Excelsior CPNE

Peripheral Vascular Assessment
Please Make Sure To Chart
P – pulses (bilat distal, at the same time)
M – motor
S – Sensation
T – Temp
C – Color/cap refill
* M – motion, assess by asking Patient to move extremities or noting movement in a child less than three and non-communicating adult.
COPS make Noise
C – consciousness
O – orientation
P – pupils
S – sensation/strength
M – movement
N – noxious stimuli respose if necessary
Abdominal Assessment
Three Ps
P – Pee?
P – Position
P – Pain ?
Look, Listen, Feel
LOOK – expose abdomen while keeping Pt modest, and look for contour, discoloration, scars, sores, drains etc.
LISTEN – with scope listen to all 4 quads, if no bowel sounds heard, listen for 1 minute and move on. If bowel sounds are heard immediately, move on.
FEEL – lightly palpate each quadrant and document findings.
Daylight – Distention
Savings – Sounds all 4 quads
Time – Tenderness, rigidity?
Skin Assessment
TIME Color
T- temperature
I – integrity – (lesion, bruising, lacerations rash, skin tears etc.)
M – moisture – (perspiration, incontinence, non-intact ostomy/drainage system)
E – edema – (document present or absence of only.)
Records data of two vulnerable skin areas: ears, elbows, occiput, sacral, trochanters, heels etc.. bilateral areas count as one
Selected Areas of Care – Management
AIR: Assess, Implement, Reassess/reevaluate Patient response.

– Comfort
– Musculoskeletal
– Oxygen
– Pain
– Respiratory
– Wound