GCS verbal
motor
Eye opening
Pupils
C.N.S
Gag refiex
lateralization
Blood Pressure
Heart Rate
CVP
Temperature
C.V.S
ECG
Auscultation
Total input in 24 hr
Total output in 24 hr
Fluid balance
balance
Intake per hr
Output per hr
Respiratory Rate
Auscultation
Respiratory
O2 saturation
Chest tube(s)
Palpation
m
A
o
b
d
n
e
Auscultation
Bowel movements
feeding
Peripheral pulsation
Extremities
Temperature changes
Muscle power
Bed sores