Assessment Inicial De Dolor

VITAL SIGNS
T ______________
P ______________
R ______________
Wt ______________
BP ___________right
___________left
Glucometer
BS ______________
□ Standard Precautions
MaintainedCARDIOVASCULAR
□ No Deficit ___________________
□ Chest Pain __________________
□ Heart Sounds ________________
□ Peripheral Pulses _____________
□ Dizziness ___________________
□ Edema______________________
□ Neck Vein Distention ___________
□ Arrhythmia __________________
□ Unchanged since last visit
RESPIRATORY
□ No Deficit ___________________
□ Rale/Rhonchi ________________
□ SOB_______________________
□ Cough ______________________
□ Sputum _____________________
□ O2 at ________________________
□ O2 Sat _______________________
□ Other _______________________
□ Unchangedsince last visit
NEUROLOGICAL
□ No Deficit
□ Oriented to Person/
Place/Time
□ Seizures/Tremors
SENSORY
□ Hearing Impaired
□ Speech Impaired
□ Visually Impaired
□ Legally Blind
□ Unchanged sincelast
Visit
PSYCHOLOGICAL
□ No Deficit □ Combative
□ Confused □ Restless
□ Depressed □ Drowsy
□ Tearful □ Semi-Comatose
□ Withdrawn □ Comatose
□ Agitative □ Lethargic
□ Hostile □ Forgetful
□Unchanged since last visit
GU
□ No Deficit
□ Incontinent
□ Distention
□ Retention
□ Burning
□ Frequency
□ Foleycath
□ Suprapubic
□ Size _________ Fr
_________ ml
□ Unchanged since
lastvisit
Medication change since last visit? □ No □ Yes

SKIN
□ No Deficit □ Warm/Dry
□ Cool/Clammy □ Turgor Adequate
Wound #1
Location
_____________
L __________
W __________
D __________DRAINAGE
Amt _________
Color ________
Odor_________
Wound #2
Location
_____________
L __________
W __________
D __________
DRAINAGE
Amt _________
Color ________
Odor_________
□ Unchangedsince last visit
DIGESTIVE/NUTRITION
□ No Deficit - Last BM _________________
□ N/V □ Diarrhea □ Constipation
□ Tube Feeding □ NPO
Type/Amt. _________________
□ ✓Placement □ ✓Residual/Amt....