Student Name: Assigned Unit: Date: Simulated medical chart Ploaso use only Initials to protect patient confidentiality. PATIENT ASSESSMENT DATE: DAY ONE DAYTWO Normal Cognitive} | CaWithin Normal Limits (Within Normal Limits Perceptual Pattern | CIDisoriented to: DDisoriented to: Person [Place DSivation Person OPiace OSitvation Net, acve, calm, {aDoes not flow commands aDees not follow commands oriented to person, place, | lLethargic CUnresponsive (Anxious | QlLethargic ClUnresponsive ClAnxious time, and station Speech: Speech: Follows commands, | Other. Other. speech clear. , Location Location: rain Scale Scale: Normal integumentary Pattern Within Normal Limits Hot CiCool CClammy CPale Caundice CFlushed ODusky CiCyanotic CMotled ‘QWithin Normal Limits Hot CiCool CClammy OPale Duaundice Flushed CDusky OCyanotic OMottled Skin: Color within normal | Cainelastic Skin Turgor inelastic Skin Turgor limits, warm, dry, intact, | COSkin Tear: Diskin Tear. skin turgor elastic Pressure Ulcer: Pressure Ulcer Heels: Osacrum incision: dressing Dressing DiTubessDrains: DTubessDrains: cast cast other other: Normal Respiratory | CiWithin Normal Limits Within Normal Limits Pattern CASOBIDyspneic CISOBDyspneic CTachypneic Btachypneic Resp. unlabored and GiPursed Lip Breathing Pursed Lip Breathing symmetrical; reg. hythm | Cllrregular Direguiar ‘and depth. Secrets: | Other. other: clear, thn, no cough, No. | CAAbnormal Breath Sounds: ‘CiAbnormal Breath Sounds abnormal breath sounds. CiUses Accessory Muscles Dises Accessory Muscles ‘Non-Productve Cough ‘DNon-Productve Cough ‘DProductve Cough: COProductve Cough: DFrothy (Thick (Green Yellow DFrothy OThick Green CYellow DBloody Bother: Bloody Bother: 0: LPM | O2: LPM Via. Via Normal Within Normal Limits Within Normal Limits Cardiovascular Olrregular Olrregular Pattern Abn. peripheral pulses Abn. peripheral pulses Scale Scale: Hear rhythm reg, Location Location: peripheral puses positive | Edema (locaton/scae) Edema (location/scale) bilteraly, oedema, | CalfTendemess: OR OL CalfTendemess: OR OL Other. Other: Telemetry Rhythm Telemetry Rhythm Pagel: of agesStudent Name: Assigned Unit Date: [ DATE: 7 7 DAYONE - DAY TWO _| Normal ROM Pattern | CiWithin Normal Limits Within Normal Limits immobilizer immobilizer Full ROM alljoints. No. | ClAbnormal ROM DiAbnormal ROM muscle weakness, Describe Describe: absence joint edema, Normal Elimination | CWithin Normal Limits Within Normal Limits Pattern Nausea CVomiting CiDiarthea DNausea Vomiting COdiarthea Constipation Constipation Gli abd. sof BS positive, | Abd: CDistended CiTender Pain ‘Abd: ODistended CTender Cain allfour quadrant. NoN/V_ | Abd. Bowel Sounds (describe): ‘Abd. Bowel Sounds (describe): diarthea or constipation. other: Dother: GU: Voiding without | Stool: GYes CINo Stoot: BYes BNo difficulty or Foley patent & | Voids: OFoley Other: Voids: DFoley other: raining. Nobladder | Urine: CStraw Amber CiBloody Urine: CStraw Camber CiBloody distention, Ciciear CCloudy OClear OCioudy Incontinent: CBowel ~ CiBladder Incontinent: CiBowel Bladder Bladder: CDistended Burning Bladder: CIDistended CIBuming Frequency: Frequency: Cdysuria Ddysuria DVaginal Drainage Bvaginal Drainage OBIGYN Owe: Breasts: Breasts: Dhochia Dhochia Funds: DFundus: (Dag Pack, (DVag Pack: Dother other: ET NUTRITIONIMETABOLIC PATTERN Breakfast Lunch Diet: Diet SupplementSnack. % | SupplementSnack % Food from Home: Yes CINo % | Food from Home: Ci¥es GINO % NPO for. NPO for Food taken per. Self CIAssist CiFed Food taken per: CISef ClAssist CiFed DAI O34 O12 (14 GNone Refused DAI 034 O12 O14 None ORetused Tolerated diet’ Ces CNo Tolerated diet’ Yes CINo Swallows with dficuly: Ces CNo Swallows with iffcuty: C1Yes CNo IF yes, explain ifyes, explain: | Dinner | Diet | SupplementSnacl % | Food from Home: Ci¥es _CINo % NPO for: | Food taken per: CiSelf CiAssist CiFed | CAI O34 1/2 C14 TNone Refused | Tolerated diet: ClYes CIN Swallows with difficulty: Yes CINo tyes, explain: Paget of pagesStudent Name: Assigned Unit: Date: inal. ACTIVITY/EXERCISE PROGRAM Bath: Bath: Bath: Given Refused ODefered | OGiven CRefused Deferred | CiGiven ORefused Deferred Type: Typ DsSponge Cshower CTub shower CiTub sponge CiShower OTub self DAssist Complete Assist CiComplete | Cseff Assist + OComplete Dori = Dory CaPeri Care Croley — CiPeriCare | Choral © Ooly Peri Care Care Care Care Care care Denture Care: Upper Dower Denture Care: Upper ClLower Denture Care: ClUpper CLower AE Hose: Yes CINo ‘AE Hose: ClYes CINo ‘AE Hose: ClYes CINo DRemoved and reapplied Removed and reapplied Removed and reapplied Ambulate: Self DAssst ‘Ambulate: CiSelf Assist Ambulate: CiSeff DAssst. Chair: OSelf DAssst Chair: OSelt Assist: Chair: OSelf Classis. Tolerated Activity: Ces CIN Tolerated Activity: Yes CINo Tolerated Activity: ClYes CINo Explain if NO: Explain if NO: Explain if NO: Bedrest Repositioned: Bedrest Repositioned: Bedrest Repositioned: OSett Oselt OSetf Dassst. CAssist Dassist ‘SPECIMENS TO LABIDIAGNOSTIC TESTS TIME ‘SPECIMEN | TIME ‘SPECIMEN | TIME ‘SPECIMEN EQUIPMENTISUPPLIES ON Pump Ok-pad CIV Pump k-pad Dv Pump ‘Ok-pad Feeding Pump — overheat DiFeeding Pump — Clovernead Feeding Pump Choverhead Trapeze Trapeze Trapeze Tubing Change Telemetry (Tubing Change Telemetry DTubing Change Telemetry Wagioral cpm DWagioral Ccem DWagloral Gopm Suction ‘Suction Suction OTubing COPCAPCEA Tubing COPCAPCEA Tubing COPCNPCEA Changed Changed Changed Cspecial Care CFrowtron Dspecial Care CFlowtron special Care OFlowtron Bed Bed Bed Other: Other: Other. ‘Signature Initial Date/Time Signature Initial [Date/Time Narrative Nursing Notes Nurse's Notes: Paget of pages