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General
Level of consciousness: alert, sedate, unconcious
Orientation: person, place and time (AAOx3)
Affect: afraid, irritable, distressed, attentive, ashamed, sad, happy, confident, shy, sleepy, calm
Skin color:
Obvious distress:
Ease of respirations and use of accessory muscles.
Observe skin throughout assessment.
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Vital Signs
- Temp
- → Normal oral, resting: 37/98.6
- → Range: 35.8 - 37.3 or 96.4 - 99.1
- → 15 after hot/cold, 2 after smoke
- Pulse
- → Normal resting 50-90 BPM
Sa02:
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Pain
- Assess
- location,
- quality,
- severity (0-10 scale),
- radiation,
- duration,
- precipitating and alleviating factors,
- associated symptoms,
- level of sedation.
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Primary Symptom
Assess client�s chief complaint and progress since hospitalization.
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Head & Neck
- Check pupils for equality and reaction to light. (PERRL)
- Check oral mucosa for color and moisture.
- Observe for facial symmetry and tracheal deviation.
- Check for neck vein distention at 45 degrees.
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Chest
- Auscultate S1 and S2 at aortic, pulmonic, tricuspid and mitral areas for rate and rhythm and location of extra sounds.
- Listen at apex for full minute.
- Auscultate anterior and lateral lung sounds.
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Abdomen
- Auscultate all quadrants for bowel sounds.
- Palpate for distention of bladder and abdominal tenderness.
- Ask about last BM, problems with urinating.
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Upper Extremities
- Inspect arms.
- Palpate radial pulses bilaterally and capillary refill;
- assess grip strength and equality.
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Lower Extremities
- Inspect legs.
- Palpate dorsalis pedis pulses bilaterally.
- Palpate legs and feet for edema.
- 0: none
- +1: slight pitting
- +2: Deeper, countours still present
- +3: Deep pittin, mpuffy appearance
- +4: Deep persistent pitting, frankly swollen
- Check foot presses.
- Check feet for resistance.
- Observe feet for lesions.
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Back
- Turn to side or sit up;
- auscultate posterior lung fields.
- Observe skin on back and coccyx.
- Palpate for sacral edema.
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Tubes and Equipment
- Check all tubes from origin to insertion.
- Verify correct oxygen flow,
- correct IV solutions and flow rates.
- Verify Foley draining and other equipment functioning appropriately.
- Check dressings if present.
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