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    The patient experiences pain that is stabbing, crushing, throbbing, and nauseating. The pain is located in their region and travels. It is worse with certain movements and activities and better with rest. Additional symptoms include sleep disturbances and difficulty eating. The patient's current treatment provides some satisfaction but their pain needs to be reassessed regularly.

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    prosie392
    23 views2 pages
    The patient experiences pain that is stabbing, crushing, throbbing, and nauseating. The pain is located in their region and travels. It is worse with certain movements and activities and better with rest. Additional symptoms include sleep disturbances and difficulty eating. The patient's current treatment provides some satisfaction but their pain needs to be reassessed regularly.

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    The patient experiences pain that is stabbing, crushing, throbbing, and nauseating. The pain is located in their region and travels. It is worse with certain movements and activities and better with rest. Additional symptoms include sleep disturbances and difficulty eating. The patient's current treatment provides some satisfaction but their pain needs to be reassessed regularly.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    23 views2 pages

    Cheatsheets

    Uploaded by

    prosie392
    The patient experiences pain that is stabbing, crushing, throbbing, and nauseating. The pain is located in their region and travels. It is worse with certain movements and activities and better with rest. Additional symptoms include sleep disturbances and difficulty eating. The patient's current treatment provides some satisfaction but their pain needs to be reassessed regularly.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    CHEPHALOCAUDAL ASSESSMENT

    Name of Patient: PAIN


    Age:
    DOB: Experiences Pain: YES/NO
    Marital Status: Character (Feeling, Appearance, Sound, Smell,
    Occupation: Taste): Stabbing/Crushing/Throbbing/Nauseating/
    S/O: Twisting/Stretching/Shard/Dull – Sudden/Gradual
    Address: _______________________________________
    Date of Admission: Onset (What were you doing when the pain
    Room #/Bed #: started): ________________________________
    Chief Complaint: Location (Region/Travels?):
    _______________________________________
    CURRENT/PAST HEALTH HISTORY Duration: Hourly/Daily/Weekly/Seasonal – Early
    Morning/Daytime/Afternoon/Night –
    Past Diseases: After/During/Before Meals
    Family History: _______________________________________
    Injuries: Severity (Pain Scale 1-10):
    Surgery: _______________________________________
    Childhood Illness: Pattern (What makes it worse/better):
    Allergies: Meds/Massage/Heat/Cold/ Changing
    Accidents: Position/Ambulation/Resting
    Hospitalized (freq., why): Movement/Bending/Lying
    Vaccine: Down/Walking/Standing/Eating
    Can Pass Gas: YES/NO _______________________________________
    Past Meds (Name, Dose): Associated Factors (Other s/s, how it affects pt.):
    Current Contraptions: IV Sleep Disturb./Diff. Eating/Activity Intolerance
    (______________________)/Ventilator/Central ______________________________________
    Line/EEG/ECG/Humedex Monitor (blood floow Patient’s Satisfaction w/ current treatment:
    sa brain)/Restraints/Compression Boots/Bedside ______________________________________
    Monitor/ICP Monitor/Feeding Tube/Foley Reassess pain every: _____________________
    Catheter _______________________________
    Can perform ADLs: YES/NO

    ADDITIONAL NOTES:
    Vital Signs 8 AM/4 PM 12 PM/8 PM
    Temp
    PR
    RR
    BP
    O2 Saturation
    Urine (amount, color,
    consistency)
    Stool (amount, color,
    consistency)

    General Vital Signs: Normal/Abnormal


    Survey Behavior:
    Anxiety:
    Level of Hygiene:
    Level of Independence: Total Assistance/Supervision/Complete Independence
    Body Position:
    Mobility:
    Speech Pattern and Articulation:
    Skin, Hair, Lesions/Bruising/Rashes/Wound in Skin and Scalp:
    Nails Skin Temp: Cold/Warm/Hot to touch
    Skin Color: Cyanotic/Redness/Necrotic
    Skin Edema:
    Skin Moisture/Turgor:
    Hair Patches:
    Shape of Nails: Normal/Clubbing/Spooning
    Capillary Refill:
    Assess Pressure Areas (heel/elbow/buttocks/hips): Needs position change?
    Head (inc. Eye Drainage (color, consistency, amount, location):
    Eyes, Ears, Ear Drainage (same same):
    Mouth) and Pupillary reaction to light:
    Neck Dentures: YES/NO
    Tongue (texture, color):
    Mouth (moisture, color, odor):
    Nasal Congestion:
    Symmetry of Face, Eyes, Mouth:
    Thorax Breath Sounds:
    (Chest) DOB/SOB: YES/NO
    Use of Accessory Muscles:
    Jugular Distension (bulging of vein on neck):
    Symmetry:
    Apical HR:
    Chest Pain (COLDSPA):
    Reproductive Menstruation: Regular/Irregular __________
    (Breast, etc.) GPTPAL: Gravida ____ Para ____ Term ____ Premature ____ Abortion ____ Live ___
    Hx of Cancer (breast, ovary, cervical, testicular, prostate, etc.)
    SBE (best 3-5 days after period starts)/STE (during/after shower when scrotum is relaxed):
    Regularly Done/Unfamiliar
    Sexual Activity: Active/Inactive
    Hx. Of STDs:
    Peripheral Pulse of Extremities:
    Vascular Leg/Arm Pain:
    Bulging of Veins:
    Leg Sore (Location):
    Edema:
    Palpate Radial, Ulnar, Brachial Pulse:
    Abdomen and Symmetry:
    Renal Bowel Sounds (RLQ):
    Function Palpate for Pain: YES/NO
    Musculo- Weight Bearing: Full/Partial
    skeletal Gait/Balance:
    Requires Assistance (from assistive devices/so):
    Risk for Falls:
    Weight Gain:
    Neurologic Alertness:
    Orientation to Person, Place, and Time:
    Headache:
    Past Head Injuries:
    Mental Conditions:
    Level of Consciousness:
    GCS: Eye Opening _______ Verbal Response _______ Motor Response ________
    Sensation (sight, smell, taste, touch, hearing):
    Lifestyle Diet:
    Smoking/Drinking/Recreational Drugs
    Exercise (frequency, type, intensity): YES/NO __________
    Coping Mechanism regarding disease:
    Sleep Pattern (how long, when start and end):
    ACTIONS DONE/ADDITIONAL NOTES:

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