Student Name: _____________________ Date(s) of Clinical Assignment:__________ Pt.

Room # ____
Clinical Instructor:__________________________

GENERAL INFORMATION AND HEALTH HISTORY

Nursing Data Base
Age Sex Wt Ht SMWD Race
Pt. Initials
Admission Date/Time Admitted From:

Primary Physician History Obtained From

Consulting Physician(s)

Diagnoses (pertinent to this admission):

Surgeries pertinent to this admission:(Date/procedure)

Reason for Admission in Patient’s Own Words

Reason for this Hospitalization (from History & Physical)  Ineffective

Health
Maintenance
 Ineffective self
Previous Hospitalizations (include past surgeries as well as past medical hospitalizations): Health
management
 Noncompliance
 Other:
 Smoker _____PPD  Alcohol ______ drinks per day/week (circle)
 N.A.  N.A.

Patient’s Medical History:

 Diabetes  Respiratory Dis.  Cancer  Kidney Disease  Mental Illness
 Hypertension  Hepatitis  GI Disease  Thyroid Disease  Arthritis
 Heart Disease  Vision Disorder  Blood Disorder  Neuromuscular  Sexual Diseases
 Tuberculosis  Seizure Disorder  Others:

Family Medical History: √ diseases; if deceased, state what they died of (last column)
HTN CVA Heart Dis. Cancer Diabetes Alcoholism Mental Ill. Died of:
Mother Hx
Father Hx
Sibling Hx
Sibling Hx

Medications patient is currently taking:  No Known Allergies

 Allergies (include food, medications and patient’s reaction):
___________________________________________
___________________________________________

Name Dose/ Name Dose/

Frequency Frequency
 DIAGNOSTIC TESTS
Mark Patient Lab Results that are lower () or higher () than normal values.
See Trends of Vital Signs and Labs Sheets (ie – the Trending Sheet)
Complete any labs below that are ordered for this patient but are not included on the Trending Sheet

Labs: Date Lab Normal Values

Results

Hematology See Trending Sheet under CBC Results.

Chemistry Other Blood work that is considered “Chemistry” includes: sodium, potassium, chloride, Co2, glucose and
accuCheck. See Trending sheet for these values.

Labs: Date Lab Normal Values

Results

Calcium 9.0 – 10.5 mg/dl

Phosphorous 3.45 mg/dl
AST (SGOT) 0-35 U/L
ALT (SGPT) 4-36 U/L
LDH 100-190 U/L
CPK (F)30-135 U/L; (M)55-170 U/L
Cholesterol < 200 mg/dl
HDL (High Density Fe > 55 mg/dl; M > 45 mg/dl
Lipoprotein)
LDL (Low Density 60-180 mg/dL
Lipoprotein)
Arterial PH 7.35-7.45
Blood
PCO2 35-45 mm Hg
Gases
PO2 80-100 mm Hg
O2 Saturation 95% - 100%
HCO3 21 – 28 mEq/L
Base Excess 0 + 2 mEq/L

Coagulation
Studies
See Trending Sheet for PT, PTT, and INR
Urinalysis See Trending Sheet for Color, Sp. Gr., RBC, WBC
C&S Source: Negative

Lab
Labs: Date Results Normal Values
Other:
 X-RAY AND SPECIAL TEST RESULTS
Record physician’s Impression only (usually found toward end of test results in chart).
TEST DATE OF RESULTS
TEST

GROWTH AND DEVELOPMENT FUNCTION Stage

Check appropriate developmental stage for your patient. (See last page of Assessment Booklet for Developmental Tasks
handout.)

 Birth to 1 year Infant Trust vs. Mistrust

 1 - 3 years
 4 - 5 years
 6 - 11 years
 12 - 18 years
 20 - 40 years
 40 - 65 years
 >65 years
Toddler Autonomy vs. Doubt and Shame
Preschool Initiative vs. Guilt
School Age Industry vs. Inferiority
Adolescence Identity vs. Identity Diffusion
Young Adulthood Intimacy vs. Isolation
Middle Adulthood Generativity vs. Stagnation
Maturity (Old Age) Integrity vs. Despair and Disgust

Based on your patient’s stage checked above, list 5 tasks in column one that your patient should be achieving. Following your
clinical experience, complete column two by stating whether or not these tasks are being met and give data.

TASKS Is task currently being met? Record patient

data that helped you to reach this conclusion.
1. □ yes □ no

2. □ yes □ no

3. □ yes □ no

4. □ yes □ no

5. □ yes □ no
 NURSING ASSESSMENT
VITAL SIGNS: BP________ p _______ R_______ T_______

COMFORT AND REST FUNCTION - (Sleep/Rest/Pain/Comfort):

Sleep Pain Assessment (√appropriate N. Dx)
 No problems  No pain currently  Time of last pain med:  Insomnia
 Difficulty staying  Pain: _______________  Acute Pain
asleep o Location:  Chronic Pain
 Difficulty falling asleep  Medication(s) used:  Sleep Deprivation
 Not rested after sleep o Scale of 1-10: _________________  Other:
 What helps you ______
sleep? o Sharp MEDICATIONS:
o Dull
o Ache
o Constant
o Other:

SUBJECTIVE/NONVERBAL DATA:
____________________________________________________________________________________________________
___________________________________________________________________________

SENSORY PERCEPTUAL FUNCTION - (Neurological):

Oriented to: Level of Pupils Other Neuro (√appropriate N. Dx)
Consciousness Symptoms
 Person  Alert  PERLA  Headache/Pain  Risk for Falls
 Place  Stuporous  Other:  Tingling  Impaired Verbal
 Time  Semi- ________  Seizures Communication
 Event comatose ________  Numbness  Acute Confusion
 Other  Comatose  Tremors  Risk for Acute
 Combative Pupil Size:  Motor Confusion
 Anxious  Right: ______ Disturbance  Chronic Confusion
 Confused (Describe):  Risk for Injury
 Left: _______  Deficient Knowledge
(specify)
 Impaired Memory
Visual Impairment Hearing Impairment Speech Impairment  Unilateral Neglect
 None  None  None  Acute Pain
 Wears Glasses  Hard of Hearing  Slurring  Chronic Pain
 Contacts  Deaf Right Ear  Mute  Risk for Peripheral
 Blind Right Eye  Deaf Left Ear  Stutters Neurovascular
 Blind Left Eye  Hearing Aid Right Ear  Cannot Dysfunction
 Hearing Aid Left Ear Express  Disturbed Sensory
 Pain/Discomfort – Ear  Cannot Perception: auditory
 Other: Understand  Disturbed Sensory
Language Barrier:  Tracheostomy Perception: tactile
 Laryngectomy  Disturbed Sensory
 Yes (describe): Perception: vision
 Disturbed Thought
Process
 No  Other:

MEDICATIONS:

SUBJECTIVE/NONVERBAL DATA:________________________________________________________________
__________________________________________________________________________________________
FLUID GAS TRANSPORT FUNCTIONS (Cardiovascular):

Blood Pressure Apical Pulse Radial P Temperature Edema (√appropriate N. Dx)

(__________) (________) (________) (_________)
 Hypertension  Regular  Regular  Oral  Location:  Decreased Cardiac
 Pacemaker  Irregular  Irregular  Tympanic _________ Output
 Chest Pain  Strong  Strong  Rectal  Pitting  Risk for deficient
 Weak  Weak  Axillary  Nonpitting Fluid volume
 Thready  Absent  Deficient Fluid
Upper Extremities Lower Extremities IV Therapy volume
 Risk for imbalanced
 Capillary Refill  Pink IV #1: Fluid volume
 Brisk < 3  Pale Solution/rate:__________________  Excess Fluid volume
secs  Cyanotic Location: _____________________  Readiness for
 Sluggish  Flushed Appearance of site: enhanced Fluid
>3 secs  Mottled balance
 Nailbeds pink  Ulcers IV #2:  Hypothermia
 Brown patching of lower legs Solution/rate:__________________  Hyperthermia
 Color of feet when dependent: Location: _____________________  Risk for Infection
_____________ Appearance of site:  Ineffective
LABS  Varicose veins Thermoregulation
 Leg pain with/ without activity PCA: Medication______________  Ineffective Tissue
RBC:_____  Capillary Refill  Intermittent dose: _____________ Perfusion: Cerebral
o Brisk < 3 secs - Lockout interval: _____________  Ineffective Tissue
Hct:______
o Sluggish> 3 secs  Basal rate: ___________________ Perfusion: Systemic
Hgb: _____  DP pulses: Location: ______________________  Ineffective Tissue
o Palpable Appearance of site: Perfusion: Peripheral
Platelets:_____
o Non-palpable  Other:
Cholesterol:_____ Epidural:
HDL:____ Medication/rate:_________________ MEDICATIONS:
Appearance of site:
LDL: ________
CPK: _______ TPN @ cc/hr
Location: _____________________
PT: ______ Appearance of site:
PTT: ______
Salinelock location:_______________
INR: ______ Appearance of site:

Other:
SUBJECTIVE DATA:___________________________________________________________________________
__________________________________________________________________________________________

FLUID GAS TRANSPORT FUNCTIONS (Respiratory) :

Cough Chest Respiratory Breath Isolation (√appropriate N. Dx)
Effort Sounds/
Location
 Productive  Symmetrical  Rate:  Clear  Respiratory  Activity Intolerance
 Nonproductive  Assymmetrical ______ Bilaterally  Protective  Risk for Activity
 Sputum color:  Chest tube L  Normal  Equal  Other: Intolerance
 Chest tube R  Dyspnea Bilaterally  Ineffective Airway
 Suctioning  Spirometer  Orthopnea  Crackles Clearance
_______ ml  Tracheost-  Ineffective Breathing
Arterial Blood high omy  Wheezes Presence of: Pattern
Gases  Oxygen  Risk for Infection
_____ L/min  Diminished  Kyphosis  Other:
PO2:  Cannula
PCO2:  Mask  Other: MEDICATIONS:
pH:  O2 Sat:
HCO3: ________

SUBJECTIVE DATA: __________________________________________________________________________________

____________________________________________________________________________________________________
ELIMINATION FUNCTON (Gastrointestinal):
General Abdominal Assessment Bowel Movement (√appropriate N. Dx)
Appearance
Bowel Sounds: Abdomen:  Passing Flatus  Bowel Incontinence
 Well-nourished  Active  Soft  Last BM _____  Constipation
 Malnourished  Hyperactive  Firm  Normal BM  Risk for Constipation
 Hypoactive  Tender  Constipated  Diarrhea
Ostomies:  Non-tender  Diarrhea  Toileting Self-Care deficit
 Distended  Blood in stool  Other:
 Colostomy  Flat  Pain with defecation
 Jejunostomy  Round  Hemorrhoids MEDICATIONS:
 Other:  Incontinent of BM

SUBJECTIVE DATA:____________________________________________________________________________________________
________________________________________________________________________________________________________________

ELIMINATION FUNCTION (Genitourinary):

Assessment Intake Output (√appropriate N. Dx)
Urine color: Urination:  Deficient Fluid volume
 Clear  No problems Day 1: ______ ______  Excess Fluid volume
 Cloudy  Nocturia Day 2: ______ ______  Risk for Deficient Fluid volume
 Hematuria  Incontinent Day 3: ______ ______  Risk for Imbalanced Fluid volume
 Straw  Frequency Total: _______ ______  Infection
 Dark amber  Urgency  Risk for Infection
 Other:  Burning Analysis of Intake and Output  Toileting Self-care deficit
 Retention  Impaired Urinary elimination
 Bladder Compare intake to output and state if  Stress Urinary incontinence
Distention Catheter type: this finding is, or is not, within normal  Urge Urinary incontinence
 Foley limits for your patient and why, or why  Urinary retention
Dialysis:  Suprapubic not:  Other:
 Peritoneal  Urostomy
 Kidney  3-way: post
TUR MEDICATIONS:

URINALYSIS LABS
Color: ________ Na+: ______
Specific Gravity: K+: _______
_____________ Cl-: _______
RBC: ________ Co2:______
WBC: _______ BUN: ______
Cr: ________

SUBJECTIVE DATA:___________________________________________________________________________________________
_______________________________________________________________________________________________________________
NUTRITION FUNCTION (Nutrition / Metabolic):

Weight/Height Diet Tube Feeding Assessment (√appropriate N. Dx)

Weight: _______  Regular  Nasogastric  Indigestion  Risk for Aspiration
 Clear liq  Gastric  Vomiting  Risk for unstable blood Glucose
Height: _______  Full liq  Jejunostomy  Nausea  Imbalanced Nutrition less than
 ADA  Type:  Full feeling in body requirements
*BMI: _______ ______cal ______________ throat  Imbalanced Nutrition more than
 Low Na  Rate:  Mouth sores body requirements
* Wt/lbs x 703  Renal _______cc/hour  Choking  Risk for Imbalanced Nutrition
(Ht/inches) 2  Cardiac  Difficulty more than body requirements
 Other: LABS swallowing  Impaired Oral mucous
Check one: Blood glucose: _____  Difficulty membrane
 Underweight Accucheck: ________ chewing  Feeding Self-Care deficit
< 18.5 Calcium: __________  Most recent  Impaired Swallowing
 Normal Phosphorous: _____ accucheck:  Other:
18.5 – 24.9 SGOT: ________ __________
 Overweight SGPT: ________ MEDICATIONS:
25-29.9 LDH: _________
 Obese Albumin: ________
30 and above Prealbumin: _______

SUBJECTIVE DATA:
Describe any recent gain or loss of weight:__________________________________________________________________

Describe any recent changes in appetite/eating patterns________________________________________________________

Other Subjective Data: _________________________________________________________________________________

PROTECTIVE FUNCTION (Hygiene, Skin, Integumentary):

Skin Color Isolation Abnormalities Wound Assess. (√appropriate N. Dx)

 normal  Wound/sk Mark any  no open areas Type of Wound:  Latex Allergy
/race in abnormal  pressure area ________________ response
 pale  MRSA areas on present Location: _______  Risk for Latex
 flushed  Other: figures shown  decubitus present ________________ Allergy response
 cyanotic below:  bruise present  Dry  Infection
 jaundice  abrasion present  Staples/sutures  Risk for Infection
 other:  skin tear present intact  Impaired Skin
 lesions present  Wound Integrity
Temperature  scars present approximated  Risk for Impaired
 warm  other:  Redness Skin Integrity
 cool _____________  Edema at  Impaired Tissue
 hot  lentigo wound site Integrity
 Condition  Hx. of skin  Other:
 dry cancers If Decubitus ulcer: MEDICATIONS
 moist  Stage:______
 Treatment:
Skin Turgor
 Good
 Fair
 poor

SUBJECTIVE DATA:__________________________________________________________________________
__________________________________________________________________________________________
ACTIVITY/MOBILITY/MOVEMENT FUNCTION (Musculoskeletal):

Mobility Assistive Limitations: Muscle Strength (√appropriate N. Dx)

Status Devices Right Left
 Ambulatory  None  None Grips Grips  Activity intolerance
 Assist  Cane  Weakness  Strong  Strong  Risk for Activity intolerance
 Transfer  Wheelchair  Restriction  Weak  Weak  Fatigue
with assist  Walker due to Foot Push Foot Push  Impaired bed Mobility
 Bedrest  Prosthesis surgery  Strong  Strong  Impaired physical Mobility
 Trapeze  Crutches  Fatigue  Weak  Weak  Impaired wheelchair Mobility
 Pillows: #  Paralysis:  Acute Pain
 Chronic Pain
 Other:  Risk for Peripheral
neurovascular dysfunction
Bathing: Pain: Amputation: Devices: R/T DVT
 Self  Location: ________________ Location:  CPM  Bathing/hygiene Self-care
 Assist  Cramping  TED deficit
 Complete  Spasms hose  Dressing/grooming Self-care
 Tremors  SCD deficit
 Joint Stiffness (Blue  Toileting Self-care deficit
 Swelling wrap)  Ineffective Tissue perfusion
LAB  Limited joint ROM  Traction  Impaired Transfer ability
 Presence of Kyphosis  Impaired Walking
Calcium: _____  Gait disturbance:  Other:
Phosphorous: ____ Yes ____ No
____________ MEDICATIONS:
Describe:

SUBJECTIVE DATA:_____________________________________________________________________________________________
_________________________________________________________________________________________________________________

GROWTH AND DEVELOPMENT FUNCTION (Reproductive): MALE

Assessment: Erection Inability Disease/Symptom Testicular Exam (√appropriate N. Dx)

 Discharge  Penile Implant  STD hx  Performs monthly  Disturbed Body image
 Tenderness  Meds (Viagra)  Itching  Needs information  Deficient Knowledge
 Pain  No problems  Other:  No problems (specify)
 Mass  Needs Information  No problems  Ineffective Role
performance
 Sexual dysfunction
 Ineffective Sexuality
patterns
 Other:

MEDICATIONS:

SUBJECTIVE DATA:_____________________________________________________________________________________________
GROWTH AND DEVELOPMENT FUNCTION (Reproductive): FEMALE

Pregnancies Assessment Breast Exam Check () if (√appropriate N. Dx)

applicable
 If child-bearing age,  Abnormal  No lumps  Disturbed Body image
is patient currently bleeding  If lump is Pain with:  Deficient Knowledge
pregnant?  Abnormal present,  Intercourse (specify)
NA _____ yes ____ discharge describe:  Menstruation  Ineffective Role
 Gravida (how many  Menopause performance
pregnancies):______ at:_______  Performs Contraception  Sexual dysfunction
 Number of children:  Hx of Sexually monthly  Currently using  Ineffective Sexuality
___________ Transmitted  Needs info. patterns
 Abortions: Infections  Experiencing:  Other:
_________  PMS
 Last menstrual  Hot Flashes MEDICATIONS:
period (LMP):  Other
___________ symptoms of
menopause
(list):

SUBJECTIVE DATA:_____________________________________________________________________________

PSYCHO/SOCIAL/CULTURAL/SPIRITUAL FUNCTION

Role Relationships:
Home Environment  Lives with  Lives  Lives  Other (√appropriate N. Dx)
spouse alone w/family
Subjective Data:  Impaired verbal
Who do you rely on for emotional support (check all that are applicable)? Communication
 Spouse  Family  Friend  Self  Other:  Dysfunctional Family
Processes
How does your illness/hospitalization affect your family/significant others? Describe:  Interrupted Family
Processes
 Anticipatory Grieving
 Complicated Grieving
 Risk for complicated
Grieving
 Impaired Parenting
 Risk for impaired
Parenting
 Social Isolation
 Impaired Social
Interaction
 Other:
 PSYCHO/SOCIAL/CULTURAL/SPIRITUAL FUNCTION (Continued)

Psycho-Social Behavior:

Subjective Data: (√appropriate N. Dx)

Describe any recent changes you have had in your life  Anxiety
(i.e., job, move, divorce, death, surgeries, abuse, etc.):  Disturbed Body Image
 Impaired verbal Communication
 Interrupted Family Processes
 Fear
How do you feel you are dealing with stressors associated with this change?  Complicated Grieving
(Describe using patient’s words):  Hopelessness
 Risk for Loneliness
 Impaired Parenting
 Powerlessness
What concerns you most about your hospitalization? (Describe using patient’s  Risk for Powerlessness
words):  Ineffective Role performance
 Chronic low Self-esteem
 Situational low Self-esteem
 Social Isolation
 Impaired Social interaction
Does your illness and/or hospitalization affect how you feel about  Chronic Sorrow
yourself? (Describe using patient’s words):  Risk for other-directed Violence
 Risk for self-directed Violence
 Other:

MEDICATIONS:
Values / Beliefs/ Spiritual

Subjective Data: (√appropriate N. Dx)

Does religion or spirituality play a part in your life:  yes  no  Spiritual distress
- If yes, in what way does it play a part? __________________________________________  Risk for Spiritual
__________________________________________________________________________ distress
 Readiness for
Does your religion or spiritual beliefs affect medical treatment (i.e., receiving blood, last rites, etc)? enhanced Spiritual
 yes (describe in what way: __________________________________________________) well-being
 no  Other:

Is your pastor (or priest, rabbi, spiritual leader, etc.) aware of your hospitalization?  yes  no

- If no, do you wish for this person to be notified?  yes  no

Do you have a special religious request at this time?  yes (state request in the space below)
 no