Vital Signs
1. Temperature:
2. Pulse:
3. Blood Pressure:
4. Respirations:
5. Sp02 (%):
6. Glucose:
Location:
Location:
Position:
Source:
Assessment
1. Head, Face, Anterior Fontanel, Neck
a. Head, Face
i.
Normocephalic
ii.
Microcephalic
iii.
Macrocephalic
iv.
Hydrocephalic
v.
Headache
vi.
Symmetrical Facial Features
vii.
Asymmetrical Facial Features
b. Anterior Fontanel
i.
Soft
ii.
Tense
iii.
Bulging
iv.
Flat
v.
Sunken
c. Neck
i.
Full Range of Motion
ii.
Limited Range of Motion
iii.
Without Swelling
iv.
Trachea Midline
v.
Trachea Shifted Right
vi.
Cervical Lymph Nodes Palpable
vii.
Thyroid Visible
viii.
Jugular Vein Distention
2. Eyes, Ears, Nose, Throat
a. Eyes
i.
Symmetrical
ii.
No Drainage
iii.
Denies Pain
iv.
Asymmetrical
v.
Exophthalmia
vi.
Glasses
vii.
Contacts
viii.
Blind
ix.
PERRLA
Flow Rate:
b. Ears:
i.
Symmetrical
ii.
No Drainage
iii.
Hearing Impared
iv.
No Pain
v.
Difficulty Hearing
vi.
Deaf
vii.
Hearing Aid
c. Nose, Throat
i.
Oral mucosa moist and intact
ii.
Oral mucosa dry
iii.
Oral lesions
iv.
Teeth missing
v.
Dentures
vi.
Bad breath
vii.
Deviated septum
viii.
Nasal discharge
ix.
Sinus pain
x.
Nose bleed
xi.
Sore throat
xii.
Throat red
xiii.
Tonsils red and swollen
3. Neurological
a. Level of Consciousness
i.
Full consciousness
ii.
Lethargy
iii.
Obtundation
iv.
Stupor
v.
Coma
b. Orientation
i.
Person
ii.
Place
iii.
Time
iv.
Event
v.
Disoriented
vi.
Unable to access
c. Cognitive
i.
WDL
ii.
No short-term memory loss
iii.
Short term memory loss
iv.
Appropriate for developmental age
v.
Inappropriate for developmental age
vi.
Appropriate attention/concentration
vii.
Poor attention/concentration
viii.
Unable to assess
d. Speech
i.
WDL
ii.
Clear
iii.
Appropriate for developmental age
iv.
Not easily understood
v.
Slurred
vi.
Not appropriate for developmental age
vii.
Receptive aphasia
viii.
Language barrier
ix.
Unable to assess
e. Pupil response
i.
Bilateral pupils reactive
ii.
Bilateral pupils fixed (non reactive)
iii.
R pupil nonreactive
iv.
L pupil nonreactive
v.
R pupil reacts sluggishly
vi.
L pupil reacts sluggishly
vii.
Unable to assess
viii.
Pupil size (mm) 1, 2, 3, 4, 5, 6, 7, 8, 9, 10
f. Glascow coma scale
i.
Best eye response
1. 4= Eyes open spontaneously
2. 3= Eyes open to verbal command
3. 2= Eyes open to pain
4. 1= Eyes do not open
ii.
Best verbal response
1. 5= Oriented
2. 4= Confused
3. 3= Inappropriate words
4. 2= Incomprehensible sounds
5. 1= No verbal response
iii.
Best motor response
1. 6= Obeys commands for movement
2. 5= Purposeful movement to pain
3. 4= Withdraw from pain
4. 3= Abnormal flexion, decorticate
5. 2= Extensor, rigid response, decerebrate posture
6. 1= No response, no movement
g. Respiratory
i.
Respiratory effort/pattern
1. WDL
2. Regular rhythm
3. Bilaterally even and unlabored
4. Irregular rhythm
5. Labored
6. Retractions
7. Dyspnea with exertion
8. Dyspnea
9. Nasal flaring
10. Tachypneic
11. Bradypneic
12. Kussmaul
13. Apnea
14. Cheynes-stokes
15. Expiratory grunting
ii.
Cough
1. None
2. Nonproductive
3. Productive
iii.
Respiratory interventions
1. Suction
2. Chest physiotherapy
3. Turn, cough and deep breathe
4. Incentive spirometry
iv.
Respiratory Airways/Drains
1. Endotracheal tube
2. Tracheostomy tube
3. Nasal tube
4. Oral tube
5. Chest tube
v.
Oxygen Source
1. Room air
2. Ventilator
3. Nasal cannula
4. Simple face mask
5. Non-rebreather mask
6. Partial rebreather mask
7. CPAP
8. BIPAP
9. Tracheostomy mask
10. Humidified high-flow oxygen
h. Cardiac
i.
Cardiac rhythm/sounds
1. WDL
2. Regular rhythm
3. Normal rate
4. S1 and S2 present
i.
5. Irregular rhythm
6. Murmur
7. Adventitious heart sounds
8. Pacemaker
ii.
Cardiac Symptoms
1. None
2. Peripheral edema-pitting
3. Peripheral edema-non pitting
4. Palpitations
5. Dizziness
6. Syncope
7. Chest pain
iii.
Monitors/telemetry
1. Yes/no
Peripheral Vascular
i.
RUE, LUE, RLE, LLE
1. WDL
2. Capillary refill less than 3 secs
3. Pulse is palpable and strong
4. No edema or pain
5. Capillary refill greater than 3 secs
6. Doppler used
7. +1 weak pulse
8. +2 Moderate pulse
9. +3 Strong pulse
10. +4 Bounding pulse
11. No pulse
12. Edema +1 (mild pitting, slight indentation)
13. Edema +2 (moderate pitting, indentation subsides rapidly)
14. Edema +3 (deep pitting, indentation remains for short time)
15. Edema +4 (very deep pitting, persistent)
16. Pain
17. Unable to access