H
HE
EA
AD
D TT O
O TT O
OE
E A
A SS SS E
E SS SS M
ME
EN
N TT
Vital Signs
Breath Sounds
Pulse ___ (rate, strength, regularity)
Anterior and Posterior ___
Temperature ___ (oral, rectal, tympanic)
Clear bilaterally (
BP ___ RR ___ SPO2 ___
Right only (
Orientation
) Left only (
)
Both poor bilaterally ___
(Orientation x 4)
Adventitious sounds ___
What year is this? _
Bowel Sounds
Tell me your name _
Assess all 4 quadrants, do not
Tell me where you are _
palpate before auscultation
Tell me why you're here _
RLQ Active (
Pupil Check
) Absent (
Hyperactive (
(PERRLA) Pupils equal, round, react to light,
RUQ Active (
accommodate _
Hyperactive (
Sluggish (
)
) No change (
Accommodation Yes (
) Brisk (
) No (
) Normal (
)
)
LUQ Active (
LLQ Active (
Pt at 45 degree angle (
Neck veins flat (
)
) Absent (
)
) Absent (
)
Soft (
Heart Tones
)
)
) Absent (
Hyperactive (
) Distended (
)
)
Hyperactive (
Neck Veins
)
)
)
) Hard (
) Distended (
)
Peripheral Edema
Apical pulse with stethoscope
Feet Yes (
Rate ___ Rhythm ___
Hands Yes (
Clarity of sounds ___ Abnormal (
)
) No (
) No (
)
)
Pain
Bilateral Checks
Where is the pain? ___
Radial pulses ___
How long has it lasted? ___
Hand strength ___
Does the pain travel anywhere? ___
Right stronger (
) Left stronger (
) Equal (
)
What makes it better/worse? ___
Pedal pulses ___
Describe the pain ___
Capillary refill ___
Scale of 1 - 10 ___
Skin
Skin Breakdown
Skin turgor (1-3 second return) ___
Normal (
Skin colour ___
Pink (
) Pale (
) Jaundice (
Conjunctiva ___
Skin temperature ___
Hot (
) Warm (
) Cool (
)
) Cyanotic (
)
) Abnormal (
)