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Time test perfomed
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Nausea/Vomiting "Do you feel sick or have you vomited?"
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Tremor- arms extended and fingers spread apart
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Paroxysmal Sweats
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Anxiety "Do you feel nervous?"
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Agitation
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Tactile Disturbances
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Auditory disturbances "Are you more aware of sounds around you? Are they harsh?, Do they frighten you?"
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Visual disturbances "Does the light appear to be too bright? Is its color different? Are you seeing things?"
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Headache/Fullness in Head "Does your head feel different? Does it feel like a band around your head? Do not rate for dizziness
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Orientation/Clouding of Sensorium "What day is this? Where are you? Who am I?
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Total Score
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Severity- None to Mild <9, Consider Comfort Meds 9-10, Administer Comfort Meds 11-20, Transfer to hospital >20
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Assessor
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