in nursing

Response

AVPU mnemonic

FORMCHECKBOX A (alert)

FORMCHECKBOX V (responds to verbal stimuli)

FORMCHECKBOX P (responds only to painful stimuli)

FORMCHECKBOX U (unresponsive)

Airway and C-Spine

Subjective Data

Acceptable/stable

FORMCHECKBOX History related to airway problem

FORMCHECKBOX Dyspnea, dysphagia, or dysarthria

FORMCHECKBOX History of injury and no injury is suspected

FORMCHECKBOX History of degenerative bone disease (e.g., ankylosing spondylitis, osteoporosis)

FORMCHECKBOX Pain on movement (flexion/extension or side/side) or with palpation of neck

Partially obstructed or obstructed/unacceptable finding requiring immediate intervention

FORMCHECKBOX Trauma to face, mouth, pharynx, neck, or chest

FORMCHECKBOX Patient eating or drinking when difficulty began

FORMCHECKBOX Recent vomiting

FORMCHECKBOX Contact with allergen

FORMCHECKBOX Patient discovered putting objects into mouth

Objective Data:

Acceptable/stable

FORMCHECKBOX Patient able to open mouth widely, and mouth is clear

FORMCHECKBOX Patient able to speak or appropriately vocalize for age without dysphonia or muffled speech (this indicates a protected airway)

FORMCHECKBOX Foreign material, drooling, or obstruction visible in upper airway (e.g., blood, vomitus, loose teeth, foreign bodies, debris, angioedema):

FORMCHECKBOX Equal rise and fall of chest with ventilations

FORMCHECKBOX Adventitious upper airway noises (e.g., stridor, grunting)

Partially obstructed or obstructed/unacceptable finding requiring immediate intervention

FORMCHECKBOX Absence of breathing

FORMCHECKBOX Panic behavior, hands on throat, waving arms, grabbing at clothing

FORMCHECKBOX Patient unable to speak or vocalize appropriate for age

FORMCHECKBOX Substernal, intercostal retractions

FORMCHECKBOX Drooling in patient other than infant

FORMCHECKBOX Nasal flaring, especially in infant

FORMCHECKBOX Facial weakness or paralysis

FORMCHECKBOX Facial engorgement: ruddy/bright purple skin color

FORMCHECKBOX Violent coughing with lacrimation

FORMCHECKBOX Sitting up and leaning forward; tripod position

FORMCHECKBOX Decreased level of consciousness

FORMCHECKBOX Inspiratory and/or expiratory stridor

FORMCHECKBOX Pale, cyanotic, dusky gray skin color, especially mucous membranes and nail beds

FORMCHECKBOX Singed nasal/facial hair

FORMCHECKBOX Carbonaceous sputum

Inability to move extremities, C-spine pain or tenderness, palpable deformity or sensory loss

FORMCHECKBOX Paralysis, paresthesia, or hypersensitivity

FORMCHECKBOX Abdominal breathing indicating possible diaphragm paralysis

FORMCHECKBOX Decreased or absent movement/sensation below level of injury

FORMCHECKBOX Weakness

FORMCHECKBOX Bowel or bladder incontinence or retention

FORMCHECKBOX Hypotension

FORMCHECKBOX Bradycardia

FORMCHECKBOX Flaccid paralysis

FORMCHECKBOX Loss of sphincter tone

FORMCHECKBOX Priapism

FORMCHECKBOX Warm, dry skin

FORMCHECKBOX Bounding peripheral pulses

FORMCHECKBOX Hypothermia; poikilothermy (loss of temperature regulation and patient’s body assumes temperature of external environment)

FORMCHECKBOX Inability to shiver or sweat

Breathing

Subjective Data

Acceptable/stable

FORMCHECKBOX No distress

FORMCHECKBOX No history of injury to head, chest, or abdomen

FORMCHECKBOX No deviation from patient’s usual breathing pattern

Compromised or absent/unacceptable finding requiring immediate intervention

FORMCHECKBOX Blunt or penetrating injury to neck, chest, back, or abdomen

FORMCHECKBOX Severe asthma, emphysema, cardiovascular disease

FORMCHECKBOX Dyspnea

FORMCHECKBOX History of respiratory arrest

Objective Data

Acceptable/stable

FORMCHECKBOX Chest rises and falls spontaneously

FORMCHECKBOX Exhaled air may be felt or heard escaping from nose, mouth, or stoma

FORMCHECKBOX Respiration quality smooth, even

FORMCHECKBOX Chest expansion equal bilaterally

FORMCHECKBOX Possible mild tachypnea, retracting, wheezing, and accessory muscle use

FORMCHECKBOX Oxygen saturation measured by pulse oximetry (SpO2) 94–98% (or patient’s normal baseline.

Compromised or absent/unacceptable finding requiring immediate intervention

FORMCHECKBOX Apnea or agonal breathing (slower than 10 breaths/minutein adults)

FORMCHECKBOX Work of breathing: use of accessory muscles, abdominal breathing, nasal flaring, grunting (in pediatrics)

FORMCHECKBOX Marked tachypnea

FORMCHECKBOX Shallow, weak, gasping respirations

FORMCHECKBOX Skin color: pallor, dusky, cyanotic

FORMCHECKBOX Marked increase in respiratory effort

FORMCHECKBOX Kussmaul respirations: regular, rapid, deep, labored

FORMCHECKBOX Cheyne-Stokes respirations: alternating periods of hyperventilation and apnea

FORMCHECKBOX Decreased/absent breath sounds, unilaterally or bilaterally

FORMCHECKBOX Inability to converse in phrases or complete sentences

FORMCHECKBOX Severe retractions

FORMCHECKBOX Open or sucking chest wounds

FORMCHECKBOX Paradoxical chest wall movement

FORMCHECKBOX Pulse oximeter SpO2 less than 94% (or patient’s baseline)

FORMCHECKBOX Arterial blood gas acutely abnormal/uncompensated

FORMCHECKBOX Decreased rate of respirations

FORMCHECKBOX Contusions/abrasions or deformities to chest wall

FORMCHECKBOX Jugular venous distention (JVD) or tracheal deviation

FORMCHECKBOX Signs of inhalation injury: singed nares, facial burns

FORMCHECKBOX Unable to lay flat

FORMCHECKBOX Decreasing level of consciousness

FORMCHECKBOX Tracheal deviation

Circulation

Subjective Data

Acceptable/stable

FORMCHECKBOX No report of cardiac arrest prior to arrival

FORMCHECKBOX No report of life-threatening dysrhythmia

FORMCHECKBOX No report or suspicion of significant blood loss

FORMCHECKBOX No history of disease or injury that could result in significant bleeding

FORMCHECKBOX Active external bleeding easily controlled prior to arrival

FORMCHECKBOX No history of injury or disease that could result in decreased perfusion

Compromised or absent/unacceptable requiring immediate intervention

FORMCHECKBOX Unconsciousness or significantly altered level of consciousness

FORMCHECKBOX Reported cardiac arrest

FORMCHECKBOX Reported or suspected significant blood loss

FORMCHECKBOX Weak or absent peripheral or central pulses

FORMCHECKBOX Skin color: pale, dusky, cyanotic

FORMCHECKBOX Skin temperature and moisture: cool, clammy

FORMCHECKBOX Reported or suspected significant blood loss prior to arrival

FORMCHECKBOX Inability to control external bleeding enroute

FORMCHECKBOX Patient weak, lightheaded, nauseated, experiencing visual dimming

FORMCHECKBOX Patient verbalizes sense of impending doom

FORMCHECKBOX Patient verbalizes feeling short of breath

FORMCHECKBOX Complaints suggestive of acute, inadequate organ perfusion (e.g., sudden onset of painless visual loss [retinal artery occlusion], sudden onset of testicular pain [testicular torsion])

Objective Date

Acceptable/stable

FORMCHECKBOX Central and peripheral pulse palpable

FORMCHECKBOX Heart rate within limited range.

FORMCHECKBOX Rhythm regular

FORMCHECKBOX Skin color, temperature, moisture: pink, warm, dry.

FORMCHECKBOX No visible active bleeding

FORMCHECKBOX Any visible bleeding is limited to oozing, low volume, dark red color

FORMCHECKBOX Patient alert and oriented to person, place, time, and event

FORMCHECKBOX Capillary refill brisk, less than 2 to 3 seconds (reliable in children only)

FORMCHECKBOX Pulse rate within normal limits; palpable in all extremities

FORMCHECKBOX Blood pressure within normal limits for age/weight

Compromised or absent/unacceptable requiring immediate intervention

FORMCHECKBOX Heart rate: less than 60 beats/minute or greater than 100 beats/minute and weak in adults

FORMCHECKBOX Heart rate: less than 100 beats/minute or greater than 220 beats/minute in infants, less than 80 beats/minute or greater than 180 beats/minute in small children

FORMCHECKBOX Unresponsive or significantly altered level of consciousness

FORMCHECKBOX Nonpalpable central (carotid and/or femoral) or peripheral pulse

FORMCHECKBOX Uncontrolled, pulsating, or high-flow bleeding

FORMCHECKBOX Marked pallor of skin, lip margins, or nail beds

FORMCHECKBOX Large amount of bleeding or clots in emesis, nares or oral cavity, stool, or vagina

FORMCHECKBOX Gross swelling of injured extremities (e.g., thigh)

FORMCHECKBOX Distended, rigid abdomen

FORMCHECKBOX Systolic blood pressure less than 90 mm Hg in adults, rapid heart rate, thready, weak pulse

FORMCHECKBOX Alerted level of consciousness: restlessness, anxiety, confusion, disorientation, obtundation

FORMCHECKBOX Increased respiratory effort or work of breathing

FORMCHECKBOX Skin moisture/temperature: diaphoretic, cool

FORMCHECKBOX Skin color: pale, dusky, cyanosis

FORMCHECKBOX Pallor or cyanosis of nail beds or lip margins

FORMCHECKBOX Central or peripheral pulses: weak, thready, rapid

FORMCHECKBOX Vomiting, retching

FORMCHECKBOX Capillary refill delayed >2 seconds (reliable in children only)

FORMCHECKBOX Hypotension (systolic <90 mm Hg in adults)

FORMCHECKBOX Extremity injury with diminished/absent pulse

FORMCHECKBOX Other indicators of acute, organ-specific, diminished perfusion (may be identified during more in-depth secondary or focused assessment—i.e., retinal artery occlusion, testicular torsion

Disability

Subjective Data

Acceptable/stable

FORMCHECKBOX No history of loss of consciousness

FORMCHECKBOX No history of neurologic trauma

FORMCHECKBOX No sudden onset of severe headache

Unacceptable/requiring immediate intervention

FORMCHECKBOX History of loss of consciousness or unconscious/coma

FORMCHECKBOX Head or traumatic brain injury

FORMCHECKBOX Sudden onset of severe headache

FORMCHECKBOX History of diabetes or alcohol abuse

Objective Date

Acceptable/stable

FORMCHECKBOX Pupil assessment—equality/reactivity: pupils equal, round, briskly reactive to light, and accommodate

FORMCHECKBOX Glasgow Coma Scale or Pediatric Coma Scale scores 15

FORMCHECKBOX Ability to respond to commands (avoid commands such as hand grasping, which may be reflexive)

FORMCHECKBOX Moves all four extremities

FORMCHECKBOX Feels pain and fine touch (sensory)

Unacceptable/requiring immediate intervention

FORMCHECKBOX Altered level of consciousness: restless, stupor, coma

FORMCHECKBOX Pupillary assessment; equality/reactivity: unequal, “blown,” slow, or absent reaction to light

FORMCHECKBOX Abnormal flexion/extension positioning

FORMCHECKBOX Hypoglycemia

FORMCHECKBOX Elevated blood alcohol or positive drug screen

FORMCHECKBOX Loss of pain or fine touch sensation

Exposure/environmental controls

Subjective Data

Acceptable/stable

FORMCHECKBOX No history of unexposed injury

FORMCHECKBOX No history of prolonged environmental exposure

FORMCHECKBOX No history of thermoregulatory disease

FORMCHECKBOX No history of critical infectious illness exposure

FORMCHECKBOX No history of head injury

FORMCHECKBOX No history of spinal cord injury

Unacceptable/requiring immediate intervention

FORMCHECKBOX Complaint of chest, abdominal, extremity, spinal or head injury or pain

FORMCHECKBOX Recent exposure to critical infectious illness

FORMCHECKBOX Prolonged exposure to environmental elements

Objective Data

Acceptable/stable

FORMCHECKBOX No injuries noted

FORMCHECKBOX No petechial/purpura rash

Unacceptable/requiring immediate intervention

FORMCHECKBOX Observable head, spinal, chest, abdominal, extremity injury

FORMCHECKBOX Petechial rash

FORMCHECKBOX Tachycardia/bradycardia.

FORMCHECKBOX Subnormal/elevated temperature.