How do I chart Gordon's???

[boemil]

Hi there, for my clinical rotation, we are asked to fill out an entire Gordon's functional assessment form. Our form has terms followed by blanks. Does anyone know of a good list of how to fill this out?

If not, how would you all chart someone with good 'Muscle mass/tone'? I know I can't say normal, but I'm not able to find the correct terms for it either.

Here is a list of the ones I can't figure out what to say, all of these were normal for my patient, not deviating:

* Traction (type, wt)

* Heart sounds (rate, rhythm, quality)

* Eye contact

* Coloring (in the respiratory section)

Any help is appreciated!

Thanks

[ItsThatJenGirl, CNA]

For heart:

Rate - beats per minute

Rhythm - regular or irregular

Quality - +1, +2, +3, etc

Coloring:

I assume this means pink/pale/blue/etc

Eye contact:

Maintains eye contact, stares, avoids eye contact, eyes closed

Traction:

What section is this under? I'm not sure on this one.

[boemil]

traction is under activity/musculoskeletal

Thank you for your help!!