Temperature (1/5 point)
Normothermic
Hyperthermic
Hypothermic
Blood Pressure (1/5 point)
Normotensive
Hypertensive
Hypotensive
Heart Rate (1/5 point)
Normal
Tachycardic
Bradycardic
Respiratory Rate (1/5 point
...
Temperature (1/5 point)
Normothermic
Hyperthermic
Hypothermic
Blood Pressure (1/5 point)
Normotensive
Hypertensive
Hypotensive
Heart Rate (1/5 point)
Normal
Tachycardic
Bradycardic
Respiratory Rate (1/5 point)
Normal
Tachypnea
Bradypnea
O2 Saturation (1/5 point)
Normal
Hypoxemia
Auscultated Breath Sounds 11 ooff 11 ppooiinntt
Breath Sounds (1/2 point)
Clear in all areas
Diminished in some areas
Absent in some areas
Adventitious Sounds (1/2 point)
No adventitious sounds
Wheezing
Fine crackles
Stridor
Rhonchi
Rales
Auscultated Heart Sounds 11 ooff 11 ppooiinntt
Heart Sounds (1/3 point)
S1 and S2 audible
S1, S2, and S3 audible
S1, S2, and S4 audible
S1, S2, S3, and S4 audible
Extra Heart Sounds (1/3 point)
No extra sounds
Gallops
Murmur
Friction rub
Valve clicks
Objective Data Collection: 21 of 21 (100%)
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Rate And Rhythm (1/3 point)
Regular rate and rhythm
Arrhythmia
Inspected Upper Extremities for Self-harm or Abuse 11 ooff 11 ppooiinntt
Observations (1/3 point)
No visible evidence of self-harm or abuse
Evidence of self-harm
Evidence of abuse
Wounds Or Scars (1/3 point)
No visible wounds or scars
Wound visible
Scar visible
Location Of Visible Abnormality (1/3 point)
No visible abnormality
Right upper arm
Right lower arm
Right wrist
Right hand
Left upper arm
Left lower arm
Left wrist
Left hand
Inspected Involuntary Facial and Oral Movements 11 ooff 11 ppooiinntt
Observations Of Involuntary Movement (1/1 point)
Normal
Frowning, smiling, or grimacing
Clenching or biting
Puckering or smacking lips
Lateral oral movement
Excessive blinking
Periorbital movement
Inspected Involuntary Movements of Upper Extremities 11 ooff 11 ppooiinntt
Observations (1/1 point)
Normal
Choreic movements (rapid, irregular mo
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