NURSING SYSTEM REVIEW CHART

Name___Omac, Alquin_______________________ Date_September 5, 2011 Vital Signs: Pulse_124__ BP_100/60__ TEMP.__39.7__ Heigth__55__ Weigth__65__
INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X]. EENT: [ ] impaired vision [ ] blind [X] pain [ ] reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth Assess eyes, ears, nose throat for abnormalities. [ ] no problem RESPIRATORY: [ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [X] cough [ ] barrel chest [ ] bradypnea [ ] shallow [ ] rhonchi [X] sputum [ ] diminished [X] dyspnea [ ] orthopnea [ ] labored [X ] wheezing [ ] pain [ ] cyanotic Assess resp. rate, rhythm, pulse blood breath sounds, comfort [ ] no problem CARDIOVASCULAR: [ ] arrhythmia [X] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [X ] fatigue [X] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain Assess heart sound, rate, rhythm, pulse, blood pressure. circulation, fluid retention, comfort [ ] no problem GASTROINTESTINAL TRACT: [ ] obese [] distention [ ] mass [ ] dysphagia [ ] rigidity [ ] pain Assess abdomen, bowel habits, swallowing bowel sounds, comfort. [ X] no problem GENITO-URINARY AND GYNE: [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia assess urine frequency, control, color, odor, comfort, gyne bleeding, discharge [X] no problem NEURO: [ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures [ ] lethargic [X ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip assess motor, function, sensation, LOC, strength grip, gait, coordination, speech [x] no problem MUSCULOSKELETAL AND SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [X ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [] deformity [] wound [ ] rash [X ] skin color [X] flushed [ ] atrophy [] pain [ ] ecchymosis [ ] diaphoretic [ ] moist assess mobility, motion, gait, alignment, joint function skin color, texture, turgor, integrity [ ] no problem _-Endotracheal Tube _- manual ambubag ________________ ________________ __none eye opening_ ___________________ _ ____ ________ ___________ _-_cough, sputum, __dyspnea,_____ _- wheezing sound __both lungs____ __________________ __________________ __Tachycardia___ __irregular 124bpm_ __________________ __________________ ___foley bag catheter_ ___attached to uro bag __________________ __________________ __________________ __________________ __________________ __________________ _____________ __________________ _____________ ________________ __________________ ______________ _____________ _____ __________________ ___hot to touch_ ___flushed skin____ ___temp 39.7 C____ ______________ __________________ __________________ ___Comatose__ _____________ ____________ ___ __________ __________________ _________________ __________________ __________________ __________________ ______________ __ __________

Nursing System Review Chart II

SUBJECTIVE

OBJECTIVE

COMMUNICATION: ( ) Hearing Loss () Denied

( ) Glasses ( ) Contact Lenses Aide Pupil size ____3mm_

( ) Languages ( ) Hearing

( ) Speech Difficulties Reaction: PERRLA- Pupil Equally Round Reactive to Light and Accommodation OXYGENATION: ( ) Dyspnea (x) Smoking History _________________ ( ) Cough ( ) Sputum ( ) Denied CIRCULATION ( ) Chest Pain Heart Rhythm ( ) Regular Ankle Edema ( - ) Pulse R_ L_ Car Rad _+______+_ + _ _ _+_ ( ) Irregular Resp. ( x ) Regular ( ) Irregular Describe: SlightlyTachypneicR _______________________________

L_______________________________

() Leg Pain
( ) Numbness of Extremities ( x ) Denied NUTRITION Diet: _ [ ]N [ ]V DP _+ +

comments

(x ) Dentures Full Upper ( ) Lower ( )

( ) None Partial With Pt. ( ) ( ) ( ) ( )

( ) recent change in weight, appetite ( ) Swallowing Difficulty ( ) Denied

SUBJECTIVE Elimination: Usual Bowel pattern Urinary frequency ___ _ ________ Constipation remedy ( ) Urgency ___ ___ ( ) Dysuria Date of Last BM ( ) Hematuria ___ _ ( ) Incontinence Diarrhea (character) ( ) Polyuria _ _ ___ ( ) Foley in place (X ) Denied

OBJECTIVE Comments: Change in bowel habits noted Bowel sounds: audible hypoactive bowel sounds Abd. Distention ( ) yes (X) No

MNGT OF HEALTH & ILLNESS (x ) Alcohol ( ) Denied (amount and frequency) Last Pap Smear __ LMP SKIN INTEGRITY: ( ) Dry ( ) Itching ( ) Denied

Briefly describe patients ability to follow treatments (diet, meds, etc) Patient claims to follow prescribed treatment regimen as long as financially able. ( ) Dry ( ) Cold ( ) Flushed ( ) Warm ( ) Cyanotic ( )Pale ( ) Moist

ACTIVITY/SAFETY ( ) Convulsion ( ) Dizziness ( ) Limited motion of joints Limitation in ability to ( ) Ambulate ( ) Bathe Self ( ) other ( ) Denied

( ) LOC and Orientation . Gait: ( ) Walker ( ) Cane ( )others ( ) Steady ( ) Unsteady ( ) Sensory and Motor Losses in face or extremities: ( ) ROM Limitation

SUBJECTIVE COMFORT/SLEEP/AWAKE () Pain (Location, frequency Remedies) ( ) Nocturia ( ) Sleep difficulty ( ) Denied

OBJECTIVE () Facial Grimace ( ) Guarding ( ) Other signs of pain None

COPING: Occupation: Members of Household: Most Supportive Person:

Observe non verbal behavior Patient displays enthusiasm in answering the student nurses question although its clear that she is uncomfortable in her current state. Person and phone number that can be reached any time:

SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) ________Daily Weight __________PT/OT____________ ________BP q Shift ________Irradiation___________ ________Neuro vs _________Urine Test__________ ________CVP/SG. Reading_______ ________24 Hour Urine collection

Date Ordered

Diagnostic/Laboratory Exams

Date done

Date Ordered

I.V Fluids/Blood

Date Disc

Liceo de Cagayan University Cagayan De Oro City

DATA BASE AND HISTORY

Name_________________________________ Civil Status_________ Income__________ Sex____ Age____ Rel _______ Nationality___________________ Informant______________________________

Date Adm.__________ Time_______

Temperature______ Pulse Rate ______ Resp. Rate _______ BP _______ Height ______ Weight ______

Chief complaint and History of Present Illness

Type of Previous Illness/ Pregnancy/Delivery Date

Type of Previous Illness/ Pregnancy/Delivery Date

Has received blood in the past:_____________ Yes __________ No if yes, list dates _______ Reaction _______________ Yes ___________ No Allergies:

Medication name

Dose/ Frequency

Time of Last Dose

Medication name

Dose/ Frequency

Time of Last Dose

Admitting diagnosis: __________________________________________________________________ Attending Physician: ______________________________

Score ___________Grade __________