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Instruction: This is a guide to quickly assess the priority Pulses: [ ] bounding [ ] weak [ ] thread [ ] normal:

area/s for comprehensive assessment. Put (+) for Amplitude: _________


present/positive/yes, (-) for absent/negative findings/no within
the [ ]. Respiratory
[ ] cough [ ] productive [ ] non-productive [ ] dry [ ] DOB
V/S: T: ______ PR: _______ RR: _______ BP: __________ [ ] Respiratory distress [ ] use of accessory muscles [ ] SOB
[ ] retraction [ ] nasal flaring [ ] orthopnea
ACTIVITIES OF DAILY LIVING I = independent [ ] Abnormal breathing pattern [ ] cyanosis/pallor
A = assistance required D = dependent [ ] hemoptysis [ ] pain [ ] scoliosis [ ] lordosis [ ] barrel chest
Mobility: Ambulatory wheelchair bound bed bound [ ] intercostal bulging
Sleep: Usual hours of sleep ___________ Naps ____________ Aus: [ ] clear [ ] crackles [ ] rhonchi [ ] wheezes [ ] friction rub
[ ] rales [ ] stridor [ ] Diminished sounds Location: _________
Hygiene: [ ] Shower [ ] bed bath [ ] Oral care [ ] Peri care Pulse oximetry %: ____________________
[ ] shampoo [ ] styling
Urinary
Head motion: ROM: [ ] Full [ ] Limited [ ] None [ ] Frequency [ ] polyuria [ ] oliguria [ ] nocturia [ ] dysuria
[ ] asymmetric head position [ ] shrugs shoulders [ ] unable to [ ] dribbling [ ] pyuria [ ] Retention [ ] infections [ ] perineal rash
support head midline & erect [ ] dull, puffy, yellow skin [ ] urgency [ ] IFC [ ] condom catheter [ ] Incontinence
[ ] periorbital edema [ ] lymph node enlargement [ ] Intermittent catheterization [ ] bladder training
[ ] thyroid enlargement [ ] tracheal displacement
Musculoskeletal
Eyes: Vision [ ] corrected: nearsighted [ ] farsighted [ ] joints pains [ ] muscle pains [ ] deformities [ ] gait problems
[ ] nystagmus [ ] PERRLA [ ] edema [ ] tearing [ ] Weakness [ ] limited ROM [ ] contractures [ ] paralysis
Visual fields/peripheral vision present: [ ] right [ ] left [ ] activity intolerance [ ] ambulatory [ ] non-ambulatory
[ ] mobile using assistive device [ ] immobile
Ears: [ ] Hearing loss [ ] aids [ ] vertigo [ ] tinnitus [ ] pain
[ ] ear infections [ ] Drainage/Discharge [ ] excessive cerumen Positioning:
[ ] Discharge/drainage [ ] obstruction [ ] adequately repositions/alters position independently
[ ] smelling ability diminished [ ] requires verbal cues to reposition/alter position during day
activities
Nose: [ ] nasal drainage [ ] inflamed [ ] tender [ ] edema [ ] requires total assistance to reposition/alter position for day
[ ] polyps/lesions [ ] altered nasal mucosa activities but adequately repositions/alters position when lying
Nasal opening: [ ] occluded [ ] patent down
[ ] requires total assistance to reposition/alter position at all times
MOUTH: [ ] altered oral mucous membrane [ ] inflamed [ ] expresses need to be repositioned/have position altered
[ ] hoarseness [ ] bruxism (grinds teeth) [ ] loose teeth [ ] decay
[ ] halitosis [ ] excessive salivation [ ] lips dry, cracked Neurologic
[ ] lip fissures [ ] lip bleeding [ ] gums inflamed [ ] gums bleed Level of consciousness (GCS) E ___ M ___ V ___
[ ] gum retraction [ ] thick tongue [ ] tongue dry, cracked [ ] convulsions [ ] dizziness [ ] Fainting [ ] tremors
[ ] tongue fissures [ ] tongue bleeds [ ] tongue deviations [ ] paresthesia/paralysis [ ] ataxia [ ] recent/remote memory loss
[ ] lesions [ ] gag reflex [ ] gag reflex hyperactive [ ] aphasia [ ] pupils size [ ] alert [ ] oriented
[ ] with dentures [ ] chewing problem [ ] missing teeth [ ] impaired consciousness [ ] changed level of consciousness
[ ] unchanged level of consciousness [ ] disoriented
NUTRITIONAL/METABOLIC PATTERN/Diet/Elimination [ ] able to communicate [ ] vocalizes sounds [ ] aphasia
Diet: [ ] Full [ ] Soft [ ] Liquid [ ] Enteral Feeding [ ] limited verbalization [ ] non-verbal
Tube Type: [ ] nasogastric [ ] gastrostomy [ ] jejunostomy [ ] intellectual impairment [ ] memory impairment
Appetite /Nutritional Status: [ ] good appetite [ ] poor appetite [ ] general knowledge deficit [ ] abstract reasoning
[ ] recurrent emesis [ ] impaired association ability [ ] impaired judgment
Eating Skills: [ ] too slow [ ] too fast [ ] excessive spillage
[ ] requires special utensils [ ] needs to be positioned CRANIAL NERVE (CN) FUNCTION
Teeth: [ ] dentures/bridges [ ] dysphagia CN I olfactory [ ] intact [ ] impaired [ ] unknown
Swallowing: [ ] difficulty [ ] delayed [ ] painful CNs II-III-IV-V optic, oculomotor, trochlear, abducens
[ ] Constipated [ ] diarrhea last BM: _________ CN VI trigeminal [ ] intact [ ] impaired
CN VII - Facial [ ] intact [ ] impaired
ABDOMEN Bowel Sounds: [ ] Present in all quadrants CN VIII Acoustic [ ] intact [ ] impaired
[ ] hypoactive [ ] hyperactive [ ] absent [ ] tympanic CN IX Glossopharyngeal [ ] intact [ ] impaired
[ ] flat [ ] distended [ ] soft [ ] firm [ ] rounded [ ] obese CN X - Vagus [ ] intact [ ] impaired
[ ] asymmetry [ ] pain [ ] rebound tenderness CN XI Spinal Accessory [ ] intact [ ] impaired
[ ] umbilical hernia [ ] mass CN XII Hypoglossal [ ] intact [ ] impaired

Integumentary/SKIN SENSORY FUNCTION


[ ] clear, healthy skin [ ] clear, healthy scalp Touch [ ] intact [ ] impaired Pain [ ] intact [ ] impaired:
[ ] lesions [ ] rashes [ ] bruises [ ] wound [ ] drainage
[ ] itching [ ] skin color variation [ ] cyanosis [ ] pallor MOTOR FUNCTION
[ ] jaundice [ ] erythema [ ] dry [ ] edema [ ] scaling [ ] impaired coordination [ ] fine motor skills impaired
[ ] poor turgor [ ] unusual hair distribution [ ] alopecia [ ] balance maintained while standing with eyes closed
[ ] reduced hair on extremities [ ] hirsutism [ ] loss of balance immediate
[ ] hair characteristics [ ] normal [ ] oily [ ] dry [ ] coarse
[ ] infestation/lice REFLEXES
Patellar reflex: [ ] 0: no response [ ] 1+ low (normal with
Cardiopulmonary slight contraction
[ ] chest pain [ ] palpitations [ ] arrhythmia [ ] varicosities [ ] 2+ normal, visible muscle twitch and extension of lower leg
[ ] Homans sign [ ] Claudication [ ] phlebitis [ ] edema [ ] 3+ brisker than normal
[ ] dyspnea [ ] fatigue [ ] palpitations [ ] tingling/ numbness [ ] 4+ hyperactive, very brisk
Color: [ ] cyanosis [ ] rubor [ ] pallor apical pulse: ________
Jugular venous distention: [ ] present [ ] absent
Capillary refill: [ ] > 1 second [ ] < 2 seconds (Adapted from Sir Don Dacumos, 2014)