Guidelines Documentation Physical Assessment

NEU ROLOG ICAL/PSYCHOSOCIAL Ability to communicate: . Language, barriers mechanical ' Ilearingdeficits/aids - Orientatedto person,place & tirne (x 3) - Pupils - reaction& size - Motor & sensorytesting (.prn) - Motor {unction & strength (pm) response to analgesia management, - Pain - presence/absence, - Patient/familyresponse to illness - Visitor interaction Gait (steadyor tursteady) devices(walker, splints,prosthesis), - l.evel of activity - includeassistive

RESPIRATORY
Spontaneous or via tracheotomy Oxygen delivery system,oxygensaturation Rate, rhytirm, effort

Chest: Air entry: equal throughout, decreased to bases? Breath sounds- no adventitioussounds.crackles.wheezes Expansion symmetry Position of trachea Cough - productiveor non productive

Suctioning: - Oral, nasal,trach - Amount, description Chest Tubes: - Drainage system (Pleurevac) - Location, suctioniunderwater seal - Fluctuation,bubbling - Drainage - amount & colour; dressing Surgical Incisions (relating to thorax): colour - Location, appearance, drainage, - Sutures,dressings

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CARDIOVASCULAR - regular or irregular Pulse BloodPressure: dry clammy, Skin colour- mottled,pink, pale,cyanotic, - cool,cold,warm,hot,diaphoretic Skintemperature route Bodytemperature - febrile,afebrile, or < 3 seconds refill: > 3 seconds Capillary
PeripheralPulses:Presentor Doppler - DP x Edema: +), - Location, Description(pitting - Dependent,peripheral,total bodY PT x

vascath (Dialysis) Lines: cvAD, PICC, Peripheral,IVAD (portacath)o - Solutionsinfused,rate,use of infusion devices swelling or infiltration) - Infusion sites- condition (redness, - dressing

GASTROINTESTINAL
NPO or Diet - type, tolerance; o TPN - rate o External feeds- tYPeand rate Type of Tube: bore- small or large,Gastricor J tube NG - to straight drainageor low gomco (suction) volumes Check placementor resiCual Nauseaor vomiting?

then Feel Abdominatassessment:-+ Look,Listen,

Inspect Auscultate Percuss etc' obesity,herniations, scars, Skin, distention, BS -+ hypo: everyminute;normal: every 15 - 20 sec;hyper: about every -i sec Tympany - Air-filled. bowels Dullness - solirl, ofgan; Flatness- Muscle,bone Resonance - Lungs; pain, always rigidity. When assessing tenderness, Pulsatiorl masses, work from areaof leastpain towards areaof most pain'

palpate

- Bowel Sound- presentin all quadrants;absent;hyperactive - Flatus/belching of drainage - site & type, amount,colour, consistency - Drains/tubes colour drainage, - Surgical incisions- location,appearance, - Suturesidressings Bowel movements: date of late BM? Formed ? Loose ? lncontinent? etc. - Route - ileostomy,colostomY,

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G EN I T O U RIN A R Y Urine output: Route- spontaneous, Foleycatheter, urinarydiversion Description colour,consistency, odour - amount,

Dialysis: Method- peritoneal, hemodialysis Cathetersite/description

SurgicalIncisionsG/t GU system) (scrotum, penis, Presence pain,swelling of drainage- tenderness, labia)

SKIN ASSESSMENT Skin integrity- intact,wounds, areas, bruising breakdown or reddened Location Dressing: Therapeutic Bed (relating Surgical incisions to circulation)

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