DATA BASE AND HISTORY

Name of Patient:________________________Sex:_________Age:_______Religion:___________________
Civil Status:_________
____Income___________ Nationality _________________________
Date Admission:_________________ __Time____________Informant______________________________
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

Preganancy/ Delivery

Date

Has received blood in the past: ____Yes____No If Yes, list dates____ Reaction____ Yes ____No
Medication Name

Dose/
Frequency

Time of
Last Dose

Medication Name

Dose/
Frequency

Time of Last
Dose

Admitting Diagnosis:_________________________________________________________________________
Admitting Physician:_________________________________________________________________________

NAME of PATIENT:
Pulse:
BP:

Temp:

NURSING SYSTEM REVIEW CHART

Date:
Height:
Weight:

EENT:
[ ] Impaired Vision [ ] Blind [ ] Pain [ ] Reddened
[ ] Drainage
[ ] Gums [ ] Hard of Hearing
[ ] Deaf [ ] Burning
[ ] Edema
[ ] Lesion
[ ] Teeth [ ] No P,roblem
Assess Eyes, Ears Nose, and Throat for Abnormalities.
RESPIRATORY SYSTEM:
[ ] Asymmetric [ ] Tachypnea [ ] Apnea [ ] Rales
[ ] Cough
[ ] Barrel Chest [ ] Bradypnea
[ ] Shallow [ ] Rhonchi [ ] Sputum [ ] Diminished
[ ] Dyspnea [ ] Orthopnea [ ] Labored [ ] Wheezing
[ ] Pain
[ ] Cyanotic
[ ] No Problem
[ ] Assess Resp. Rate, Rhythm, Depth, Pattern,
Breath Sounds, and Comfort.
CARDIO VASCULAR:
[ ] Arrhythmia
[ ] Tachycardia [ ] Numbness
[ ] Diminished Pulses [ ] Edema
[ ] Fatigue [ ] Irregular
[ ] Bradycardia [ ] Murmur [ ] Tingling [ ] Absent Pulses
[ ] Pain [ ] No Problem
Assess Heart Sounds, Rate, Rhythm, Pulse,
Blood Pressure, Circulation, Fluid Retention, and Comfort.
GASTRO - INTESTINAL TRACT:
[ ] Obese [ ] Distention [ ] Mass [ ] Dysphagea
[ ] Rigidly [ ] Pain
[ ] No Problem
[ ] Assess Abdomen, Bowel Habits, Swallowing,
Bowel Sounds, and Comfort.
GENITO - URINARY AND GYNE:
[ ] Pain [ ] Urine Color [ ] Vaginal Bleeding
[ ] Hematuria [ ] Discharge [ ] Nocturia
[ ] No Problem
[ ]Assess Urine Frequency, Control, Color,
Odor, Comfort, Gyne-Bleeding and Discharge.
NEURO:
[ ] Paralysis [ ] Stuporus [ ] Unsteady [ ] Seizures
[ ] Lethargic [ ] Comatose [ ] Vertigo
[ ] Tremors
[ ] Confused [ ] Vision [ ] Grip
[ ] No Problem
Assess Motor Function, Sensation, LOC, Strength,
Grip, Gait, Coordination, Orientation and Speech.
MUSCULOSKELETAL and SKIN:
[ ] Appliance [ ] Stiffness [ ] Itching [ ] Petechiae
[ ] Hot [ ] Drainage [ ] Prosthesis [ ] Swelling
[ ] Lesion [ ] Poor Turgor [ ] Cool [ ] Deformity
[ ] Wound [ ] Rash [ ] Skin Color
[ ] Flushed
[ ] Atrophy [ ] Pain [ ] Ecchymosis [ ] Diaphoretic
[ ] Moist
[ ] No Problem
[ ]Assess Mobility, Motion, Gait, Alignment,
Joint Function, Skin Color, Texture, Turgor, and Integrity.

Place an (X) in the area of abnormality. Indicate the location of the problem in the figure if appropriate, using (X).

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NURSING ASSESSMENT 2
SUBJECTIVE
COMMUNICATION:
hearing loss
visual changes
denied

OXYGENATION:
Dyspnea
Smoking history
_______________
Cough
Sputum
Denied
CIRCULATION:
Chest pain
Leg pain
Numbness of
Extremities
denied

NUTRITION:
Diet:_________________
N
V
Character:
Recent change in weight,
appetite
swallowing difficulty

ELIMINATION:
Usual bowel pattern:
________________
Constipation
Remedies
________________
Date of last BM:
________________
Diarrhea character
_________________

Comments:___________
____________________
____________________
_____ _______________
_____________________
Comments:____________
_____________________
_____________________
______________________
______________________
______________________
Comments:_____________
______________________
______________________
______________________
______________________
______________________
______________________

OBJECTIVE
Glasses
Contact lens
R
Pupil Size:__________
Reaction:___________

Resp.:
regular
irregular
Describe:_____________________________________________
____________________________________________________
R:__________________________________________________
L:__________________________________________________
Heart Rhythm: regular
irregular
Ankle Edema:________________________________________
Carotid
Radial
Dorsalispedis
Femoral
R:__________________________________________________
L:__________________________________________________
Comments:__________________________________________
____________________________________________________
*if applicable:_________________________________________
Dentures

Comments:______________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
_______________________
urinary frequency
______________________
urgency
dysuria
hematuria
incontinence
polyuria
foley in place
denied

MGT. OF HEALTH AND ILLNESS

Alcohol
denied
(amount, frequency)
___________________________________________________
___________________________________________________
SBE Last Pap Smear:______________________________
LMP:

languages
hearing aide
L
speech difficulties

None

Full

Partial

With Patient

Upper
Lower

Comments:_______________ Bowel Sounds:_____________

________________________ Abdominal Distention
________________________
Present: Yes
No
________________________ Urine*(color, consistency,
________________________
odor)
________________________ __________________________
________________________ __________________________
________________________ * if foley bag catheter is in place
________________________
________________________
Briefly describe the patients ability to follow treatments
(diets,meds, etc.) for chronic health problems (if present).
_____________________________________________________
_____________________________________________________
_____________________________________________________

SUBJECTIVE
SKIN INTEGRITY:
Dry
Itching
Other
Denied

ACTIVITY/SAFETY:
Convulsion
Dizziness
Limited motion
of joints
limitation in ability to
ambulate
bathe self
others
denied

COMFORT/SLEEP/AWAKE:
Pain (location, frequency
remedies)
nocturia
sleep difficulties
denied

OBJECTIVE

Comments:___________________
____________________________
____________________________
____________________________
____________________________
____________________________
Comments:__________________
___________________________
___________________________
____________________________
____________________________
____________________________
_____________________________
____________________________
_____________________________
_____________________________

Comments:___________________
_____________________________
_____________________________
____________________________
_____________________________
_____________________________
_____________________________

COPING:
Occupation:
Members of household:_________________________________
_____________________________________________________
_____________________________________________________
Most supportive person:________________________________
_____________________________________________________

___________Daily weight
___________BP q Shift
___________Neuro V/S
___________ CVP/SG Reading
Date
Ordered

Diagnostic/Laboratory
Exams

Dry
cold
pale
Flushed
warm
Moist
cyanotic
*rashes, ulcers, decubitus(describe size, location, drainage)
____________________________________________________
____________________________________________________
____________________________________________________
LOC and orientation_________________________________
____________________________________________________
Gait:
walker
care
other
Steady
unsteady
Sensory and motor losses in face or extremities:
____________________________________________________
____________________________________________________
____________________________________________________
ROM limitations ____________________________________
_____________________________________________________
_____________________________________________________

Facial grimaces
Guarding
Other signs of pain:__________________________________
_____________________________________________________
Side rail release form signed (60+ years)
____________________________________________________
Observed non-verbal behavior:___________________________
____________________________________________________
____________________________________________________
____________________________________________________
Person(Phone Number)_______________________ _________
____________________________________________________

SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)

_________PT/OT________________
_________ Irradiation
__________ Urine test_____________
__________24 hour Urine Collection
Date
Done

Date
Ordered

I.V. Fluids/Blood

Date Disc.

Drug Study
Name of Client:
Name of Drug

Classification

Date
Ordered

Dose,
Frequency,
Route

Mechanism of
Action

Indication

Contraindication

Side
Effect

Nursing
Implications

Drug Study
Name of Client:
Name of Drug

Classification

Date
Ordered

Dose,
Frequency,
Route

Mechanism of
Action

Indication

Contraindication

Side
Effect

Nursing
Implications

Drug Study
Name of Client:
Name of Drug

Classification

Date
Ordered

Dose,
Frequency,
Route

Mechanism of
Action

Indication

Contraindication

Side
Effect

Nursing
Implications

Nursing Care Plan

Name of Client:
Cues

Nursing
Diagnosis

Objectives

Intervention

Rationale

Evaluation

Nursing Care Plan

Name of Client:
Cues

Nursing
Diagnosis

Objectives

Intervention

Rationale

Evaluation

Nursing Care Plan

Name of Client:
Cues

Nursing
Diagnosis

Objectives

Intervention

Rationale

Evaluation

Name of Patient:

S
O
A
P
I

HEALTH TEACHINGS
NAME OF PATIENT:

MEDICATIONS

EXERCISE

TREATMENT

OUT-PATIENT

DIET

PATHOPHYSIOLOGY
Name of Patient:____________________________________________ Date:_______________________________
Diagnosis:__________________________________________________

Reference:______________________