Eyes x palpation liver span other head neck

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Eyes x Palpation Liver Span Other ___________ Head & Neck Conjunctiva/lids CV Spleen Skin Spine/Ribs x Pupils (Reactivity/Accom) x PMI Inguinal Area Inspection Pelvis Disc/Fundi x Palpation GU – Male Palpation RUE Stability EOM x Auscultation Scrotum/Testes Neuro LUE ROM ENMT x Rhythm Penis Cranial Nerves RLL Strength Ear Infection x Rate Anus Tendon Reflexes LLE TMs & Canal S1 Perineum Biceps ROM Hearing (Whisper, Etc.) S2 Rectal Area (Ext.) Triceps Gait Weber x Carotid Art. Prostate (DRE) Patellar Clubbing/Cyanos Rhinne Abd. Aorta Occult Blood Achilles Edema Nasal Mucosa/Septum/ x Fem. Pulses GU – Female Brachioradialis Psychiatric Turb. x Extremities (Edema/ Ext. Genitalia Motor Strength Orientation Lips/Gums/Teeth Varicose Veins) Urethra Upper Ext. – Strength (Person, Place, Time) Oropharynx Chest Cervix Lower Ext. – Strength Mental Status Neck x Inspection Adnexa Sensory Judgment Appearance x Palpation Uterus Light Touch Insight Symmetry Right Breast Bladder Pin Prick Short-Term Mem Trachea Left Breast Saline/KOH Vibration Long-Term Mem Thyroid Right Axillae Rectal Exam x Temperature Mood Lymph Nodes Left Axillae Occult Blood Proprioception Affect Lungs Abdomen Lymph Nodes Romberg Concentration x Resp. Effort Inspection Neck RAM Speech x Rib Excursion Supraclavicular Babinski Eval Comments: ___Mr. Smith seems to be in the middle of an acc_________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________ Assessment & Plan: ____The critical care nurse plan considers immediate intubation of the patient with 100% oxygenation, and to continue sedation and
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  • Fall '19
  • Physical examination, Available ,   PND

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