SHADOW HEALTH - EDWARD CARTER - PAIN - OBJECTIVE

SHADOW HEALTH - EDWARD
CARTER - PAIN - OBJECTIVE
[Document subtitle]




[DATE]
[COMPANY NAME]
[Company address]

, Assessment Findings

1. Assessed Vitals

1. Temperature: Normothermic

2. Blood Pressure: Normotensive

3. Heart Rate: No abnormal findings

4. Respiratory Rate: No abnormal findings

5. O2 Saturation: No abnormal findings

2. Assessed IV Bag

6. Appropriate Fluid: Normal saline

7. Appropriate Label: Name and dosage correct

8. Fluid Appearance: No visible abnormalities

3. Assessed IV Pump

9. Observations: Infusing at ordered rate

4. Inspected IV Site

10. Insertion Site: No abnormal signs

11. Dressing: Dry and intact

5. Inspected Head and Face

12. Skull Symmetry: Symmetric

13. Facial Feature Symmetry: Symmetric

14. Appearance: No visible abnormalities

6. Inspected Eyes

15. Eyelids: No abnormalities

16. Conjunctiva and Lens: No abnormalities

17. Pupillary Reaction: No abnormalities (PERRL)

7. Inspected Mouth

18. Oral Mucosa and Gums: Moist, pink, no bleeding

19. Lips: Smooth, pink, moist

20. Tongue: Moist, pink