Assessed Vitals
Temperature: normothermic
Blood Pressure: hypertensive
Heart Rate: no abnormal findings
Respiratory Rate: no abnormal findings
O2
... [Show More] Saturation: no abnormal findings
Assessed IV Bag
Appropriate Fluid: bag is normal saline
Appropriate Label: name and dosage are correct
Fluid Appearance: no visible abnormal appearance
Assessed IV Pump
Infusion Rate: IV pump is infusing IV fluid at the ordered rate
Assessed IV Site
Insertion Site: no visible abnormal signs
Dressing: dry and intact
Assessed Urine Quality
Clarity of Urine: clear
Color of Urine: pale yellow
Odor: no noticeable odor
Inspected Head and Face
Skull Symmetry: symmetric
Facial Feature Symmetry: symmetric
Appearance: no visible abnormal findings
Inspected Eyes
Eyelids: no visible abnormal findings
Conjunctiva and Lens: no visible abnormal findings
Pupillary Reaction: no visible abnormal findings (PERRL)
Accommodation: normal constriction and dilation
Inspected Mouth
Oral Mucosa and Gums: moist and pink, no bleeding
Lips: smooth, pink, and moist
Tongue: moist, pink
Inspected Lower Legs
Right: Appearance: no visible abnormal findings
Left: Appearance: no visible abnormal findings
Symmetry: symmetric bilaterally
Inspected Skin
Wounds or Sores: no abnormal findings
Signs of Skin Trauma: scarring
Color or Appearance: freckles, birthmarks, melasma, or other lesions
Masses or Texture: no abnormal findings
Skin Characteristics and Hair Growth: no abnormal findings
Auscultated Carotids
Right: no bruit
Left: no bruit
Auscultated Breath Sounds
Breath Sounds: clear in all areas
Adventitious Sounds: no adventitious sounds
Auscultated Heart Sounds
Heart Sounds: S1 and S2 audible
Extra Heart Sounds: no extra sounds
Rate and Rhythm: regular rate and rhythm
Palpated Temporal Arteries
Right: Observations: no abnormal findings
Right: Amplitude: 2+ expected
Left: Observations: no abnormal findings
Left: Amplitude: 2+ expected
Palpated PMI
Location: present at midclavicular line and 5th intercostal space
Size: <2 cm (penny or dime sized)
Characteristics: brisk and tapping
Palpated Posterior Tibial Pulse
Right: Vibration: no thrill
Right: Amplitude: 2+ expected
Left: Vibration: no thrill
Left: Amplitude: 2+ expected
Palpated Dorsalis Pedis Pulse
Right: Vibration: no thrill
Right: Amplitude: 2+ expected
Left: Vibration: no thrill
Left: Amplitude: 2+ expected
Tested Cognition
Clock Drawing Test: missing or incorrectly placed numbers, or hands do not display requested time (0 points)
Word Recall: correctly recalled one word (1 point)
Tested Posture
Observations: no difficulty standing erect, shoulders even; no reported pain; no swaying, falling, or widening of feet
Tested Fine Motor Skills
Observations at Rest: able to perform without difficulty; no tremor
Observations with Held Posture: able to perform without difficulty; no tremor
Observations with Movement: able to perform without difficulty; no tremor
Tested Grip Strength
Strength: 5 - active movement against full resistance without fatigue
Tested Skin Turgor
Observations: no tenting
Tested Capillary Refill
Capillary Refill Time: less than 2 seconds [Show Less]