44812929 Assessment Form

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Patient: ________________________________ Date: ____________________________ ___ _____________________________ ____

INTEGUMENTARY -  SKIN 

M OUT  OUT H  H 

 Color normal Color normal for race  pale 

ucous membrane  Moist   Dry  Pink  M uc  Red  Lesions __________________________________ _ ___________________________________ T ong ongue  At midline  Deviates _________________  Tremors  Pink   Red  White  Black   Fissures  Lesions/other ______________________  ps  Pink   Pale  Moist   Dry  Intact  Li ps  Lesions/other ____________________________________ ____________________________________ Gums  Pink   Pale  Red  Swelling  Bleeding __________________________________________ __________________________________________ Teeth  White  Yellow  Brown/Black   Caries  Missing  Uses dentures ____________ ________________________________________________________ Br eath  Pleasant   Fruity  Halitosis ________________________________________________________ ________________________________________________________

cyanotic  Jaundice  erythema ________________________ Textur e  Dry  diaphoretic Temp  Warm  hot   cool  cold Turgor   Elastic   elasticity  Tenting  Edema: ______________________________ _________________________________________ ___________ Pitting  1+  2+  3+  Vascularity: ___________________________ __ __________________________________ _________  Skin clean, no odor  Odor  Dirty  Thick   Moderate  Thin Lesions: ______________________________________ _____________________________________________ _______ _______________________________________________________ _______________________________________________________ _______________________________________________________ HAIR Color: ____________________ 

Normal distrubution  Abnormal distribution _________________________ _________________________  Full  Thinning  Alopecia __________________  Dry  Oily Dandruff/foreign matter  Lesions: ____________________________________ __________________________________________ ______ _______________________________________________________ _______________________________________________________ N  AILS   Color normal  Other _________________________ ___________________________  Thick   Thin  Angle 160°  Clubbing  Concave  Convex Beauǯs lines  Paronychia  Splinter hemorrhages  Brittle  CRT < 3 sec  > 3 sec _______________ Other _____________________________________________ ________________________________________________ ___ HEAD

Facial expression  Pleasant/smiling  Tearful  Blank stare/mask-like  Sleepy  Startled  Head symmetrical  Asymmetrical  Round Ptosis  Other ________________________

N EC  EC K  K  & T H  HRO R   O AT  Blood  vessel s  No distention  JVD se  Equal  Unequal  Weak  Carot id  pul se  Absent   Bruit _________________________________ Thy roi roid   not enlarged  Enlarged  T ra rache a at midline  Deviation Throat  Lesions/inflamm ________________________ Difficulty swallowing?  No  Yes es  Not palpable  Palpable L ymph nod es  Hard  Soft   Size & Location ________________ ________________________________________________________ ________________________________________________________ CV 

Apical pulse rate: _________  Regular  Irregular Blood Pressure: _______________  S1 & S2 heard in all four locations  Abnormal sounds/exceptions __________________ ________________________________________________________ ________________________________________________________ P V  V 

EYE 

e  mit ies  Color normal for race  Cyanotic rem E  xt r 

 Sclera white  jaundiced



 Bulbar conjuct. clear 

Pink  Vascularity  Palpebral conjunct pink   Red  Jaundiced  Discharge/Drainage______________________________ ________________________________________________________ NOS E  E  _______________________________  Drainage/discharge _____________________________  Lesions _________________________________ ____________________________________________ ___________

Dry  Diaphoretic  Bilaterally  Asymmetrical ____________________________ _____________________________________ _________  Nailbeds pink   Cyanotic  Clubbing ________  No JVD  JVD  Moves all extremities  Exceptions ______________________________ ________________________________________ __________ ________________________________________________________  Edema ________________________________ ___________________________________________ ___________  Non-Pitting  Pitting  1+  2+  3+  4+

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P V, C ONT.

P er i pheral P ul ses  All palpated

Pulse quality  Extr  0  1+  2+  3+  4+  Extremities  0  1+  2+  3+  4+  Bilaterally  Exceptions _____________________ _____________________________________________________ _____________________________________________________  Parestheisas ___________________________________  Pain ____________________________________________  CRT < 3 sec  > 3 sec  Temp ______________ M US CU   LOSK EL   E T A   L

 Obese  Overweight  

Muscular  Lean  Thin  Emaciated  Petite P ostur e  Erect   Stooped  Kyphosis  Lordosis  Scoliosis Gait  Smooth & Coordinated  Shuffling  Hesitancy  Assistive devices ________________ ______________________________________________________  Movement purposeful & controlled  Tics/tremors  Decreased muscle tone  Immobility _______________________________________ _______________________________________________________  Balance intact   Abnormalities ________________  Deformities _______________________________________   mit ies  Aligned & symmetrical E  xt re  Muscle grps symmetrical  Toned  Atrophy  Masses ____________________________________________  Exceptions ________________________________________   ngth (0-5): Upper arms ______ Forearms ______ S tr  e Wrists: ______ Fingers: ______ Hips: _______ Hamstrings: ______ Quads: ______ Ankles: _______ Toes: ______ Feet: ______  Grip strength equal  Exceptions/other ________________________________ ________________________________________________________ ________________________________________________________  J oints  Symmetrical  Enlarged  Discolored  Heat   Edema  Tenderness  Pain  Nodules  Crepitus _____________________________ ________________________________________________________ ________________________________________________________ ROM   Full ROM:  Shoulders  Elbows  Wrists  Fingers  Hips  Knees  Ankles  Feet   Toes Limitations __________________________________________ ________________________________________________________ ________________________________________________________

Patient: ________________________________ Date: ________________________________ RE  S P IR ATORY  P er  P at ient:   Difficul ty br eathing   Cou gh   P rod uct ive F re  quency ___________________________________________  putum color/amount __________________________   S   Alert   LOC ___________________________________  Cyanosis __________________________________________  Chest symmetrical  Barrel chested Rate: ____________  Regular  Irregular  Deep  Moderate  Shallow  Use of accessory muscles  SOB  Normal lung sounds in all fields  Adventitious sounds (type & location): ________ ________________________________________________________ ________________________________________________________  Cough  Productive  Non-productive Frequency/Sputum ________________________________ SaO2: ____________  Room Air  Nasal cannula  Other device ______________  Flow rate _________  Mucous membranes moist   Dry  Bleeding/Irritation _____________________________ G U/ GI     Abdomen  Round 

Flat   Convex  Incisions/scars __________________________________ Bow el S ound s  Present x4  Hyperactive >5-6  Hypoactive (<5-6)  Absent ___________________  Soft   Firm  Distended  Tenderness  Masses ____________________________________________ ________________________________________________________ U ri  ne  Pale  Yellow  Amber  Tea-colored  Red  Clear  Cloudy/sediment  Frequency: __________________________________________  Foley Catheter ___________________________________ ________________________________________________________ Diet : ______________ Tolerance: ______________________  NG Tube: R / L Nare Suction:  Low  Moderate  Intermittent   Continuous Drainage color/consistency: _______________________  Feeding tube: Type ______________________________ Rate: ____________________ Place Val. _________________ BM : Date of last _____________ Amt ___________________  Formed  Loose  Liquid Color ________________  Abnormal odor Frequency ___________________________________________ Flatus  Present   Not present 

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N EU   RO LOC :  Awake/alert   Responds appropriately  Lethargic  Confused  Stuporous  Comatose S  peech:  Moderate tone & pace  Clear  Slurred  Garbled  Grunts/moans  Aphasic  No response M ood :  Cooperative/friendly  Feelings appropriate to situation  Positive feelings  Other ______________________________________________ ________________________________________________________ ________________________________________________________ Thou ght P rocesses: Full, free flowing thoughts  Follows directions  Realistic perceptions  Makes sense  Positive/healthy thoughts  Suicidal thoughts  Other ______________________ ________________________________________________________ ________________________________________________________ Oriented to  Self   Others  Place  Time ________________________________________________________ ________________________________________________________ Concent rat ion  With  Without Difficulty (Backwards from 100, Alphabet backwards) ________________________________________________________ ________________________________________________________ ________________________________________________________ Recent M emor  y   With  Without Difficulty (What did you have for breakfast?) ________________________________________________________ ________________________________________________________ ________________________________________________________ Long-Ter m M emor  y  President now Previous  Motherǯs maiden name  Address ________________________________________________________ ________________________________________________________ ________________________________________________________  y  With  Without difficulty N ew M emor   1  2  3  4 of 4 words remembered Words: _______________________________________________ ________________________________________________________ ________________________________________________________  Abst ract  r easoning  With  Without difficulty (Apple/orange, Proverb) ___________________________ ________________________________________________________ ________________________________________________________  J udgement   With  Without difficulty What would you do if_______________________________ ________________________________________________________ ________________________________________________________

Patient: ________________________________ Date: ________________________________ S ensor  y  f unct ion:  Correctly IDs dull & sharp

stimuli  Paresthesias  Pain ________________________________________________________ ________________________________________________________ M ot or Funct ion  Gag reflex intact   Absent   Swallows w/out difficulty  W/ Difficulty  Involuntary movements/tremors  MAE on command ________________________________________________________ ________________________________________________________ Glascow Coma S cal e T OT  AL: ________________ E  ye O pening: ___________  Spontaneous (4)  Verbal stimuli (3)  To pain (2)  None (1) V er bal  Response: ___________  Oriented/talks (5)  Confused/talks (4)  Inappropriate words (3)  Incomprehensible sounds (2)  None (1) M ot or Response: ____________  Obeys commands (6)  Localizes pain (5)  Flexion/withdraws (4)  Flexes abnormally (3)  Extention to pain (2)  None (1) S  pecial senses: S mell   Discharge  Epistaxis  Snoring  Reddened mucous membranes  Pain  Lesions __________________________________________ _______________________________________________________  Correctly  Incorrectly IDǯs scents _______________________________________________________ T aste:  Correctly  Incorrectly IDǯs tastes _______________________________________________________ V ision:  Reads print at 14dz  PERRLA  Exceptions _______________________________________  Corrective lenses ________________________________  Drainage  Pain  Lesions  Redness _______________________________________________________ H ear ing:  Hears whispered words  Hearing aids  Drainage  Redness _______________________________________________________ Supplies check list:  Stethoscope  BP cuff   Tongue blade  Pen light   Items to taste and smell  