Qnad _porieek = ‘Student Name Ca AQ WIHT ASA Date _ Patient Age/Sex_t (6 __ Medical Diagnosi loons Sen bowe| costrudkiaN is Code Status_ fu "NEURO STATUS/MENTALSTATUS [DEE LOC and orientation X3 Ea fee cheed RY, pean, Hons, Verbal response/behavior observed na ) auctor Pupil size and reaction = feociye TS Tight Mood, Affect, Coping observed ee Neptopei ty Cain Compare | a Location severity, quay, adation duration, precipitating/alleviating factors, associated symptoms Relea ~ ¥L(o- o) INTERVENTION: IF YOU INTERVENE YOU MUST REASSESSPAIN: 30 MINUTES FOR, 1 MED AMD 60 MINUTES FOR PO MED. SLEEF/RESTOR REPOSITIONING SHOUD BE RE-ASSISSED WITHIN THE HOUR No acken req, WOUNDS: Location, Type, Appearance, Closure, Drainage, Dressing type, Interventions, Drains associated with wound U, Wound ach CARDIOVASCULAR Heart tones Apical pulse rate/rhythm (auscutate ful minute) iNTEGUMENTARY Cpe mee Skin Color skin intact, pink set dt Hasan alo Eyes: sclera, conjunctivae, pupil reactivity oclera White’ Coach! MNGi Eyes: vision/aids feaden. lasses Ears: lesions, hearing/aids earine bifate ratio ‘Nose: symmetry, mucosa, drainage Na tube “in & leigy Tabac oo a9 ‘Mouth: mucosa, tongue, dentation, lesions pink, anid ‘ no woundsd pean ho CatdiovAseUSES Symptom Apicoe purse gly Se CE OPMOF Pulses (brachial, radial, pedal) Onion Codiond Capillary refill Respiratory effort/pattern a panied ditt a SOB w/activity or lying G6 SCH us) ackivity. ef Laine Oxygen, device, settings in use (NC @ __L) Nk ‘oom | OA ‘Cough/sputum act present Lung sounds anterior and posterior Kear a Ve At Lobes As? an area Gen pa nomena ae i: Contour, Symmetry, Tenderness [Riot , Soht 1 Symemorric~ sive ‘Bowel sounds in 4 quadrants Last BM (date and character) MUSCULOSKELETAL SS eae General movement, gait, gait pattern ‘Gout Sfeacky wha sate wy ) Weight bearing/activity aid ed libs Strength/Tone/ROM strength > Stang , Nor mal FoM_ | Injury/surgical/trauma: Identify Type and Toguidal “hucaig ceguic’ pfosdatect