cyanosis R L

Sclera: White Jaundice Redness R L Vision: Sight both eyes Myopia Presbyopia Blind

EARS: External: Equal Size Auricles Aligned Lumps Lesions Discharge Pain Swelling

Hearing: In Both Ears Hard of Hearing R L Hearing Aid R L Deaf

MOUTH: Lips: Pink Moist Dry Pallor Cyanotic Red Edema Lesions Cleft

Teeth: Full Set Missing (Dentures: upper lower ) Partial Gums: pink moist firm red swollen bleeding

Tongue: Pink Moist Dry Black/hairy Smooth/reddish/shinny Coated Enlarged Lesions

Breath Odor: No unusual odor Foul Fruity Acetone Ammonia Fecal Sulfur

NOSE: Nares: Symmetrical Patent Blocked R L Nasal Exudate: None Watery Thick Yellow / Green Bloody

SINUSES: Frontal: Non Tender Tender/Pain Maxillary: Non Tender Tender/Pain

Throat: Lymph Nodes: preauricular, postauricular, occipital, tonsillar, submandibul;ar, submental, superficial cerival, posterior cervical, supraclavicular.

Thyroid Assessment: Thyroid Bruit:

SKIN, HAIR, NAILS ASSESSMENT

SKIN: Color: Appropriate for Ethnicity Pallor Cyanosis Jaundice Flushed Temperature: Warm Cool Hot Cold

Moisture: Dry Moist Diaphoresis Clammy Body Odor: None Strong Foul

Texture: Smooth and Even Rough Flaky Dry Thickness: Appropriate for age Very Thin Thick Atrophy

Turgor: Normal (pinches easily / immediately returns to normal) Decreased (return to normal takes > 30 seconds)

Skin Integrity: Intact Open Wound Skin Tear Laceration Abrasion Location: Characteristics:

Decubitus: Location: Stage: Drainage: Dressing:

HAIR: Color Distribution on scalp and body: Even distribution Patchy Hair Loss Hirsutism Absent

Hair Texture: Fine Coarse Dull Fragile Dry Oily

Scalp: Clean Lesions Parasites Scaliness

FINGER NAILS: Clean Artificial Nails Beaus Line Spoon Nails Clubbing Pitting Paronychia

TOE NAILS: Clean Very Long Very Short Thick Yellow

HEART AND NECK VESSEL ASSESSMENT / CIRCULATION/CARDIAC

Apical Pulse Rate _____ quality /4 Regular Irregular Tachycardia Bradycardia

Radial Pulse Rate: R ______ /4 L _____ /4 Carotid Pulse Rate: R _____ /4 L _____ /4

Carotid Bruit R Y N L Y N Pulses: Diminished Absent Extra Heart Sounds Y N

Capillary Refill fingers 3 toes 3 Julgular Neck Vein Distension Absent Present @ _____ degrees

EKG Rhythm

Generalized Edema Scale 0 1+ 2+ 3+ 4+ Pitting Non pitting Location:

THORACIC AND LUNG ASSESSMENT / RESPIRATORY

Respiratory Rate_____Rhythm: Regular Irregular Labored Shallow Fremitus Y N Bilateral Expansion Equal Not equal

Breathing pattern: Even Dyspnea Tachypnea Bradypnea Orthopnea Apnea Hyperventilation Hypo-ventilation Cheyne-Stokes Biots

Breath sounds: Clear Diminished: (specify lobe RUL LUL RML RLL LLL)

Crackles: Fine Coarse (specify lobe RUL LUL RLL LLL ) Pleural Friction Rub: Y N

Wheezes: Inspiratory Expiratory Sibilant Sonorous ( specify lobe RUL LUL RML RLL LLL)

Cough: Non Productive Productive Sputum: Describe:

Accessory Muscle Use: None Neck Abdomen Nasal Flaring Pursed Lips Retraction Intercostals

General Cyanosis: Lips Nail beds Mucous Membranes O2 _______ L/M Pulse Oximeter ____

Chest configuration: Symmetrical Barrel Chest Pectus Excavatum Pectus Carinatum Kyphosis Scoliosis

PERIPHERAL VASCULAR ASSESSMENT

EXTREMITIES: ARMS: Bilaterally symmetrical Rapid Change of Color Swelling Pain Numbness Tingling Burning Throbbing Coldness

Pulses: Ulnar R _______ /4 L _______ /4 Brachial R ______ /4 L _______ /4

Temporal R _______ /4 L __________ /4

IV SITE: Location: Condition: clean and dry redness swelling pain leaking

EXTREMITIES: LEGS: Bilaterally symmetrical Temperature: warm cool warm to cool

Pulses: Femoral R _______ /4 L _______ /4 Popiteal R _______ /4 L _______ /4

Pulses: Dorsalis Pedis R /4 L /4 Posterior Tibial R /4 L /4

Femoral Bruit: Varicose Veins: Absent Present

Peripheral Edema: None Location: Right: Non Pitting Pitting Scale 1+ 2+ 3+ 4+

Left: Non Pitting Pitting Scale 1+ 2+ 3+ 4+

Leg Ulcer: Absent Present Describe: Location: Margins: Tissue:

Drainage: Skin: Pain:

ABDOMINAL ASSESSMENT

TYPE OF DIET: Intake Output

Tolerates: All None NPO Nausea Vomiting NG Tube PEG Colostomy

Abdomen: Flat Rounded Scaphoid Protuberant Distended Soft Firm Non Tender Tender Masses

Abdominal Girth: _______ cm Ascites: Y N

Bowel Sounds: Present X 4 Normal Active Hyperactive Hypoactive Absent: RUQ RLQ LUQ LLQ

Scars Incisions Sutures / Staples Dressings Location & Characteristics:

LAST BM: Color: Consistency: Continent Incontinent

Urinary System: Urine: Color: Clarity: Odor :

Bladder: Not distended Distended Voids Freely Hesitancy Frequency Urgency Dysuria

Continent Incontinent Foley Suprapubic Urostomy

MUSCLOSKELETAL ASSESSMENTUPPER EXTREMITIES: ROM: Shoulders R L Elbows R L Wrist R L Paralyzed Amputation

Handgrips: Bilateral Equal Not Equal Strong R L Weak R L

Arms: Muscle Tone: Strong Atrophy Flaccidity Tremors Pain

LOWER EXTREMITIES: ROM: Hips R L Knee R L Ankles R L Paralyzed Amputation

Quad Lift: Strong R L Weak R L Pedal Push: Strong R L Weak R L

Gait: Steady Coordinated Balanced Unsteady Cerebellar Ataxia Parkinsonian Gait Scissors Gait

Legs: Muscle Tone:: Strong Atrophy Flaccidity Tremors Pain Footdrop

JOINTS: Flexion Extension Hyperextension Abduction Adduction Supination Pronation Deformity Pain

Swelling Crepitation

Specify location of abnormalities:

Nurses Notes

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