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Neurological Alert, oriented to person, place, time?

Clear
speech? Cooperative?
Cardiovascular S1S2 regular/irregular. Pulses: strong/weak,
regular/irregular? Edema? Cap refill <3 sec. Tele?
SCD/TEDS? Calf pain? IV site?
Respiratory Effort: Unlabored, Even, shallow, retractions,
nasal flaring, accessory muscle use, dyspnea
Lung sounds: clear, diminished, crackles, rhonchi,
bilaterally?
O2? Cough: productive/non?
Gastrointestinal N/V? Last BM? Continent?
abd: soft, firm, distended, round, rigid, painful?
Sounds: hyper, hypo, normal, absent
Genitourinary Continent? Foley? Urgency? Burning?
Urine: clear, yellow, amber, tea color, cloudy,
sediment, blood? Odor?
Musculoskeletal Full ROM in all extremities? Strength (hand
grips)? Joint swelling?
Integumentary Color: flush, pale, cyanotic, jaundice, ashen,
normal
Temp: warm, dry, cool, clammy, diaphoretic, hot
Eyes/Ears/Mouth Clear, red, dry, cloudy, yellow? Discharge?
PERRL
Mouth: missing teeth? Dentures? Moist, dry? Lips
intact?
Safety Call light within reach. Bed in low position. SR up.
Aids for walking? Fall risk? Bed alarms?
Pain Characteristics.Dull, achy, sharp, stabbing,
pressure?
Onset ...........................................When did it start?
Location ...................................Where does it hurt?
Duration...........How long does it last? Frequency?
Exacerbation ........................What makes it worse?
Radiation...............Does it travel to another part of
the body?
Relief.....................................What provides relief?
Associated s/s ..............................Nausea, anxiety?