Professional Documents
Culture Documents
Neuro: (10)
LOC (Level of
Consciousness) and
Orientation
Pupils (PERRLA-
Pupils are Equal,
Round, Reactive to
light, and
Accommodating)
Sensation (Any
numbness or
tingling)
Neuro movement Could grasp fingers, push up and down against resistance,
plantar flexion and extension against resistance
CV: (10)
Heart Sounds S1 and S2 clear on aortic, pulmonic, Erb’s point, tricuspid, and
(Diaphragm and Bell) mitral on diaphragm and bell
Resp: (10)
2
GI: (10)
Abdomen (soft, round, Soft, round, non-tender
non-tender would be
baseline normal)
Bowel Sounds Active in all four quadrants
Flatus Normal amount for pt., not interfering with daily life
GU/Renal: (5)
Voiding patterns
Urine characteristics
(Color, clarity,
amount, odor)
Integ/Skin: (7)
Skin Warm and dry to the touch, color appropriate for race and
age