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Instruction: This is a guide to quickly assess the priority Capillary refill: [ ] > 1 second [ ] < 2 seconds

area/s for comprehensive assessment. Put (+) for Pulses: [ ] bounding [ ] weak [ ] thread [ ] normal:
present/positive/yes, (-) for absent/negative findings/no within Amplitude: _________
the [ ].
Respiratory
V/S: T: ______ PR: _______ RR: _______ BP: __________ [ ] cough [ ] productive [ ] non-productive [ ] dry [ ] DOB
[ ] Respiratory distress [ ] use of accessory muscles [ ] SOB
ACTIVITIES OF DAILY LIVING I = independent [ ] retraction [ ] nasal flaring [ ] orthopnea
A = assistance required D = dependent [ ] Abnormal breathing pattern [ ] cyanosis/pallor
Mobility: Ambulatory wheelchair bound bed bound [ ] hemoptysis [ ] pain [ ] scoliosis [ ] lordosis [ ] barrel chest
Sleep: Usual hours of sleep ___________ Naps ____________ [ ] intercostal bulging
Aus: [ ] clear [ ] crackles [ ] rhonchi [ ] wheezes [ ] friction rub
Hygiene: [ ] Shower [ ] bed bath [ ] Oral care [ ] Peri care [ ] rales [ ] stridor [ ] Diminished sounds Location: _________
[ ] shampoo [ ] styling Pulse oximetry %: ____________________

Head motion: ROM: [ ] Full [ ] Limited [ ] None Urinary


[ ] asymmetric head position [ ] shrugs shoulders [ ] unable to [ ] Frequency [ ] polyuria [ ] oliguria [ ] nocturia [ ] dysuria
support head midline & erect [ ] dull, puffy, yellow skin [ ] dribbling [ ] pyuria [ ] Retention [ ] infections [ ] perineal rash
[ ] periorbital edema [ ] lymph node enlargement [ ] urgency [ ] IFC [ ] condom catheter [ ] Incontinence
[ ] thyroid enlargement [ ] tracheal displacement [ ] Intermittent catheterization [ ] bladder training

Eyes: Vision [ ] corrected: nearsighted [ ] farsighted Musculoskeletal


[ ] nystagmus [ ] PERRLA [ ] edema [ ] tearing [ ] joints pains [ ] muscle pains [ ] deformities [ ] gait problems
Visual fields/peripheral vision present: [ ] right [ ] left [ ] Weakness [ ] limited ROM [ ] contractures [ ] paralysis
[ ] activity intolerance [ ] ambulatory [ ] non-ambulatory
Ears: [ ] Hearing loss [ ] aids [ ] vertigo [ ] tinnitus [ ] pain [ ] mobile using assistive device [ ] immobile
[ ] ear infections [ ] Drainage/Discharge [ ] excessive cerumen
[ ] Discharge/drainage [ ] obstruction Positioning:
[ ] smelling ability diminished [ ] adequately repositions/alters position independently
[ ] requires verbal cues to reposition/alter position during day
Nose: [ ] nasal drainage [ ] inflamed [ ] tender [ ] edema activities
[ ] polyps/lesions [ ] altered nasal mucosa [ ] requires total assistance to reposition/alter position for day
Nasal opening: [ ] occluded [ ] patent activities but adequately repositions/alters position when lying
down
MOUTH: [ ] altered oral mucous membrane [ ] inflamed [ ] requires total assistance to reposition/alter position at all times
[ ] hoarseness [ ] bruxism (grinds teeth) [ ] loose teeth [ ] decay [ ] expresses need to be repositioned/have position altered
[ ] halitosis [ ] excessive salivation [ ] lips dry, cracked
[ ] lip fissures [ ] lip bleeding [ ] gums inflamed [ ] gums bleed Neurologic
[ ] gum retraction [ ] thick tongue [ ] tongue dry, cracked Level of consciousness (GCS) E ___ M ___ V ___
[ ] tongue fissures [ ] tongue bleeds [ ] tongue deviations [ ] convulsions [ ] dizziness [ ] Fainting [ ] tremors
[ ] lesions [ ] gag reflex [ ] gag reflex hyperactive [ ] paresthesia/paralysis [ ] ataxia [ ] recent/remote memory loss
[ ] with dentures [ ] chewing problem [ ] missing teeth [ ] aphasia [ ] pupils size [ ] alert [ ] oriented
[ ] impaired consciousness [ ] changed level of consciousness
NUTRITIONAL/METABOLIC PATTERN/Diet/Elimination [ ] unchanged level of consciousness [ ] disoriented
Diet: [ ] Full [ ] Soft [ ] Liquid [ ] Enteral Feeding [ ] able to communicate [ ] vocalizes sounds [ ] aphasia
Tube Type: [ ] nasogastric [ ] gastrostomy [ ] jejunostomy [ ] limited verbalization [ ] non-verbal
Appetite /Nutritional Status: [ ] good appetite [ ] poor appetite [ ] intellectual impairment [ ] memory impairment
[ ] recurrent emesis [ ] general knowledge deficit [ ] abstract reasoning
Eating Skills: [ ] too slow [ ] too fast [ ] excessive spillage [ ] impaired association ability [ ] impaired judgment
[ ] requires special utensils [ ] needs to be positioned
Teeth: [ ] dentures/bridges [ ] dysphagia CRANIAL NERVE (CN) FUNCTION
Swallowing: [ ] difficulty [ ] delayed [ ] painful CN I olfactory [ ] intact [ ] impaired [ ] unknown
[ ] Constipated [ ] diarrhea last BM: _________ CNs II-III-IV-V optic, oculomotor, trochlear, abducens
CN VI trigeminal [ ] intact [ ] impaired
ABDOMEN Bowel Sounds: [ ] Present in all quadrants CN VII - Facial [ ] intact [ ] impaired
[ ] hypoactive [ ] hyperactive [ ] absent [ ] tympanic CN VIII Acoustic [ ] intact [ ] impaired
[ ] flat [ ] distended [ ] soft [ ] firm [ ] rounded [ ] obese CN IX Glossopharyngeal [ ] intact [ ] impaired
[ ] asymmetry [ ] pain [ ] rebound tenderness CN X - Vagus [ ] intact [ ] impaired
[ ] umbilical hernia [ ] mass CN XI Spinal Accessory [ ] intact [ ] impaired
CN XII Hypoglossal [ ] intact [ ] impaired
Integumentary/SKIN
[ ] clear, healthy skin [ ] clear, healthy scalp SENSORY FUNCTION
[ ] lesions [ ] rashes [ ] bruises [ ] wound [ ] drainage Touch [ ] intact [ ] impaired Pain [ ] intact [ ] impaired:
[ ] itching [ ] skin color variation [ ] cyanosis [ ] pallor
[ ] jaundice [ ] erythema [ ] dry [ ] edema [ ] scaling MOTOR FUNCTION
[ ] poor turgor [ ] unusual hair distribution [ ] alopecia [ ] impaired coordination [ ] fine motor skills impaired
[ ] reduced hair on extremities [ ] hirsutism [ ] balance maintained while standing with eyes closed
[ ] hair characteristics [ ] normal [ ] oily [ ] dry [ ] coarse [ ] loss of balance immediate
[ ] infestation/lice
REFLEXES
Cardiopulmonary Patellar reflex: [ ] 0: no response [ ] 1+ low (normal with
[ ] chest pain [ ] palpitations [ ] arrhythmia [ ] varicosities slight contraction
[ ] Homans sign [ ] Claudication [ ] phlebitis [ ] edema [ ] 2+ normal, visible muscle twitch and extension of lower leg
[ ] dyspnea [ ] fatigue [ ] palpitations [ ] tingling/ numbness [ ] 3+ brisker than normal
Color: [ ] cyanosis [ ] rubor [ ] pallor apical pulse: ________ [ ] 4+ hyperactive, very brisk
Jugular venous distention: [ ] present [ ] absent
(Adapted from Sir Don Dacumos, 2014)