Pain / Comfort Verbalizes no acute pain Pain ____/10 Verbalizes no chronic pain Pain ___/10 No observable s/s of pain

Neurological PERRLA__________ Loc AA Ox ___ Active ROM x___ Symmetry of Strength UE __ LE__ Swallowing without difficulty Cardiovascular CRT < 3 sec. Edema ________

Gastrointestinal Abd Soft ___ Nondistended ____ BS x_____ W/O N/V _____ LBM______ Diet ______ Genitourinary Voiding ____ Foley____ Color and Character ____ Without Pain and discharge

No JVD

Mucous membrane pink Tele _____________ S1 S2 Rhythm Rate Pulses Apical __ UE__ LE__ Skin warm and dry Respiratory Breath Sounds clear and equal Respirations even and unlabored Chest expansion symmetrical No secretions / sputum Sputum clear, if present O2 ____ Chest Tube ___ Drainage Color and Character

Integumentary Braden Score ____ Without Rash____ Without Skin Breakdown_______ IV Sites ______ Last changed_____ IV Sites ______ Last changed_____ Muscoloskeletal Fall Risk Score ____ Full Active ROM ______ Assist ________ Psychosocial Coping well / Appropriate Short and Long Term Memory Intact Family Supportive to Pt.___________

Pain / Comfort Verbalizes no acute pain Pain ___/10 Verbalizes no chronic pain Pain ___/10 No observable s/s of pain Neurological PERRLA__________ Loc AA Ox ___ Active ROM x___ Symmetry of Strength UE __ LE__ Swallowing without difficulty Cardiovascular CRT < 3 sec. Edema ________

Gastrointestinal Abd Soft ___ Nondistended ____ BS x_____ W/O N/V _____ LBM_____ Diet ______ Genitourinary Voiding ____ Foley____ Color and Character ____ Without Pain and discharge

No JVD

Mucous membrane pink Tele _____________ S1 S2 Rhythm Rate Pulses Apical __ UE__ LE__ Skin warm and dry Respiratory Breath Sounds clear and equal Respirations even and unlabored Chest expansion symmetrical No secretions / sputum Sputum clear, if present O2 ____ Chest Tube ___ Drainage Color and Character

Integumentary Braden Score ____ Without Rash____ Without Skin Breakdown_______ IV Sites ______ Last changed_____ IV Sites ______ Last changed_____ Muscoloskeletal Fall Risk Score ____ Full Active ROM ______ Assist ________ Psychosocial Coping well / Appropriate Short and Long Term Memory Intact Family Supportive to Pt.___________