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Course Number and Name

StudentDate
InstructorCourse
Patient InitialUnit/ Room#DOB
Code StatusHeight/Weight
Allergies
Temp (C/F Site)Pulse (Site)RespirationPulse Ox (O2 Sat)Blood PressurePain Scale 1-10
History of Present Illness including Admission Diagnosis &Chief Complaint (normal & abnormal) supported with Evidence Based CitationsPhysical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations
Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),include dates and rationales supported with Evidence Based CitationsPast Medical & Surgical History,Pathophysiology of medical diagnoses(include dates, if not found state so)Supported with Evidence Based Citations
Erikson’s Developmental Stage with RationaleAnd supported by Evidence Based CitationsSocioeconomic/Cultural/Spiritual Orientation& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations
Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each(“At Risk for…” nursing dx)Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationalesupported with Evidence Based Citations

Signs and

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Symptoms

As evidenced by

Related to

Contributing

Factors

Diagnostic

Label

Priority Nursing Diagnosis(at least 2)Written in three part statementPlanning(outcome/goal)Measureable goal during your shift(at least 1 per Nursing diagnosis)Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching(at least 4 per goal)Rationale Each must besupported with Evidence Based CitationsEvaluationGoal Met, Partially Met,or Not Met& Explanation

MEDICATION LIST

Medications (with APA citationsClass/PurposeRouteFrequencyDose (& range)If out of range, why?Mechanism of actionOnset of actionCommon side effectsNursing considerationsspecific to this patient

Revision Date: Month, Year (i.e. February, 2010) Page 1

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Date: ____________________________________________________________________________________

Student Name:

Faculty Name:

1. ADMISSION INFORMATION
Date of Care:Pt. Name:Admission Date:Age:Gender:Growth and Development (Erikson):Ethnicity:Occupation:Spiritual Beliefs:
Reason for Hospitalization/Chief Complaint (in pt’s own words):Surgical Procedures/Date:Medical Diagnoses History: (Present and past diagnoses, Physician’s History and Physical notes in the chart, nursing intake assessment, with length of history if possible)
Admitting Medical Diagnosis:History of Present Illness:
ADVANCE DIRECTIVES (Nursing Admission Assessment):
Living Will: ☐ Yes ☐ NoDurable Power of Attorney: ☐ Yes ☐ NoCode status : ☐ Full Code ☐ DNR (Do Not Resuscitate)
2. MEDICATIONSALLERGIES:
DrugClassificationDosageRouteFrequency(time due)PurposeNursing Considerations
3. LABORATORY DATA
TestNormsOn admissionCurrent valueTestNormsOn admissionCurrent value
WBCSodium
HemoglobinPotassium
HematocritCalcium
PlateletsBUN
PTCreatinine
INRMagnesium
aPTTBlood Glucose
HA1cUrinalysis
BNPCultures blood/sputum
DIAGNOSTIC TESTS
Chest X-ray:EKG:Abnormal studies:
Abnormal studies:Abnormal studies:Abnormal studies:
4. PHYSIOLOGICAL DATA-VITAL SIGNS
Vital Signs: Temp_________ oF / oC ☐Axillary ☐Tympanic ☐Oral ☐ Core ☐RectalPulse______ ☐Apical _______ ☐RadialRespiratory Rate______ ☐Even/regular ☐Labored/SOB ☐Dyspnea on ExertionBP ______/_______ ☐Supine ☐Sitting ☐StandingAdmission weight:___________Yesterday’s weight___________Today’s weight______________Height__________
5. NEUROLOGICAL/SENSORY
Orientation: ☐Time ☐Place ☐Person ☐PurposeSensation: ☐Normal ☐Impaired ☐Absent
Pain: Grade ____ /10 Scale used: ☐0-10 Numeric ☐FLACC ☐ Wong-Baker FACESPain Location:_______________Character: ☐ Sharp ☐Dull ☐Ache ☐Heavy ☐Pinprick ☐Cramp ☐Other______________What makes the pain worse:______________________________________________________What makes the pain better:___________________________________________________
Level of Consciousness: ☐Alert ☐Lethargic ☐Obtunded ☐Stuporous ☐Semicomatose ☐Coma
Coordination: ☐Symmetrical ☐Asymmetrical ☐UnsteadyPERRLA : #____mm ☐Brisk ☐Sluggish ☐Fixed ☐NystagmusImage0011 2 3 4 5 6 7 8mm
Strength: ____Right arm _____Left arm _____Right leg _____Left leg0=No movement1=Trace movement2=Moving, not against gravity3=Moving against gravity, not against resistance4=Moving against gravity, some resistance5=Full powerGlascow Coma Scale: Total of all 3 columns__________
Eyes4=Open spontaneously3=To speech2=To pain1=NoneTotal_______Motor6=Obeys command5=Localizes pain4=Withdraws3=Flexion2=Extension1=NoneTotal________Verbal5=Oriented4=Confused3=Inappropriate words2=Incomprehensible words1=NoneTotal______
Touch: ☐Normal ☐DecreasedSmell: ☐Normal ☐DecreasedHearing: ☐Normal ☐Tinnitus ☐HOH ☐Hearing Aid ☐Deaf
Vision: ☐Normal ☐Glasses ☐Contacts ☐Cataracts ☐Glasses ☐Glaucoma ☐Blurred vision ☐ Diplopia
Neurosensory comments:
Nursing Diagnosis:
6. CIRCULATORY/CARDIOVASCULAR
Color: ☐Pink ☐Pale ☐ Jaundice ☐Flushed ☐Cyanotic ☐Mottled ☐DuskyCapillary refill: ☐<3 seconds☐>3 seconds
Skin:☐Dry ☐Moist ☐Clammy ☐Warm ☐Cold ☐HotTele monitored rhythm:________________________________
Peripheral Edema: ☐None ☐+1 ☐+2 ☐+3 ☐+4☐Pitting ☐Non-pittingLocation:_____________________________________________Heart Sounds: ☐S1 ☐S2 Rhythm: ☐Regular ☐Irregular
Implanted Pacemaker: ☐ Yes ☐No
Peripheral pulses:Right radial ☐Present ☐Absent Left radial ☐Present ☐Absent Right pedal ☐Present ☐Absent Left Pedal ☐Present ☐Absent
Circulatory Comments:
Nursing Diagnosis:
7. RESPIRATORY/PULMONARY
Breath Sounds:☐Clear ☐Diminished ☐Absent ☐ Crackles ☐WheezesLocation:☐Throughout☐RUL ☐RML ☐RLL ☐LUL ☐LLLPattern: ☐Regular ☐IrregularCharacter: ☐Full ☐Shallow ☐Deep ☐Labored ☐SOB
Sputum: ☐White/Clear ☐Tan ☐Yellow ☐Green ☐Rusty ☐Pink ☐RedAmount: ☐Small ☐Moderate ☐Large
Cough: ☐None ☐Nonproductive ☐Productive ☐Suctioning requiredSecretions: ☐Yes ☐No Consistency: ☐Frothy ☐Thick ☐ThinPulse Oximeter: ______%Oxygen: ☐Room air O2 ____L/min. or O2 _____%Mode: ☐N/C ☐Mask ☐Trach
Suctioning Method: ☐Oral ☐Nasotracheal ☐ETT ☐Trach ☐BulbABGs: pH_____ pO2________ pCO2_______ HCO3___________
Respiratory Comments:
Nursing Diagnosis:
8. NUTRITION/HYDRATION
Diet: ☐NPO ☐Regular ☐Cl. Liquid ☐Full liquid ☐Soft ☐Pureed☐Other____________________Aspiration Risk: ☐Yes ☐No
Feeding Method: ☐Self ☐Assisted ☐NG ☐G-Tube ☐J-TubeParenteral Nutrition: ☐TPN ☐PPNNausea: ☐Yes ☐NoVomiting: ☐Yes ☐NoFlatus: ☐Yes ☐No
Tube Feeding Formula:_____________ Rate: mL/hr.Residual: ☐No ☐Yes Amt.______mL
Weight: ☐Gain______# lbs./kg☐Loss______# lbs./kg ☐No changeMucous Membranes: ☐Dry ☐Moist
Skin Turgor: ☐No problem☐Tenting ☐Taut
Intake:PO______IV______NG______Blood_______Other_______24 hour total_________Output:Urine_____NG_______Emesis________Stool________Drains________Other________24 hour total_________24 hour net I/O: +/-_____
Nutrition/Hydration comments:
Nursing Diagnosis:
9. GI/FECAL ELIMINATION
Bowel Sounds:☐Absent ☐Hypoactive ☐Active ☐HyperactiveLocation: ☐RUQ ☐RLQ ☐ LUQ ☐LLQ ☐ Throughout
Abdomen: ☐Soft ☐Flat ☐Distended ☐Round ☐Firm ☐Tender ☐FlatusOstomy: ☐No ☐Yes Type:______Incontinence: ☐Yes ☐No
Last BM: _______Stool: ☐Formed ☐Soft ☐Hard ☐ Liquid #_____Color: ☐Brown ☐Black/Tarry ☐Clay/Gray ☐Yellow ☐Green
Fecal Elimination Comments:
Nursing Diagnosis:
10. GU/URINARY ELIMINATION
Urine: ☐Clear ☐Cloudy ☐SedimentColor: ☐Straw ☐Yellow ☐Amber ☐Pink ☐Red
Last void: time____________ amount mLCatheter: ☐None ☐In/Out ☐Condom ☐Foley ☐SuprapubicInsertion date:_________________
Symptoms: Frequency: ☐ Urgency: ☐ Dysuria: ☐ Nocturia: ☐ Incontinence: ☐Yes ☐No
Urinary Elimination Comments:
Nursing Diagnosis:
11. REST AND EXERCISE
Activity: ☐ Bed rest ☐BSC ☐BRP ☐ Chair ☐ AmbulateMobility Aids: ☐Cane ☐W/C ☐Crutches ☐Walker
Functional level: ☐Independent ☐Dependent ☐AssistanceGait: ☐Steady ☐Unsteady ☐Unable to ambulate
ROM: ☐Active ☐Passive ☐Assistive ☐Limited ☐FullSleep Patterns: ☐Uninterrupted ☐Interrupted ☐Insomnia☐Day time sleepiness # hrs sleep/night__________
Cast/Brace/Traction: Type___________ Location_______________Restraints: Type______________ Location_______________
Rest and Exercise Comments:
Nursing Diagnosis:
MORSE FALL SCALE/RISK SCREENING
VariablesScore
History of Falls within last 12 monthsNoYes025To obtain the Morse Fall Score add the score from each category.Morse Fall Score☐ High Risk 45 and higher☐ Moderate Risk 25-44☐ Low Risk 0-24
Secondary DiagnosisNoYes015
Ambulatory AidsNone/bedrest/nurse assist0
Crutches/cane/walker15
Furniture30
IV or IV accessNoYes020
GaitNormal/bedrest/wheelchair0
Weak10
Impaired20
Mental StatusKnow own limits0
Overestimates or forgets limits15
Total
Rest and Exercise Comments:
Nursing Diagnosis:
12. SKIN INTEGRITY/INTEGUMENTARY
Skin Condition: ☐Intact ☐ Skin tear ☐Bruise ☐Rash ☐Burn ☐Wound/Ulcer (complete documentation) Location_____________ Stage___________☐Incision ☐Other______________Location#1_____________Type of condition____________ ☐Drainage__________ ☐OdorLocation#2_____________Type of condition____________ ☐Drainage__________ ☐OdorLocation#3_____________Typeof condition____________ ☐Drainage__________ ☐OdorStep 3  Body Skin AssessmenIndicate location or Intact:S Surgical siteM EdemaB BurnR RashE EcchymosisD DressingF Fracture/CastPe PetechaieN InflammationG Gangrene/NecrosisP Pressure ulcer & stage _______________O Other ____________________________I IV Site A DrainsPatent NoneSwollen PenroseRed HemovacInfiltrated JP
Braden ScaleScore
Sensory1. Completely limited2. Very limited3. Slightly limited4. No Impairment
Moisture1. Constantly moist2. Very moist3. Occasionally moist4. Rarely moist
Activity1. Bedfast2. Chairfast3. Walks occasionally4. Walks frequently
Mobility1. Completely immobile2. Very limited3. Slightly limited4. No limitations
Nutrition1. Very poor2. Probably inadequate3. Adequate4. Excellent
Friction and Shear1. Problem2. Potential problem3. No apparent problemScore of 18 or less= at risk_____
IV sites: ☐ Patent ☐Swollen ☐Red ☐Infiltrated Location:____________ Gauge Needle:____________ Start date:______________
Skin Comments:
Nursing Diagnosis:
13. HORMONE REGULATION/REPRODUCTION/ENDOCRINE
Thyroid Disease: ☐Yes ☐ No Estrogen Use: ☐Yes ☐ No Testosterone use: ☐Yes ☐ No Steroid use: ☐Yes ☐ No
Diabetes: ☐Yes ☐ No ☐Type I ☐Type II Number of year with diabetes: _______
14. PSYCHOSOCIAL VARIABLES
Mood/Affect: ☐Cooperative ☐Cheerful☐Angry ☐Anxious ☐Crying ☐Withdrawn ☐Flat Affect ☐Depressed ☐Fearful ☐Combative
Level of education: ☐None ☐Elementary ☐High School ☐College ☐Post GraduateUnderstands directions: ☐Yes ☐ No
Decision-making: ☐None ☐Concrete ☐Abstract ☐ImpairedJudgment: ☐Appropriate ☐Inappropriate ☐Dementia
History/Evidence of: ☐Physical Abuse ☐Neglect ☐Sexual Abuse ☐Thoughts of suicide or self-harm ☐Depression ☐Psychiatric history
Recreational drug use: ☐ Drug How much____ How long____Alcohol use: ☐ How often_____ How much_______
Tobacco use: In the last 12 months ☐Yes ☐ No How often ___________ How much_____________
Recent life stress or loss: ☐Yes ☐ No ___________Coping methods with current illness/hospitalization: ☐Good ☐Fair ☐Poor
Body Image: ☐Positive ☐Negative ☐ChangingSexuality: ☐Heterosexual ☐Bisexual ☐Homosexual ☐Transgender ☐Transsexual
Ability to write English: ☐Yes ☐NoAbility to read English: ☐Yes ☐No
Language Barrier: ☐None ☐ESL ☐Speech Impediment ☐Intubated ☐ TrachedSupport System: ☐Yes ☐NoLiving Situation: ___________________________________
Psychosocial Comments:
Nursing Diagnosis:
Narrative Charting:

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