ASSOCIATE DEGREE PROGRAM IN NURSING



Student Name_____________________________ Clinical date(s)______________ Pt. Initials ________ Age______ Sex______ Rm #_________Dr._________________ Adm. Date_____________Allergies____________________________________________________________________________________Current Medical Diagnosis______________________________________________________________________Surgical Procedure/ Date ______________________________________________________________________Admission Height__________ Weight__________ Socioeconomic/Health history:Religion___________________ Ethnic identity_________________ Primary language__________________Cultural practices________________________________________________________________________________________________________________________________________________________________________________Educational level___________________ Occupation__________________________________ FT__ PT__ Retired__Living arrangements: Alone___Spouse___ Parent____ Other:_____________________________________________Institution (name & describe)________________________________________________________________Insurance: Yes____ No____Health patterns at home:ADL’s: Independent___ Needs help with:_____________________________________________________Diet: ________________ # of Meals a day____ Snacks (describe)_______________________________Sleep pattern ________________________________ Aids to sleep_________________________________Elimination pattern: Voiding_______________________________________________________________ BM__________________________________ Use of laxatives/enemas: Yes__ No__ Alcohol use: No__ Yes ___ Type______________ Daily amount____________________________Smoking: No__ Yes __ Quit/ When? ________________ Type& Amount____________________________Recreational drugs: No__ Yes ___ Type & Amount______________________________________________List community resources used___________________________________________________________________________________________________________________________________________________________________Relevant family history: Hypertension ___ Diabetes___ Heart disease____ Stroke____ Cancer___ Other__________________Advanced Directive: Yes ___ No__ Developmental Stage (Erickson): ___________________________________________________________________ Justify with examples of stage:_________________________________________________________________________________________________________________________________________________________________ Nursing considerations for stage_________________________________________________________________________________________________________________________________________________________________ Pertinent medical/surgical or OB/GYN history: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Medications, herbs & OTCs (over the counter) use:Medication & DoseFrequencyReason for takingPathophysiology of current medical diagnosis (explain how the medical diagnosis changes the client’s normal physiology)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Symptoms on admission: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Admission Vital Signs:T._____ P.______ R. ____ B.P. _______Pain: location___________________ Scale 0/10_____What does client state as reason for admission: _________________________________________________________________________________________________________________________________________________________Current functional health status (what can the client do now?) _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Most recent V.S.: T_____ P______ R_____ BP_______ Pain: Location________________________ Scale 0/10_____Last 24hr. Intake_________ Output ___________ Most recent weight__________ Date of last BM___________Current Primary Care Provider (MD) Orders:Activity: Fall risk: low__ med__ high__Assist devices:Vital signs:I&O: CSBG: I.V. site: _______________________ Saline (peripheral) lock: No __ Yes__ Flush frequency__________Intravenous solution(s):_____________________________rate: ________ml/hr _______gtts/min rate:________ ml/hr _______gtts/minDiet: Tube feedings: method_____________ formula____________________ rate______Oxygen:________L/min method____________________ TCDB: __________ IS__________Respiratory treatments/procedures: Tubes, Drainage devices, Catheters: __________________________________________________________________Dressings:Restraints:Other:Scheduled diagnostic tests:Code Status: Full______ DNR_______ Other____________ Living Will________ DPA_____Current Teach/Learn needs: ______________________________________________________________________________________________________________________________________________________________________Possible discharge needs: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Neuro/Sensory LOC Speech/Pupils Motor ResponseCommunicationVision/HearingRestraintsPain Alert Oriented Disoriented Lethargic Unresponsive Clear Slurred Aphasia Nonverbal PERRL Other (L)____ (R)____ Follows instruction/spontaneous movement Other ______________________________________________Movement/Strength of U.E. Rt_________ Lt_________ L.E. Rt_________ Lt_________ Grasps ideas and questions Other_________________________________________________WNL Wears glasses Blind WNL Hearing aid R L DeafNA Type _____________ None Yes Location:________________ Intensity (0-10)________ Radiates_______________ Relieved by:______________________________________________________________________ Other observations:__________________________________________________________________________Plan: __________________________________________________________________________________________________________________________________________________________________________________CardiovascularPulses Heart soundsEdemaRhythm: Regular Irregular R Radial L Radial R Pedal L Pedal Present Present Absent Absent Strength________________ B.P._____________ Pulse Rate_________ Apical rate_______________ none Pitting Non-pitting Location _______________________________________________________________________________________________________________Other observations:__________________________________________________________________________Plan: __________________________________________________________________________________________________________________________________________________________________________________RespiratoryEffortBreath soundsCough/Sputum Rate____ Respirations even, regular, unlabored SPO2 ___ room air SPO2 ___ via _____@__L/minClear Diminished Crackles Rhonchi Wheezes AbsentLocation of adventitious sounds:________________________________________________________________None Nonproductive Productive Sputum (describe)_________________________________Other observations:__________________________________________________________________________Plan: __________________________________________________________________________________________________________________________________________________________________________________GastrointestinalDiet/swallowingComfortAbdomenBowel soundsTubes Elimination Diet type ________________, _____%taken NPO Dysphagia ____________ Enteral feeding____ml/hr Tolerates diet well Nausea Emesis (describe) _________________________________________Soft Hard Firm Distended Tender Active in all quads Hypoactive Hyperactive Absent State location:________________________None N/G Salem Other: _________ Ostomy (type)_________ Describe drainage: _________BM this shift (describe) _______________________ Constipation Diarrhea Other observations:__________________________________________________________________________Plan: __________________________________________________________________________________________________________________________________________________________________________________Describe assessments that are not within normal limitsRenal/UrinaryVoiding/patternDiversion Urine Without complaints Dysuria Incontinent Condom Indwelling urinary catheter SuprapubicAmount:_____________ Color: ______________ Clarity:______________ Sediment:_______________________ Other observations:__________________________________________________________________________Plan: _______________________________________________________________________________________________________________________________________________________________________________MuscuoskeletalMovementROMAssist devicesActivity Feed/Bath Turn/Oral Strength/movement equal Flaccid/weak: Rt___ Lt____ Tolerates activity well Other____________Full active Passive Restricted___________________ Immobile_____________________________Contractures ______________________________________ Hip precautions None Cane Crutches Walker W/C CPM Venodyne/SCD/Pneumonatic boots Ambulates by self Ambulates with assist Up in chair Other:_________________________________ No assistance required Fed with assistance Fed by staff Partial bath Complete bathTurn with partial assist Turn with max. assist Oral care with assist Oral care by staffOther observations:__________________________________________________________________________Plan: _______________________________________________________________________________________________________________________________________________________________________________IntegumentaryAppearanceIncision Dressing 4855845114935Warm Dry Skin color appropriate Cool Diaphoretic Pale Flushed Cyanotic JaundicedIntact Redness/Rash Lesion/Wound (describe)____________________________________________________________________________________________________________None Approximated Clean Dry Staples in place Reddened Open Swollen None Yes/Location__________________________________________________________ Dry Drainage(describe)_____________________________________________________ Other observations:__________________________________________________________________________Plan: _______________________________________________________________________________________________________________________________________________________________________________ReproductiveComplete on all patientsBirth control method______________ Last menses___________ Last PAP smear _____________None Itching Bleeding Discharge (describe)_____________________ Pain Breast lumpsPregnant SBE STE Last mammogram___________ Last testicular exam_________ Rectal__________Other observations:__________________________________________________________________________Plan: ____________________________________________________________________________________________________________________________________________________________________________Endocrine/MetabolicTemperature ______________ Height__________ Weight_______________ Blood glucose________________Polyuria Polydipsia Polyphagia Heat intolerance Cold intolerance NervousnessOther observations:__________________________________________________________________________Plan: _______________________________________________________________________________________________________________________________________________________________________________PsychosocialEmotional statusSupport/Coping Care participation Code status Calm Anxious Depressed Irritable Frightened Aggressive Other:__________________Coping/support systems adequate Family/friends visit Visit by chaplain Sacraments of the sickSupport system:______________________________________________________________________________ Active Passive Non-compliant Non-responsive Full Code No Code Limited Code_________________________Concerns related to hospitalization:________________________________________________________________Other observations:__________________________________________________________________________Plan: _______________________________________________________________________________________________________________________________________________________________________________Risk I.D.PrecautionsSiderails/Safety Skin breakdown Falls Patient checked q1hr Restraints Type ______________________________Respiratory Contact Neutropenic All down Top rails up Top & bottom up Bed in low position Call bell within reach Brake onOther observations:__________________________________________________________________________Plan: _____________________________________________________________________________________ ................
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