Pain / Comfort Gastrointestinal

Verbalizes no acute pain Pain ____/10 Abd Soft ___ Nondistended ____
Verbalizes no chronic pain Pain ___/10 BS x_____ W/O N/V _____ LBM______
No observable s/s of pain Diet ______

Neurological Genitourinary
PERRLA__________ Voiding ____ Foley____
Loc AA Ox ___ Color and Character ____
Active ROM x___ Without Pain and discharge
Symmetry of Strength UE __ LE__
Swallowing without difficulty

Cardiovascular Integumentary
CRT < 3 sec. Braden Score ____
Edema ________ No JVD Without Rash____
Without Skin Breakdown_______
Mucous membrane pink IV Sites ______ Last changed_____
Tele _____________ S1 S2 IV Sites ______ Last changed_____
Rhythm Rate
Pulses Apical __ UE__ LE__ Muscoloskeletal
Skin warm and dry Fall Risk Score ____
Full Active ROM ______ Assist ________
Respiratory
Psychosocial
Breath Sounds clear and equal Coping well / Appropriate
Respirations even and unlabored Short and Long Term Memory Intact
Chest expansion symmetrical Family Supportive to Pt.___________
No secretions / sputum Sputum clear, if present
O2 ____ Chest Tube ___ Drainage Color and Character

Pain / Comfort Gastrointestinal

Verbalizes no acute pain Pain ___/10 Abd Soft ___ Nondistended ____
Verbalizes no chronic pain Pain ___/10 BS x_____ W/O N/V _____ LBM_____
No observable s/s of pain Diet ______

Neurological Genitourinary
PERRLA__________ Voiding ____ Foley____
Loc AA Ox ___ Color and Character ____
Active ROM x___ Without Pain and discharge
Symmetry of Strength UE __ LE__
Swallowing without difficulty

Cardiovascular Integumentary
CRT < 3 sec. Braden Score ____
Edema ________ No JVD Without Rash____
Without Skin Breakdown_______
Mucous membrane pink IV Sites ______ Last changed_____
Tele _____________ S1 S2 IV Sites ______ Last changed_____
Rhythm Rate
Pulses Apical __ UE__ LE__ Muscoloskeletal
Skin warm and dry Fall Risk Score ____
Full Active ROM ______ Assist ________
Respiratory
Psychosocial
Breath Sounds clear and equal Coping well / Appropriate
Respirations even and unlabored Short and Long Term Memory Intact
Chest expansion symmetrical Family Supportive to Pt.___________
No secretions / sputum Sputum clear, if present
O2 ____ Chest Tube ___ Drainage Color and Character