patient background

room # age admitting diagnosis/medical history

name

sex
male female

code
full DNR limited
precaution
allergies
nka droplet contact airborne

Assessment
Neuro Vitals bp rr
hr t
pulse 02

Cardiac Respiratory

GI / GU Musculoskeletal

Integumentary Iv / fluids / drips/ blood

labs notes
Hgb
Na Cl BUN
WBC PLT Glucose
K HCO3 Cr
HCT

PT Ca TP AST LDH
PTT BILI
INR PO2 ALB ALT ALP

© 2021 NurseInTheMaking LLC

 Head to toe assessment Template
1 inspect 2 palpate 3 percuss 4 auscultate

Level of Consciousness hair

person time A&O x clean infestation

place situation diRty hair loss

sparse baldness
orientation
awake drowsy eyes
alert sedated drainage
conjuntiva scerla or discharge?
restless confused moist white yes
pink yellow/jaundice no
vital signs
REMEMBER:
Blood pressure: PERRLA
Pupils Equal, Round, Reactive to Light, & Accommodation
Heart rate:
skin
Respiratory rate: temperature color
hot pink
Temperature: warm pale
cold flushed
oxygen saturation:
turgor moisture
nose elastic
tented
clamy
dry
symmetrical sneezing diaphoretic

Congestion runny nose

PAIN
Skin intact
no
pain INTENSITY: worst
pain

0 1 2 3 4 5 6 7 8 9 10
Mouth
Mucosa: LOCATION:
pink dry moist sore/lesions
description:

© 2021 NurseInTheMaking LLC

 Head to toe assessment Template

ears abdomen
Assess in different order:
symmetrical earwax
1 inspect 2 auscultate 3 percuss 4 palpate

hearing devices discharge inspection bowel sounds

symmetrical absent hypoactive
Rlq
normoactive hyperactive
neck rounded
absent hypoactive
ruq
symmetrical distended normoactive hyperactive
absent hypoactive
use of accessory muscles ascites luq
normoactive hyperactive

scars absent hypoactive

jugular vein distention llq
normoactive hyperactive

upper extremities lower extremities

grip strength grip strength capillary refill
range of motion
range of motion edema
radial pulse *
location:
dorsalis pedis pulse*
capillary refill
non-pitting
posterior tibial pulse* pitting
capillary refill time (CRT)
0 +1 +2 +3 +4
normal <2-3 seconds

chest
heart sounds
normal murmurs muffled gallop bruits whooshing
other: Aortic
Right 2nd intercostal space
Pulmonic
rhythm Left 2nd intercostal space
Auscultate heart sounds ERB’s Point
regular irregular (A, P, E, T, M) with (S1, S2) Left 3rd intercostal space

diaphragm and bell Tricuspid

breath sounds
Lower left sternal border 4th
intercostal
Mitral
clear wheezing crackles diminished Left 5th intercostal,
medial to midclavicular line

other: *
pulse chart
0 pulse is absent
rhythm Auscultate lung sounds 1+ diminished
regular irregular posteriorly & laterally 2+ normal
3+ full
4+ bounding, strong
© 2021 NurseInTheMaking LLC
 S Situation
room # age chief complaint

name

sex male female

code
full DNR limited precaution

allergies droplet contact airborne

nka

b background
Past medical hx Comorbities

a assessment
Neuro vitals bp rr
hr t
pulse 02
cardiac
Iv / fluids / drips / Blood

gi/gu
labs
integumentary

medications
Musculoskeletal

Respiratory orders

r recommendation
plan of care discharge

© 2021 NurseInTheMaking LLC

 SBAR
Use this script when calling the attending physician

S Situation

Hello, identify yourself & unit.

I’m calling about patient’s name & location.
The reason I’m calling is state the problem.

b background

The patient was admitted on _________

with a diagnosis of ________. State Patient History:
Code status Meds, Fluids, Allergies
Test results Past or pending procedures
Consults Significant health problems

a assessment

I think the problem is resp, cardiac, neuro issue, etc.

because during my assessment I found
provide assessment findings & current vital signs.
OR
I’m not sure what the problem is but the client is
deteriorating, unstable, has changed, etc.

r recommendation
Remember
I recommend the patient needs state the to read bac
all verbal a k
request (more orders, clarification, transfers etc.) telephone o nd
rders

© 2021 NurseInTheMaking LLC

 concept map template
nursing diagnosis nursing diagnosis

supporting data supporting data

goals goals

patient info

medical history

nursing diagnosis nursing diagnosis

supporting data supporting data

goals goals

© 2021 NurseInTheMaking LLC