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PATIENT assessment PAGE 2
Procedures
- BC
- CT Scan
- CXray
- Echo
- EEG
- EGD
- EKG
- MRCP
- MRI
- Pet Scan
- Pulmonary
- Stress Test
- UA
- UC /S
- U/S
- V Q Scan
- X-Ray
assessment
Neuro (AA0X3, confused, disoriented, PERRLA, paralysis, pain, ambulation, gait)
Respiratory (wheezes, crackles, rhonchi, rales, stridor, trach, 02, IS, chest tube, cough, non/productive)
Cardio (pulses, HR, rhythm & character, capillary refill, edema, vascular access devices, apical S3, S4)
GI (soft, distended, BM, + BS, NG tube, N/V, flatus,
tube feeding, colostomy, ileostomy, incontinent )
GU (voiding, bladder distended, nephrostomy tube, Miami pouch, urine frequency, character, foley, incontinent.
Integumentary (edema, drsg, incision, temp, turgor, clammy, dry intact, fricition, TEDS, SCD, lesions, rashes)
Consults
Neuro, ENT, Optometry, Endocrine, Cardiac, Pulmonary, GI, Colorectal, GU, GYO, Nephrology, ID, Derm, Surgery, Anesthesia, Plastics, Oncology, Speech, Ortho, Spine, Pain, Wound Care,
RadOnc, Psych, Social Work
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