Head to Toe - created from Mind Map

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Bracelet

Vital signs m.jhkjhlg

Neuromuscular

Cardiovascular

Respiratory

Genito-URINARY - GU

Gastro-INTESTINAL - GI

Aphasia

Pain

Skin

IV

Extremities

3 checks - the chart, the bracelet, ask the patient his name

Within normal limits - Resp 12-20, Pulse 60-100, O2 95-100%, Temp 36.5-38, BP 100/60 - 130-90

Alert, Oriented x 3, Pupils: PERRLA (Pupils are Equal, Round, Reactive to Light, Accommodation), Msk with gravity & resistance (head, hands, arms, legs)

Cap refill. Skin: warm/dry, diaphoretic, Turgor, BP. Pulse: Radial, Femoral, Pedial, Post tib. Auscultate: S1 & S2 sounds heard (S1 & S2 @ erbs. S1 @ tricuspid & mitral. S2 atrium or aortic, pulmonary or pulmonic

O2 stats 95-100%, Respiration rate 12-20 ppm,, Cough, Respiration effort, Resp Rhythm. AUSCULTATE anterior & poster - Chest sounds (upper, mid, lower)

When did the patient last urinate? Frequency? Any pain or discomfort? Amount WNL (over 30 mls/hr) , colour, characteristic odour. Assess the catheter if they have one.

When was the patients last bowel movement? Bristol stool chart. Are they passing gas? How much are they eating? Any nausea or vomiting? Oral mucosa, Tongue. Auscultate the 4 quadrants, as well as listen for bruits (locations.....???). Palpate for any distention or tender. Tubes: NG, PEG, Feeding tube, Stoma?

Difficulty speaking - Dysarthria, problems with speech, Expressive aphasia - understands but can't respond w/ great difficulty, Receptive aphasia - cannot understand spoken words but speaks fluently

Are you experiencing any pain or discomfort? Provoke, Quality, Region/Radiating, Severity 0-10,Time

Is the patient itchy? Any turgor, dry skin, bruising, rash, colour. Examine common pressure ulcer points, identify any wounds or scars. Edema or signs of infection?

If the patient has an IV does the bag need to be changed, are the lines clear? Check the IV site for any Redness, Tenderness/Pain, Warmth, Swelling, Drainage

Capillary refill, Colour, Temp, Sensation, Pain, Swelling