*If no bowel movement, chart in the progress notes how long without one, assessment and what interventions were done.

5-Oriented/Coos: Babbles4-Confused/Irritable Cries3-Inappropriate Words/Cries to Pain2-Incomprehensible Sounds/Moans to Pain1-NoneT-Tracheostomy/Intubated

6-Obeys Commands/n Spont. Movement5-Localize to Pain/Withdraws to Touch4-Withdraws to Pain3-Flex to Pain/Abn. Flexion2-Extend to Pain/Abn. Extension1-None

4-Spontaneously3-To Speech 2-To Pain1-None

N = Normal   M = Mild Weakness  S = Severe Weakness   E = ExtensionF = FlexionA = Absent (No Movement)

S1 S2S3S4Murmur Rub

ClearFine CracklesCoarse CracklesGurgles/RhonchiInspiratory Wheezes (stridor)Expiratory WheezesDiminished

ClearFine CracklesCoarse CracklesGurgles/RhonchiInspiratory Wheezes (stridor)Expiratory WheezesDiminished

ClearFine CracklesCoarse CracklesGurgles/RhonchiInspiratory Wheezes (stridor)Expiratory WheezesDiminished

ClearFine CracklesCoarse CracklesGurgles/RhonchiInspiratory Wheezes (stridor)Expiratory WheezesDiminished

ClearFine CracklesCoarse CracklesGurgles/RhonchiInspiratory Wheezes (stridor)Expiratory WheezesDiminished

RegularIrregularDeepShallowShortness of AirNone

SymmetricalAsymmetrical

ProductiveNonproductive

StrongWeakNone

ThickThinNone

+4 = Bounding+3 = Normal+2 = Weak+1 = Very WeakD = Doppler0 = Absent

+4 = Bounding+3 = Normal+2 = Weak+1 = Very WeakD = Doppler0 = Absent

+4 = Bounding+3 = Normal+2 = Weak+1 = Very WeakD = Doppler0 = Absent

+4 = Bounding+3 = Normal+2 = Weak+1 = Very WeakD = Doppler0 = Absent

+4 = Bounding+3 = Normal+2 = Weak+1 = Very WeakD = Doppler0 = Absent

+4 = Bounding+3 = Normal+2 = Weak+1 = Very WeakD = Doppler0 = Absent

+4 = Bounding+3 = Normal+2 = Weak+1 = Very WeakD = Doppler0 = Absent

+4 = Bounding+3 = Normal+2 = Weak+1 = Very WeakD = Doppler0 = Absent

N = Normal   M = Mild Weakness  S = Severe Weakness   E = ExtensionF = FlexionA = Absent (No Movement)

N = Normal   M = Mild Weakness  S = Severe Weakness   E = ExtensionF = FlexionA = Absent (No Movement)

N = Normal   M = Mild Weakness  S = Severe Weakness   E = ExtensionF = FlexionA = Absent (No Movement)

YesNoIntubated

SoftFirmRigid

DistendedNondistended

AbsentHypoactiveActiveHyperactive

Yes NG to Low Intermittent Suction (LIS)Yes NG clampedYes OG to LISYes OG clampedYes G-Tube clampedYes G-Tube to dependent drainageYes G-Tube to LISYes J-Tube with Tube FeedingYes J/G-Tube (J-tube with Feeding, G-tube to LIS)Other (chart in progress note area)No Tube

Yes gastric tube patentNo gastric tube not patentNo gastric tube not checkedContraindicated

GreenBrownYellowRedBlack

ContinentIncontinentCatheter

YesNo

LargeMediumSmall

LiquidSemi-LiquidSoftFirm

ContinentIncontinent

CoolWarmHot

MoistDryElastic skin turgorTight skin turgor

Normal for patient's skin colorPalePeripheral cyanosisCentral cyanosisRed

PatentNot patentIV not present

Dressing dry and intactDressing wet and intactDressing not intact

YesNo

YesNo

If patient has peripheral line(s), please list location(s) and size of catheter(s) here: List the types and rates of IV infusions here:

Nasal CannulaSimple MaskNon-rebreather MaskVenturi MaskHigh Flow Nasal CannulaHigh Flow MaskIntubated/Ventilator

OralRectalAxillaryCore Through FoleyCore Through Swan

LyingSittingStanding

No Accessory Muscles UsedAccessory Muscles Used MildAccessory Muscles Used ModerateAccessory Muscles Used Severe

ApicalBrachialCarotidRadialFemoral

Active and FullAcitve and PartialPassive and FullPassive and PartialPassive and None

Active and FullAcitve and PartialPassive and FullPassive and PartialPassive and None

Active and FullAcitve and PartialPassive and FullPassive and PartialPassive and None

Active and FullAcitve and PartialPassive and FullPassive and PartialPassive and None

FullPartialNone

FullPartialNone

FullPartialNone

FullPartialNone

YesNo-NPO strictNo-Ice chips sparingly

YesNo

SteadySteady w/Assistive DevicesUnsteady

X 3X 2X 1

YesNo

No RednessRedRed/EdemaRed/Edema/HotRed/Edema/Cold

YesNo

YesNo

None+1  1-2 mm depression+2  3-4 mm depression+3  5-6 mm depression+4  7-8 mm depression

< or = 2 seconds> 2 seconds

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