Initals Age RM by alicejenny

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									                                           Physical Assessment
                                                                                     Chad Smallwood
Initals:_____ Age:_____ RM #_______                    Wounds:

C/O:_______________________________________            Location:____________________________

___________________________________________            Size:_____________ Pink Red Black

                                                       Drainage: Color:______ Odor:_______
HX:_______________________________________
                                                       Consistancey:_______ Amt:_________
___________________________________________
                                                       Breakdown:_________________________________

                                                       Dressings:__________________________________
Meds:______________________________________
                                                       Dressing Changes:____________________
___________________________________________
                                                       ___________________________________
___________________________________________
                                                       Wound Appearance:__________________
___________________________________________
                                                       ___________________________________
___________________________________________

___________________________________________


Alergies:___________________________________

___________________________________________


TX: C-collar O2_____lpm CPM

Wound vac Traction Walker Cane

Wheel Chair Crutches
                                                       SKIN

Airway: Clear Gurgling Stridor FB                      Color: Pink Pale Blue Gray

Breathing: Rate:_____ shallow agonal                   Temp: Warm Cool

Irregular paradoxal movement                           Lesions: ____________________________

Circulation: Pulse:_____bpm Weak Thready               Turgor: <2sec >2sec

Irregular Site: Radial Brachial Carotid
                                                       Hair: Clean Dirty Dry Moist
Apical:____bpm Regular Irregular Murmur:______
                                                       Eyes:
Gallop:______ Clicks_______
                                                       Sclera Color: White Red
BP:___________ Temp:_________
                                                       PERRLA__________________
HT:________ WT:_________
                                                       Drainage:____________________________
Special Considerations:_______________________
                                        Physical Assessment
                                                                                  Chad Smallwood
Ears:                                               Upper Extremities:

Canals: Clear Impacted R L                          FROM w/o difficulty Rom:_________ L R

TM: Gray Red Perforated R L                         Radial Pulse: Present Diminished Absent L R

                                                    ___________________________________________
Nose:
                                                    ___________________________________________
Nares: Pink Red Mucus Deviation R L

                                                    Lower Extremities:
Mouth:
                                                    FROM w/o difficulty ROM:_________      L   R
Lips: Moist Dry Pink Blue
                                                    Pedal Pulse: Present Diminished Absent L R
Teeth: Intact Broken Bleeding
                                                    ___________________________________________
Gums: Moist Dry Pink Red
                                                    ___________________________________________
Throat: Moist Dry Pink Red Injected Exudate

                                                    Neuro:
Neck:
                                                    Alert Oriented to Person Place Time Situation
Supple Lymphadnopathy Trachial Deviation JVD
                                                    Loss of sensation:____________________________
Step off Tender     Decreased ROM______________
                                                    ___________________________________________
___________________________________________
                                                    Loss of function:_____________________________

                                                    ___________________________________________
Chest:

Respiratory Movement: Symmetrical Paradoxical
                                                    Additional Notes:____________________________
Breath Sounds: Clear Wheezes Rhonchi Rales
                                                    ___________________________________________
Decreased Movement R       L
                                                    ___________________________________________
Cough: Productive    Non-Productive
                                                    ___________________________________________
Trach: Yes No
                                                    ___________________________________________
Care performed______________________________
                                                    ___________________________________________
Cyanosis: YES     NO
                                                    ___________________________________________

                                                    ___________________________________________

                                                    ___________________________________________

                                                    ___________________________________________

                                                    ___________________________________________

								
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