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Pt Neuro WDL, EENT WDl except impaired vision bilaterally, CV WDL except left lower extremity pedal pulse present only with doppler, Respiratory WDL except lung sounds coarse throughout, GI/GU WDL, except urinary incontinence, musculoskeletal with partial and passive range of motion in all extremities, integumentary is WDL
| Parameter | Updated Value |
|---|---|
| Neurovascular Left Lower Extremity WDL | Exceptions to WDL |
| Right Eye | Impaired vision |
| Left Eye | Impaired vision |
| Cardiac WDL | Exceptions to WDL |
| Pulse Dorsalis Pedis Lt | 1+=Present with Doppler |
| Pulse Post Tibial Lt | 1+=Present with Doppler |
| Respiratory WDL | Exceptions to WDL |
| All Breath Sounds | Coarse crackles |
| Genitourinary WDL | Exceptions to WDL |
| Urine Function | Incontinence |
| Musculoskeletal WDL | Exceptions to WDL |
| Right Upper Extremity | Partial ROM, Passive ROM |
| Left Upper Extremity | Partial ROM, Passive ROM |
| Right Lower Extremity | Partial ROM, Passive ROM |
| Left Lower Extremity | Partial ROM, Passive ROM |
Pt neuro WDL except pain and numbness in right lower extremity, strengths in right upper extremity 2, left lower extremity 4, neurovascular check right lower extremity is 2+ strength, pain present, dorsalis pedis pulse is 1+, post tibial pulse 1+, skin is warm, race appropriate with a cap refill 3 seconds, Cardiac is WDL except 3 second cap refill, non-pitting edema present in right lower extremity, Respiratory WDL, GI WDL, GU WDL except foley present (urinary device), musculoskeletal is WDL except partial range of motion in bilateral lower extremities and an external fixator present on right lower leg with some bleeding present around pin sites, Integumentary is WDL except bruising and scratches noted on upper extremities and bruising on lower extremities. A foam prevention dressing has been placed on the sacrum.
| Parameter | Updated Value |
|---|---|
| Neurological WDL | Exceptions to WDL |
| All Extremity Sensation | Abnormal sensation in specific extremity/extremities |
| Sensation RLE | Pain, Numbness |
| All Extremity Strength | Abnormal strength in specific extremity/extremities |
| Extremity Strength RUE | 2=Active Movement Against Gravity |
| Extremity Strength RLE | 2=Active Movement Against Gravity |
| Extremity Strength LLE | 4=Active Movement Against Moderate Resistance |
| Extended Neurological Assessment | Yes |
| Neurovascular Right Lower Extremity WDL | Exceptions to WDL |
| Right Lower Extremity Temperature | Warm |
| Right Lower Extremity Cap Refill (Seconds) | 3 seconds |
| Right Lower Extremity Color | Race Appropriate |
| Cardiac WDL | Exceptions to WDL |
| Cap Refill (secs) | 3 seconds |
| RLE Edema | Non-pitting |
| Pulse Dorsalis Pedis Rt | 1+=Present with Doppler |
| Pulse Post Tibial Rt | 1+=Present with Doppler |
| Genitourinary WDL | Exceptions to WDL |
| Urine Function | Urinary device/ostomy present (See LDA) |
| Musculoskeletal WDL | Exceptions to WDL |
| Right Lower Extremity | Partial ROM |
| Left Lower Extremity | Partial ROM |
| Musculoskeletal Devices | Yes |
| Fixator 1 Location | Right |
| Fixator 1 Assessment | Bleeding |
| Integumentary WDL | Exceptions to WDL |
| Upper Extremities Condition | Bruising, Scratches |
| Lower Extremities Condition | Bruising |
| Prevention Dressing | Foam dressing |
| Prevention Dressing Location Options | Sacrum/Coccyx |
Neuro WDL, EENT WDL, except impaired vision bilaterally and missing teeth, Cardiac WDL except generalized non-pitting edema 1+, Respiratory WDL, GI is WDL except bowel incontinence, last BM 5/3/24, GI WDL except foley present (urinary device), musculoskeletal is WDL except all extremities with partial ROM, integumentary system WDL'
| Parameter | Updated Value |
|---|---|
| Right Eye | Impaired vision |
| Left Eye | Impaired vision |
| Teeth | Missing teeth |
| Cardiac WDL | Exceptions to WDL |
| Generalized Edema | Non-pitting |
| Gastrointestinal WDL | Exceptions to WDL |
| All Quadrants Bowel Sounds | Present |
| Bowel Function | Incontinent |
| Last Bowel Movement Date | 5/3/24 |
| Genitourinary WDL | Exceptions to WDL |
| Urine Function | Urinary device/ostomy present (See LDA) |
| Musculoskeletal WDL | Exceptions to WDL |
| Right Upper Extremity | Partial ROM |
| Left Upper Extremity | Partial ROM |
| Right Lower Extremity | Partial ROM |
| Left Lower Extremity | Partial ROM |
PT neuro WDL except hoarse speech, pupils 3 brisk and round bilaterally, Cardiac WDL except generalized non pitting edema, Respiratory is WDL, except decreased lung sounds in right lower lobe, cough is spontaneous and productive, patient suctioned with small amount of thick cloudy yellow secretions, GI is WDL except abdomen is tender and patient is incontinent of stool, GU WDL, Musculoskeletal WDL except partial ROM in all extremities, integumentary system is WDL.
| Part | Condition |
|---|---|
| Neurological WDL | Exceptions to WDL |
| Speech/Communication | Hoarse |
| Pupil Reaction Right | Brisk |
| Pupil Shape Right | Round |
| Pupil Size Right (mm) | 3 |
| Pupil Reaction Left | Brisk |
| Pupil Shape Left | Round |
| Pupil Size Left (mm) | 3 |
| Precautions | Aspiration |
| Cardiac WDL | Exceptions to WDL |
| Generalized Edema | Non-pitting |
| Respiratory WDL | Exceptions to WDL |
| Right Base Breath Sounds | Decreased |
| Cough | Spontaneous, Productive |
| Suction Route | Oral suctioned |
| Sputum Amount | Small |
| Sputum Consistency | Thick |
| Sputum Color | Cloudy |
| Gastrointestinal WDL | Exceptions to WDL |
| Abdomen | Tender |
| All Quadrants Bowel Sounds | Present |
| Bowel Function | Incontinent |
| Musculoskeletal WDL | Exceptions to WDL |
| Right Upper Extremity | Partial ROM |
| Left Upper Extremity | Partial ROM |
| Right Lower Extremity | Partial ROM |
| Left Lower Extremity | Partial ROM |
Neuro WDL except pt is anxious but cooperative, follows commands appropriately, intubated/trached, strengths are 4s in uppers and 3s in lowers, EENT is WDL except bilateral hearing and vision impairments, tongue and oral mucosa is dry, teeth are decayed and missing, Cardiac is WDL except click present, Respiratory is WDL except decreased lung sounds in the right base, GI is WDL except abdomen is distended, pt with diarrhea and incontinence, GU is WDL except foley present, Musculoskeletal is WDL, Integumentary is WDL except skin over trunk back and upper extremities is bruised, dry and flaking.
| Part | Condition |
|---|---|
| Neurological WDL | Exceptions to WDL |
| Behavior/Affect | Cooperative |
| Cognition | Follows Commands |
| Speech/Communication | Intubated/trached |
| All Extremity Strength | Abnormal strength in specific extremity/extremities |
| Extremity Strength RUE | 4=Active Movement Against Moderate Resistance |
| Extremity Strength RLE | 3=Active Movement Against Gravity |
| Extremity Strength LUE | 4=Active Movement Against Moderate Resistance |
| Extremity Strength LLE | 3=Active Movement Against Gravity |
| Precautions | Aspiration |
| Right Eye | Impaired vision |
| Left Eye | Impaired vision |
| Right Ear | Impaired hearing |
| Left Ear | Impaired hearing |
| Throat | Dry |
| Tongue | Dry |
| Oral Mucous Membrane | Dry |
| Teeth | Decayed, Missing teeth |
| Cardiac WDL | Exceptions to WDL |
| Heart Sounds | Click |
| Respiratory WDL | Exceptions to WDL |
| Right Base Breath Sounds | Decreased |
| Artificial Airway | Present (See LDA) |
| Gastrointestinal WDL | Exceptions to WDL |
| Abdomen | Distended |
| Bowel Function | Diarrhea, Incontinent |
| Genitourinary WDL | Exceptions to WDL |
| Urine Function | Urinary device/ostomy present (See LDA) |
| Integumentary WDL | Exceptions to WDL |
| Trunk/Back Condition | Bruising, Dry, Flaky |
| Upper Extremities Condition | Bruising, Dry, Flaky |
| Prevention Dressing | Foam dressing |
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