Clients Rights/Respect Introduce self Identify Client/patient Provide Privacy Vital Signs Time T P R B/P Manual/Electric Location Body

Position Head Mental Status Alert Person(name) Place(location) Time (date) Pupils Left/Right Drainage P, E, R, R, L, A Mouth Teeth Tongue Moist Color Sores Neck Palpates Neck (lymph nodes) Assess Cartoids (one @ time) Ausultate Cartoids Assess neck vein distention Upper Extremities Skin Color Skin Temp Turgor(Chest) Sensation Brachial Pulses Radial Pulses Ulnar Pulses Capillary refill

Handgrip Movement ROM (?) Chest Apical Pulse Rate Regular Regular Irregularity Irregular Irregularity Breath Sounds Anterior/Posterior Upper Middle Lower Inspiratory/Expiratory Adventitious sounds Abdomen Ausultate bowel sounds Soft Round Non Tender LUQ RUQ LLQ RLQ Bruits (aortic) BM Continent/incontinent Color Consistency Amount Elimination Voiding freely Continent/incontinent Foley Patent Color Clarity Lower Extremities Skin Color Skin Temp Femoral Pulses Popliteal Pulses Tibial Pulses Pedal Pulses Capillary refill Movement

Strength Bilaterally ROM (?) Hohmans Sign Bilaterally

Pain Location Radiate Duration Describe Scale (1 10) Intervention Evaluation (within 30 minutes) Oxygen Oximetry Liters/Minute Room Air Nasal Cannula Mask IV/ Peripheral/Central Solution Rate Site Redness Irritation Edema Pain Dressing Location Clean Dry Intact Drainage Color Amount Odor Consistency Miscellaneous Pt in bed Low position Side rails up

Call light within reach Special equipment CMST

(color, movement,sensation,temp)

A(talking) B(color, resp # spO2) C (BP, pulse)