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Assessheet 122
Assessheet 122
Assessheet 122
itals Temp R BP Pulse Ox Head Hair PERLA Nose Ears Mouth o Midline tongue o Moist o Lesions o Dentition Neck Carotid pulse JVD + Trachea midline Chest Apical Pulse Muffled Arrhythmia Breath Sounds - Anterior Posterior Lateral Chest Symmetry Skin Turgor (clavicle) Abdomen Inspection Ausculation o LUQ (active / hyper o RUQ (active / hyper o LLQ (active / hyper o RLQ (active / hyper Palpation Upper Extremities
Date: Time: Radial pulses equal, +2 o Other: Temp vs. trunk (warm / cool) Grip equal and strong Capillary refill <3 sec Vein filling rapid
mm
Lower Extremities Hair present Edema Foot strength Homain's (+ / -) Claudication (+ / -) Temp vs. Trunk (warm / cool) Nails Yellowed Thickened Ingrown Pedal pulse R(palp / doppler) L(palp / doppler) ROM / Strength Upper R Upper R Upper L Upper L Lower R Lower R Lower L Lower L Sensation General Assessment Weight/Height BM Pain Assessment Acute/Chronic Intensity (0-10) Location Duration Characteristics Precipitation Frequency Non-verbals Relief factors Sleep Skin Assessment Description:
Courtesy of http://nursing.arizela.com
Courtesy of http://nursing.arizela.com