HEAD- Normocephalic Scalp and hair LOC/Speech: State full name/DOB Where are you now

? Why are you here? Current US President? Pain – Do you have pain right now? Pupils – PERRLA Sclera Palpebral conjunctiva-lining of eyelid Nose- Symmetry Drainage? Easy breathing/closed mouth? Ears – Symmetry Drainage? Whisper test Mouth – Dentures? Lesions? Tongue, midline and mobile? Pink and moist Neck – Tender, swollen nodes? Trachea, midline? JVD – Semi-Fowler’s Carotid Pulses (separately) UPPER EXTREMITIES -Symmetry Edema? Hand grips/muscle strength/ROM Sensation Cap refill Equal radial pulses? CHEST– Turgor – top of sternum Heart sounds Aortic 2nd ICS/R SB Pulmonic 2nd ICS/L SB Erb’s Point 3rd ICS/L SB Tricuspid 4th ICS/L SB Mitral 5th ICS/ L MCL Apical Pulse – 1 full minute

Breath Sounds Anterior Posterior Lateral (3 lobes on right)

ABDOMEN -Order of Assessment Inspection Auscultation Percussion Palpation Bowel Sounds – RLQ, RUQ, LUQ, LLQ Last BM? Normal for you? If no BM, flatus? GENITOURINARY- normal genitalia? Catheter?/Tubes? Voiding – Pain? Difficulty? Evaluate urine for: Color Clarity Amount LOWER EXTREMITIES– Symmetry Edema? Muscle strength/ROM Sensation Cap refill Equal pulses Dorsalis pedis Posterior tibial SKIN– Evaluate as you go for Color – Pallor? Jaundice? Temperature – Warm Moisture - Dry Turgor – elasticity Lesions, dressings, wounds Edema Braden Scale – No Risk 19-23 At Risk 15-18 Moderate Risk 13-14 High Risk 10-12

” . dry and intact over bony prominences with a Braden Scale score of 23.Very High Risk 9 or less “Warm.

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