Health Perceptions-Health Management Nutrition-Metabolic Pattern

Reason for seeking health care: Ht: Wt: Recent change in wt(amt/time):
Treated at home: Diet: Appetite:
Past medical hx: Bkft: % Lunch: % Dinner: %
Past surgical hx: Problems eating: difficulty swallowing/nausea/vomiting/ abdominal
Allergies: pain/ antacid use
Code status: Advance Directives: Dentition/Dentures:
Medical Durable Power of Attorney: Taste sensation: normal/impaired
Family hx: Tests blood glucose at home: yes/no
Tube feeding: Type of feeding: _______ Residual: ________
NG/PEG/PEJ Rate: _________
IV Site: peripheral/PICC/central line/port appearance: __________
I: O:
Nails: Skin:
Braden Scale
Elimination Pattern Activity-Exercise Pattern
Usual bowel habits: ___________ Last BM: ____________ Tobacco Use: yes/no How long: __________ PPD ________ Quit
Diarrhea/Constipation/Incontinent/_________ Color: _________ smoking? _______
Consistency: Ostomy: Respiratory effort:
Rectum: Respiratory depth: DIB:
Bladder function: Cough: Sputum: Color ______ Consist. _____ Amt _____
Bladder distention: ADL- eat/toilet/ambulate/bath/bed mobility/dress/transfer
Urine: Color___________ Clarity__________ Response to ADL:
Gait: steady/unsteady/Posture______
Assistive devices: Participates PT:
Hx of falls:
Sleep-Rest Pattern Sexuality-Reproductive Pattern
Home sleep: _______ hrs/night Naps: _____________ Verbalized impact of illness, meds, tx: _____________________
Hospital sleep: ________ hrs/night Naps: _____________ Breasts: _______________________ Hx of STD’s: _________
Insomnia/Sleep Apnea/Other _________ Sleep Aids _______ Genitalia: _____________________ Prostate: ____________
Sexually Active: ________ GYN/Mammogram: ___________
Cognitive-Perceptual Pattern Role-Relationship Pattern
Memory: intact/recent memory deficit/remote memory deficit Occupation (current or retired): _____________________
Thought process: appropriate/poor historian/ __________ Support Systems: married/widowed/divorced/single/life partner
Restraints: ______________ Alternatives: __________________ Identified support systems/individuals: ____________________
Verb. understand illness: _____________ Glasses: yes/no Socialization: phone calls/visitors/cards
Barriers to learning: _________________ Hearing Aids: yes/no Verbalized Fear of Violence
Heat/cold intolerance: yes/no numbness/tingling: yes/no
Pain: __/10 Longer than 6 months: yes/no Desired pain: ___/10
What makes it worse: __________________________________
What makes it better: __________________________________
Self-Perception/Self-Concept Pattern Coping-Stress Tolerance Pattern
Erickson’s Age related Developmental Stage: _______________ Behaviors/Statements indicating adjustment to stressors/illness:
Client’s Developmental Stage ___________________ AEB
____________________ Behaviors/Statements indicating impaired adjustment:
Verbalized identification with cultural group: _______________
Indicators of culture: __________________________________ Drugs/Alcohol for coping: yes/no
Identified/Verbalized major losses/life changes: _____________ Interest in alternative coping strategies: yes/no
Emotional/Behavioral State: calm/happy/sad/depressed/agitated/
combative/angry/anxious/other: ______________
Values-Belief Pattern Vital Signs:
Verbalization of that which is most valued in life: ____________ BP T R P PO Pain
Verbalization of self as a spiritual/religious person: ___________
8am
Request for spiritual support while hospitalized: _____________
Environmental spiritual cues: ____________________________ Noon
Behavioral/Verbalized cues of spiritual distress: _____________
Diagnostic Studies Done: yes/no Labs: Date: ___________
X-rays/Scans: RBC: ____ HGB: _____ HCT: _____Platelets: ____ WBC:____
Procedures: Na: ____K: ____ Cl: ____ CO2: ____ Mg: ____ Ca: ____ P: ___
EKG: Others:
Other:
Initials: ________ Room Number: _______ Age: ______ M/F
Admission Date: __________ From: home / ECF / assisted living
Medical DX: _________________________________________
Surgical Procedure: ____________________________________
7.8 Collect data & come up with plan for day & nursing diagnosis Pre-conference 8-9 Vitals then chart, AM Care, start
baseline assessment 9-10 Activities of Daily Living and chart, finish baseline assessment 10-11 Ongoing Adult
Assessment (should be on task list) 11-12 Activities of Daily Living 12-1 Vitals and chart 1-2 Activities of Daily
Living 2-3 Post Conference
 Head
LOC: clear/confused (oriented to person, place, time)
alert/lethargic
PERRL: pupils __ mm at rest, equal/round/ reactive to light
MUCOUS MEMBRANES: dry/moist, pink/pale/cyanotic,
intact/fissured
Thorax
SHAPE: (1:2), (1:1)
BREATH SOUNDS: clear/crackles/wheezing,
effortless/DIB
HEART: regular/irregular, rate ______ bpm
Abdomen
CONTOUR: flat/round, soft/firm, distended, tender
OTHER: stoma________ drains_________ scars_________
BOWEL SOUNDS: present x 4 quadrants/absent
Limbs
UPPER: radial pulse (0, +1, +2, +3) capillary refill </> 3 sec
Hand Grasps = / R < > L
ROM full/restricted explain: _________________________
LOWER: pedal pulse (0, +1, +2, +3) = / R < > L
Edema absent/present, firm/pitting (+1, +2, +3, +4)
ROM full/restricted explain: _________________________
Skin
COLOR: pink / pale / cyanotic / jaundiced
CONDITION: dry / moist, cool / warm
TURGOR: elastic / tents
INJURY: contusion / abrasion / laceration / ulceration /
excoriation / descriptors: Size ________________
Color _______________ Dry/Drainage_________________
Equipment
FOLEY: urine color ___________ clarity ____________
Amount__________
IV: Site Infiltration (cool, pale, pain) Phlebitis (warm, red,
pain)
Solution: ___________________ Rate: ________________
OXYGEN THERAPY: device _________ L/min ________
OTHER: Pain: no ______ yes _____ Pain scale: _____/10
NOC: ___________________________________________
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Medications: 0800 _________________________________
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0900 ____________________________________________
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1000 ____________________________________________
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Name: ___________________________________
Room #: _____________
Diagnosis/Surgery: ________________________________
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Vital Signs (how often): ____________________________
Activity (what needs to happen today): ________________
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Diet (any restrictions):
I&O (has to be monitored regardless of whether or not it
was ordered): _____________________________________
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O2/Resp Tx (what kind & how much): _________________
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IV & rate (what solution, site, rate in gtts/min): __________
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Treatments (dressings, SCD’s, trach care, etc.): __________
Accucheck (how often?): ___________________________
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Labs (what needs to be drawn? Results to view today?): ___
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Priority Assessment Data: ___________________________
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Nursing Dx: _____________________________________
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Nursing Interventions: ______________________________
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Medications: 1200 _________________________________
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1300 ____________________________________________
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1400 ___________________________________________
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