Professional Documents
Culture Documents
Cardiac
Rhythm: □ Regular □ Irregular
Radial: RT □ Present □ Absent LT □ Present □ Absent
Pedal: Rt □ Present □ Absent LT □ Present □ Absent
Edema: □ None □ Present (□ 1+ □ 2+ □ 3+ □ 4+) Location: _______________
Musculoskeletal
Mobility: □ Full □ Limitations Describe: ____________________________________________
Gait: □ Steady □ Unsteady Activity: □ Self □Assist □ Total
HOB: □ Up _____ Deg. ROM: □ Self □ Assist
Skin
Color: □ Normal □ Cyanotic □ Pale Condition: □ Dry □ Moist
Temperature: □ Cool □ Warm Integrity: □ Intact □ Not intact
Skin Integrity Protocol: □ Yes □ No □Turned approximately every 2 hours □Turns Self
Psych
Affect: □ Calm □ Anxious □ Flat □ Confused □ Depressed □ Combative □ See Behavior documentation MAR
Communication: □ Intact □ Impaired
Involvement with plan of care: □ Active □ Refuses □ Dependent
Nutrition
Appetite: Good / Fair / Poor
Safety
Siderails: □ Full □ Half Transfers: □ Use lift □ 1 asst □ Total □ Independent
Fall Risk Protocol: □ Yes □ No □ Call light in reach □ Low Bed □ Restraint
VITAL SIGNS: B/P _________ PULSE _______ RESP ______ TEMP _____