Pain Assessment

Verbal scale 0-10; Characteristics: What has worked? Hasn't? Quality? Radiation? Severity? Timing/onset? Affecting you?

Neurological Assessment

Swallowing liquids/solids? with or without coughing? without choking? A & Ox3? Memory intact?

Behavior appropriate? Verbalization clear/understandable? Thought process coherent? Able to see/read written material? Hear spoken word? Check mouth- moist? pink? good oral hygiene?

Check pupils- equal, round & reactive to light?

Hand grasps strong & equal?

(Neck veins flat at 45degrees?)

Cardiovascular Assessment

 Chest pain? Apical pulse regular? s1s2 present?

Capillary refill <3secs in all extremities? peripheral pulses strong, equal, palpable bilaterally?

 Edema? Calf tenderness?

Respiratory Assessment

Any S.O.B? Any sputum? (coca)

Cough? strong/(non)productive? Respirations regular, even & unlabored? Lungs clear in all lobes bilaterally? Nail beds pink? Symmetrical chest movement?

Gastrointestinal Assessment

Passing flatus? Tolerat diet w/o N&V? BM's within own pattern/consistency? x a day? Last BM? (coca)

Abdomen flat with no distention? Bowel sounds active in all 4 quadrants? Abdomen soft/pain/tenderness?

Urinary Assessment

Continent? Able to empty bladder without dysuria/urgency/frequency/nocturia? (coca)

Bladder distended?

Integumentary Assessment

Skin bruises/rashes/scars/tattoos? Skin color normal to pt? Warm/dry/intact? Hair supple/intact? Nail surface smooth, intact without clubbing? Skin turgor <3 secs?

Musculoskeletal Assessment

Painful joints/muscles? Tremors? Tolerate activity? Active ROM (symmetry/strength)? (flexion/extension/abduction/adduction)

Steady gait? Upright posture, balance?

Neurovascular Assessment

Pain? Sensation intact? Numbness/tingling? (describe defecit)

Circulation intact- pink, warm, pulse present, no edema, capillary refill <3 secs, ROM