Vital Signs - Texas Department of State Health Services Mobile



Vital SignsPulse ____beats/minRespirations ____breaths/minBlood Pressure ____mm Hg/ ____mm HgOxygen Saturation _____ SO2aTemperature ____ degrees FahrenheitHeight ______ft _____inchesWeight _____lbsNotes:________________________________________________________________________________________________________________________________________________________________________History of Present IllnessMental StatusHave you experienced any disorientation or confusion recently?Have you experienced any depression or anxiety recently?________________________________________________________________________________________________________________________________________________________________________GrowthHave you noticed any weight loss, weight gain, or physical changes lately?________________________________________________________________________________________________________________________________________________________________________NutritionHave you noticed any weight loss, weight gain, or physical changes lately?Have you made any recent changes to your eating habits?Have you felt exhausted lately?________________________________________________________________________________________________________________________________________________________________________PainHave you noticed any pain lately? If so when did it start, where does it hurt, what is its intensity, has it effected on your daily activities and mood, has it caused any other sort of discomfort or symptoms?________________________________________________________________________________________________________________________________________________________________________Skin, Hair, NailsHave you noticed any rashes, bumps, red spots or irritation on your skin recently?Have you noticed any changes in your hair’s thickness, color, feel, or growth lately?Have you noticed any changes in your nail’s lately?________________________________________________________________________________________________________________________________________________________________________Lymphatic SystemHave you experienced any swelling lately?________________________________________________________________________________________________________________________________________________________________________Head & NeckHave you had headaches or a stiff neck recently?Have you experienced a head injury recently?________________________________________________________________________________________________________________________________________________________________________Eyes, Ears, Nose, ThroatHave you experienced any trouble seeing, or discomfort in your eyes?Have you had trouble hearing or experienced ear pain recently?Have you had any nosebleeds, a runny nose, and/or been snoring recently?Have you experienced any pain, pressure, and/or stuffiness around your nose recently?Have you had any toothaches, cuts, and/or general discomfort in your mouth lately?Have you had a sore throat, difficulty swallowing, or sounded funny recently?________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Chest & LungsHave you experienced any coughing, shortness of breath, or chest pain recently?________________________________________________________________________________________________________________________________________________________________________HeartHave you experienced any fatigue, difficulty breathing, or shortness of breath lately?Have you experienced any chest pain recently?Have you any episodes where you lost consciousness recently?________________________________________________________________________________________________________________________________________________________________________Blood Vessels?Have you had any leg pain or cramps lately?Have your ankles been swollen recently?________________________________________________________________________________________________________________________________________________________________________AbdomenHave you experienced any abdominal pain, indigestion, nausea, or vomiting recently?Have you had any instances of diarrhea or constipation lately?Have you had any trouble peeing lately or felt the need to pee frequently?________________________________________________________________________________________________________________________________________________________________________MusculoskeletalHave you experienced any discomfort in your joints?Have you experienced any discomfort in your muscles?Have you had any recent injuries or back pain?________________________________________________________________________________________________________________________________________________________________________NeurologicHave you experienced any seizures, convulsions, or tremor lately?Have you experienced any general weakness lately?Have you had a moto issues or experienced a lack of coordination lately?________________________________________________________________________________________________________________________________________________________________________Upon completion of Vital Signs, an assessment of History of Present Illness, and a Physical Examination, the nursing staff recommend the development of an Emergency Care Plan: YESNONurse’s Printed Name:___________________________________________Nurse’s Signature: ______________________________________________ Date: ___ / ___ / ______Physical ExaminationMental StatusPhysical Appearance and BehaviorGroomingEmotional StatusBody LanguageState of ConsciousnessCognitive AbilityAnalogiesAbstract ReasoningArithmetic CalculationWriting AbilityExecution of Motor SkillsMemoryAttention SpanJudgementSpeech and Language SkillsVoice QualityArticulationComprehensionCoherenceEmotional StabilityMood and FeelingsThought Process and ContentPerceptual Distortions and HallucinationsAdditional ProceduresGlasgow Coma ScaleGrowthWeight and Standing HeightBody Mass IndexUpper to Lower Segment RatioArm SpanNutritionAnthropometricsWaist CircumferenceWaist-to-Hip Circumference RatioDetermination of Diet AdequacyTwenty-Four-Hour Recall DietFood DiaryMeasures of Nutrient AnalysisMy Pyramid Food Guide (MyPlate)Vegetarian DietsEthnic Food Guide PyramidsMeasures of Nutrient AdequacySpecial ProceduresTriceps Skinfold ThicknessMid-Upper Arm CircumferenceMidarm Muscle Circumference/Midarm Muscle AreaPainSelf-Report Pain Rating ScalesAssessing Pain BehaviorsSkin, Hair, NailsSkinInspectionPalpationHairNailsInspectionPalpationLymphatic SystemInspection and PalpationHead and NeckAxillaeEpitrochlear Lymph NodesInguinal and Popliteal Lymph NodesSpleenHead & NeckHead and FaceInspectionPalpationPercussionAuscultationNeckInspectionPalpationLymph NodesThyroid GlandEyes, Ears, Nose, ThroatVisual Acuity TestingExternal ExaminationSurrounding structuresEyelidsPalpationConjunctivaCorneaIris and PupilLensScleraLacrimal ApparatusExtraocular MusclesOphthalmoscopic ExaminationUnexpected FindingsEars and HearingExternal earOtoscopic ExaminationHearing EvaluationNose, Nasopharynx, and SinusesExternal NoseNasal CavitySinusesMouth and OropharynxLipsBuccal Mucosa, Teeth, and GumsOral CavityOropharynxChest & LungsInspectionRespiratory PatternsObserving RespirationLooking for Clues at the PeripheryPalpationExamining the TracheaPercussionDiaphragmatic ExcursionAuscultationBreath SoundsVocal ResonanceCoughsSputumHeartInspectionPalpationPercussionAuscultationBasic Heart SoundsExtra Heart SoundsHeart MurmursRhythm DisturbanceBlood VesselsPeripheral ArteriesPalpationAuscultationAssessment for Peripheral Arterial DiseaseBlood PressurePeripheral VeinsJugular Venous PressureHepatojugular RefluxEvaluation of Hand VeinsAssessment for Venous Obstruction and InsufficiencyAbdomenInspectionSurface CharacteristicsContourMovementAuscultationBowel SoundsAdditional Sounds and BruitsPercussionLiver SpanSpleenGastric BubbleKidneysPalpationLight PalpationModerate PalpationDeep PalpationMassesUmbilical RingPalpation of Specific Organs and StructuresAdditional ProceduresAscites AssessmentPain AssessmentAbdominal SignsRebound TendernessIlliopsoas Muscle TestObturator Muscle TestBallottementMusculoskeletalInspectionPalpationRange of MotionMuscle StrengthSpecific Joints and MusclesHands and WristsElbowsShouldersTemporomandibular JointCervical SpineThoracic and Lumbar SpineHipsLegs and KneesFeet and AnklesAdditional ProceduresHand and Wrist AssessmentShoulder AssessmentLower Spine AssessmentHip AssessmentKnee AssessmentLimb MeasurementNeurologicCranial NervesOlfactoryOpticOculomotorTrochlearAbducensTrigeminalFacialAcousticGlassopharyngealVagusSpinal AccessoryHypoglossalProprioception and Cerebellar FunctionCoordination and Fine Motor SkillsBalanceSensory FunctionPrimary Sensory FunctionsCortical Sensory FunctionsReflexesSuperficial ReflexesDeep Tendon ReflexesAdditional ProceduresProtective SensationMeningeal SignsPosturing ................
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