Professional Documents
Culture Documents
NEU ROLOG ICAL/PSYCHOSOCIAL Ability to communicate: . Language, barriers mechanical ' Ilearingdeficits/aids - Orientatedto person,place & tirne (x 3) - Pupils - reaction& size - Motor & sensorytesting (.prn) - Motor {unction & strength (pm) response to analgesia management, - Pain - presence/absence, - Patient/familyresponse to illness - Visitor interaction Gait (steadyor tursteady) devices(walker, splints,prosthesis), - l.evel of activity - includeassistive
RESPIRATORY
Spontaneous or via tracheotomy Oxygen delivery system,oxygensaturation Rate, rhytirm, effort
Chest: Air entry: equal throughout, decreased to bases? Breath sounds- no adventitioussounds.crackles.wheezes Expansion symmetry Position of trachea Cough - productiveor non productive
Suctioning: - Oral, nasal,trach - Amount, description Chest Tubes: - Drainage system (Pleurevac) - Location, suctioniunderwater seal - Fluctuation,bubbling - Drainage - amount & colour; dressing Surgical Incisions (relating to thorax): colour - Location, appearance, drainage, - Sutures,dressings
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CARDIOVASCULAR - regular or irregular Pulse BloodPressure: dry clammy, Skin colour- mottled,pink, pale,cyanotic, - cool,cold,warm,hot,diaphoretic Skintemperature route Bodytemperature - febrile,afebrile, or < 3 seconds refill: > 3 seconds Capillary
PeripheralPulses:Presentor Doppler - DP x Edema: +), - Location, Description(pitting - Dependent,peripheral,total bodY PT x
vascath (Dialysis) Lines: cvAD, PICC, Peripheral,IVAD (portacath)o - Solutionsinfused,rate,use of infusion devices swelling or infiltration) - Infusion sites- condition (redness, - dressing
GASTROINTESTINAL
NPO or Diet - type, tolerance; o TPN - rate o External feeds- tYPeand rate Type of Tube: bore- small or large,Gastricor J tube NG - to straight drainageor low gomco (suction) volumes Check placementor resiCual Nauseaor vomiting?
palpate
- Bowel Sound- presentin all quadrants;absent;hyperactive - Flatus/belching of drainage - site & type, amount,colour, consistency - Drains/tubes colour drainage, - Surgical incisions- location,appearance, - Suturesidressings Bowel movements: date of late BM? Formed ? Loose ? lncontinent? etc. - Route - ileostomy,colostomY,
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G EN I T O U RIN A R Y Urine output: Route- spontaneous, Foleycatheter, urinarydiversion Description colour,consistency, odour - amount,
SKIN ASSESSMENT Skin integrity- intact,wounds, areas, bruising breakdown or reddened Location Dressing: Therapeutic Bed (relating Surgical incisions to circulation)
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