DATABASE PAGE 1
Student Name: Date:
Date of Care: Age: Sex: Ht: Erikson's Stage of Development: Admission Date:
Race: Wt:
Chief Compaint: Medical History/Diagnoses:
Surgical Procedures:
Do Not Resuscitate Order: ____yes ____no
LABORATORY DATA:
TEST Norms Admisison Current TEST Norms Admission Current
WBC's Potassium
Differential Blood Glucose
Hemoglobin Glycohemoglobin
Hematocrit Cholesterol
Platelets LDL
Prothrombin time Urinalysis
INR
APPT Other Abnormal
Other Abnormal Other Abnormal
DIAGNOSTIC TESTS:
Chest X-ray: EKG: Other abnormal reports:
Other: Other: Other:
ALLERGIES: (list Food/Medication and reaction)
MEDICATIONS:
Medication/Time of administration Medication/Time of administration Medication/Time of administration
VITAL SIGNS:
TIME: TIME: TIME: TIME: TIME:
BP: BP: BP: BP: BP:
HR: HR: HR: HR: HR:
RR: RR: RR: RR: RR:
O2 Sats: O2 Sats: O2 Sats: O2 Sats: O2 Sats:
Temp: Temp: Temp: Temp: Temp:
Other: Other: Other: Other: Other:
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MEDICAL TREATMENTS:
Treatments: Support Services: Consults:
DIET/FLUIDS:
Diet Type: Restrictions: Gag Reflex Intact? Appetite: Breakfast Lunch Supper
____yes ____no _____% _____% _____%
Fluid Intake: Circle those that apply:
24 hours _______ *Problems:swallowing, chewing, dentures *Belching
Tube Feedings: *Needs assistance with feedings *Overhydrated or dehydrated
Type + Rate *Nausea/Vomiting *Other
IV FLUIDS:
Type + Rate: IV Dressing: Circle those that apply :
*dry *redness *edema *positional
Type + Rate: *leaking *no redness *other___________________
Date of IV insertion:
Type + Rate: Date of site care/change:
Date of tubing change:
ELIMINATION:
Date of last bowel movement: 24 Hour Urine Output: Foley/Condom Catheter: Urine appearance:
____yes ____no
Circle those that apply:
Bowel: constipation diarrhea flatus incontinence belching
Urinary: hesitancy frequency burning incontinence odor
Other:
ACTIVITY:
Gait: Activity Order: Use of Assistive Devices:
Fall-risk assessment rating: #of side rails required: Restraints: Weakness:
____yes ____no ____yes ____no
PAIN ASSESSMENT:
Score/Scale: Onset: Duration: Quality: Location:
Aggrivating Factors: Alleviating Factors: Effective pain meds:
____yes ____no
REPRODUCTIVE CONCERNS: ____WNL
Date/Time of delivery: Sex of Infant: G__T__P__A__L__
Method of delivery: Breast/Bottle Feeding:
Episiotomy:____no ____yes _____degree Lacerations:
Complications: circle all that apply
*forceps *labor augmentation/induction *PIH/PE
*vacuum extraction *fetal distress *Gestational Onset Diabetes
*shoulder dystocia *abruption *Multiple gestation
*nuchal cord *previa (partial or complete) *GBS positive
*PPROM (since_______) *premature delivery(EGA______) *fetal abnormality(cleft palate, club foot, etc.)
*fetal resuscitation *miscarriage/fetal demise *other
PAGE 3
REVIEW OF SYSTEMS: ( Choose WNL if normal and use space to describe abnormalities)
NEUROLOGICAL/MENTAL STATUS ____WNL
LOC: (A&Ox3, confused, etc.) Speech: (clear, inappropriate, etc.) Motor: (ROM) Sensation:
Pupils: Sensory Deficits: Glascow Coma Score:
MUSCULOSKELETAL SYSTEM ____WNL
Bones, Joints, Muscles: (fractures, arthritis, etc.) Extremity Circulation Status: (pulses, edema, etc.)
Assistance Devices: (Ted hoses, compression devices, etc.) Casts, Splints, Collars, or Braces:
CARDIOVASCULAR SYSTEM ____WNL
Pulses: (to touch or with Doppler) Capillary Refill: Edema, pitting vs. non-pitting:
Neck vein: Heart Sounds: Chest Pain: Other:
RESPIRATORY SYSTEM ____WNL
Depth, rate, rhythm: Accessory muscle use: Cyanosis: Sputum: (color, amount)
____yes ____no
Cough: Breath sounds: R Oxygen use: Flow rate of O2:
L
Oxygen Humidified: Pulse Oximeter: Smoker:
____yes ____no ___yes ____no
GASTROINTESTINAL SYSTEM ____WNL
Abdominal pain, tenderness,guarding; distention, soft, firm: Bowel Sounds:
NG tube: (describe drainage) Ostomy: (describe stoma/stools) Other:
INTEGUMENTARY SYSTEM/ WOUNDS ____WNL
Color/Turgor: Rash/Bruises/Cuts/Abbrasions:
Describe Wounds: (size, location, etc.) Edges approximated: Wound Drains:
____yes ____no
Describe drainage:
Dressings: (clean, dry, etc.) Sutures, staples, etc. in place: Risk for decubitus ulcers:
EYES, EARS, NOSE & THROAT ____WNL
Eyes: (redness, drainage, etc.) Ears: (drainage) Nose: (redness, drainage, etc.) Throat: (sore)
PSYCHOSOCIAL AND CULTURAL ASSESSMENT
Religious Preference: Marital Status: Occupation: Health care benefits/Insurance available:
____yes ____no
Emotional state: Ability to Learn: Cultural Barriers/Concerns: