Assignments

1. ADMISSION INFORMATION

Date of Care:

Pt. Name:

Admission Date:

Age:

Gender:

Growth and Development (Erikson):

Ethnicity:

Occupation:

Spiritual Beliefs:

Reason for Hospitalization/Chief Complaint (in pt’s own words):

Surgical Procedures/Date:

Medical Diagnoses History: (Present and past diagnoses, Physician’s History and Physical notes in the chart, nursing intake assessment, with length of history if possible)

Admitting Medical Diagnosis:

History of Present Illness:

ADVANCE DIRECTIVES (Nursing Admission Assessment):

Living Will: ☐ Yes ☐ No

Durable Power of Attorney: ☐ Yes ☐ No

Code status : ☐ Full Code ☐ DNR (Do Not Resuscitate)

2. MEDICATIONS

ALLERGIES:

Drug

Classification

Dosage

Route

Frequency

(time due)

Purpose

Nursing Considerations

3. LABORATORY DATA

Test

Norms

On admission

Current value

Test

Norms

On admission

Current value

WBC

Sodium

Hemoglobin

Potassium

Hematocrit

Calcium

Platelets

BUN

PT

Creatinine

INR

Magnesium

aPTT

Blood Glucose

HA1c

Urinalysis

BNP

Cultures blood/sputum

DIAGNOSTIC TESTS

Chest X-ray:

EKG:

Abnormal studies:

Abnormal studies:

Abnormal studies:

Abnormal studies:

4. PHYSIOLOGICAL DATA-VITAL SIGNS

Vital Signs: Temp_________ oF / oC ☐Axillary ☐Tympanic ☐Oral ☐ Core ☐Rectal

Pulse______ ☐Apical _______ ☐Radial

Respiratory Rate______ ☐Even/regular ☐Labored/SOB ☐Dyspnea on Exertion

BP ______/_______ ☐Supine ☐Sitting ☐Standing

Admission weight:___________

Yesterday’s weight___________

Today’s weight______________

Height__________

5. NEUROLOGICAL/SENSORY

Orientation: ☐Time ☐Place ☐Person ☐Purpose

Sensation: ☐Normal ☐Impaired ☐Absent

Pain: Grade ____ /10 Scale used: ☐0-10 Numeric ☐FLACC ☐ Wong-Baker FACES

Pain Location:_______________

Character: ☐ Sharp ☐Dull ☐Ache ☐Heavy ☐Pinprick ☐Cramp ☐Other______________

What makes the pain worse:_______________

_______________________________________

What makes the pain better:________________

___________________________________

Level of Consciousness: ☐Alert ☐Lethargic ☐Obtunded ☐Stuporous ☐Semicomatose ☐Coma

Coordination: ☐Symmetrical ☐Asymmetrical ☐Unsteady

PERRLA : #____mm ☐Brisk ☐Sluggish ☐Fixed ☐Nystagmus

1 2 3 4 5 6 7 8mm

Strength: ____Right arm _____Left arm _____Right leg _____Left leg

0=No movement

1=Trace movement

2=Moving, not against gravity

3=Moving against gravity, not against resistance

4=Moving against gravity, some resistance

5=Full power

Glascow Coma Scale: Total of all 3 columns__________

Eyes

4=Open spontaneously

3=To speech

2=To pain

1=None

Total_______

Motor

6=Obeys command

5=Localizes pain

4=Withdraws

3=Flexion

2=Extension

1=None

Total________

Verbal

5=Oriented

4=Confused

3=Inappropriate words

2=Incomprehensible words

1=None

Total______

Touch: ☐Normal ☐Decreased

Smell: ☐Normal ☐Decreased

Hearing: ☐Normal ☐Tinnitus ☐HOH ☐Hearing Aid ☐Deaf

Vision: ☐Normal ☐Glasses ☐Contacts ☐Cataracts ☐Glasses ☐Glaucoma ☐Blurred vision ☐ Diplopia

Neurosensory comments:

Nursing Diagnosis:

6. CIRCULATORY/CARDIOVASCULAR

Color: ☐ Pink ☐Pale ☐ Jaundice ☐Flushed ☐Cyanotic ☐Mottled ☐Dusky

Capillary refill: ☐ <3 seconds ☐ >3 seconds

Skin:☐ Dry ☐Moist ☐Clammy ☐Warm ☐Cold ☐Hot

Tele monitored rhythm:________________________________

Peripheral Edema: ☐None ☐+1 ☐+2 ☐+3 ☐+4

☐Pitting ☐Non-pitting

Location:_____________________________________________

Heart Sounds: ☐S1 ☐S2 Rhythm: ☐Regular ☐Irregular

Implanted Pacemaker: ☐ Yes ☐No

Peripheral pulses:

Right radial ☐Present ☐Absent Left radial ☐Present ☐Absent Right pedal ☐Present ☐Absent Left Pedal ☐Present ☐Absent

Circulatory Comments:

Nursing Diagnosis:

7. RESPIRATORY/PULMONARY

Breath Sounds:☐Clear ☐Diminished ☐Absent ☐ Crackles ☐Wheezes

Location:☐ Throughout ☐RUL ☐RML ☐RLL ☐LUL ☐LLL

Pattern: ☐Regular ☐Irregular

Character: ☐Full ☐Shallow ☐Deep ☐Labored ☐SOB

Sputum: ☐White/Clear ☐Tan ☐Yellow ☐Green ☐Rusty ☐Pink ☐Red

Amount: ☐Small ☐Moderate ☐Large

Cough: ☐None ☐Nonproductive ☐Productive ☐Suctioning required

Secretions: ☐Yes ☐No Consistency: ☐Frothy ☐Thick ☐Thin

Pulse Oximeter: ______%

Oxygen: ☐Room air O2 ____L/min. or O2 _____%

Mode: ☐N/C ☐Mask ☐Trach

Suctioning Method: ☐Oral ☐Nasotracheal ☐ETT ☐Trach ☐Bulb

ABGs: pH_____ pO2________ pCO2_______ HCO3___________

Respiratory Comments:

Nursing Diagnosis:

8. NUTRITION/HYDRATION

Diet: ☐NPO ☐Regular ☐Cl. Liquid ☐Full liquid ☐Soft ☐Pureed

☐Other____________________

Aspiration Risk: ☐Yes ☐No

Feeding Method: ☐Self ☐Assisted ☐NG ☐G-Tube ☐J-Tube

Parenteral Nutrition: ☐TPN ☐PPN

Nausea: ☐Yes ☐No

Vomiting: ☐Yes ☐No

Flatus: ☐Yes ☐No

Tube Feeding Formula:_____________ Rate: mL/hr.

Residual: ☐No ☐Yes Amt.______mL

Weight: ☐Gain______# lbs./kg

☐Loss______# lbs./kg ☐No change

Mucous Membranes: ☐Dry ☐Moist

Skin Turgor: ☐No problem ☐Tenting ☐Taut

Intake:

PO______

IV______

NG______

Blood_______

Other_______

24 hour total_________

Output:

Urine_____

NG_______

Emesis________

Stool________

Drains________

Other________

24 hour total_________

24 hour net I/O: +/-_____

Nutrition/Hydration comments:

Nursing Diagnosis:

9. GI/FECAL ELIMINATION

Bowel Sounds:☐Absent ☐Hypoactive ☐Active ☐Hyperactive

Location: ☐RUQ ☐RLQ ☐ LUQ ☐LLQ ☐ Throughout

Abdomen: ☐Soft ☐Flat ☐Distended ☐Round ☐Firm ☐Tender ☐Flatus

Ostomy: ☐No ☐Yes Type:______

Incontinence: ☐Yes ☐No

Last BM: _______Stool: ☐Formed ☐Soft ☐Hard ☐ Liquid #_____

Color: ☐Brown ☐Black/Tarry ☐Clay/Gray ☐Yellow ☐Green

Fecal Elimination Comments:

Nursing Diagnosis:

10. GU/URINARY ELIMINATION

Urine: ☐Clear ☐Cloudy ☐Sediment

Color: ☐Straw ☐Yellow ☐Amber ☐Pink ☐Red

Last void: time____________ amount mL

Catheter: ☐None ☐In/Out ☐Condom ☐Foley ☐Suprapubic

Insertion date:_________________

Symptoms: Frequency: ☐ Urgency: ☐ Dysuria: ☐ Nocturia: ☐ Incontinence: ☐Yes ☐No

Urinary Elimination Comments:

Nursing Diagnosis:

11. REST AND EXERCISE

Activity: ☐ Bed rest ☐BSC ☐BRP ☐ Chair ☐ Ambulate

Mobility Aids: ☐Cane ☐W/C ☐Crutches ☐Walker

Functional level: ☐Independent ☐Dependent ☐Assistance

Gait: ☐Steady ☐Unsteady ☐Unable to ambulate

ROM: ☐Active ☐Passive ☐Assistive ☐Limited ☐Full

Sleep Patterns: ☐Uninterrupted ☐Interrupted ☐Insomnia

☐Day time sleepiness # hrs sleep/night__________

Cast/Brace/Traction: Type___________ Location_______________

Restraints: Type______________ Location_______________

Rest and Exercise Comments:

Nursing Diagnosis:

MORSE FALL SCALE/RISK SCREENING

Variables

Score

History of Falls within last 12 months

No

Yes

0

25

To obtain the Morse Fall Score add the score from each category.

Morse Fall Score

☐ High Risk 45 and higher

☐ Moderate Risk 25-44

☐ Low Risk 0-24

Secondary Diagnosis

No

Yes

0

15

Ambulatory Aids

None/bedrest/nurse assist

0

Crutches/cane/walker

15

Furniture

30

IV or IV access

No

Yes

0

20

Gait

Normal/bedrest/wheelchair

0

Weak

10

Impaired

20

Mental Status

Know own limits

0

Overestimates or forgets limits

15

Total

Rest and Exercise Comments:

Nursing Diagnosis:

12. SKIN INTEGRITY/INTEGUMENTARY

Skin Condition: ☐Intact ☐ Skin tear ☐Bruise ☐Rash ☐Burn ☐Wound/Ulcer (complete documentation) Location_____________ Stage___________

☐Incision ☐Other______________

Location#1_____________Type of condition____________ ☐Drainage__________ ☐Odor

Location#2_____________Type of condition____________ ☐Drainage__________ ☐Odor

Location#3_____________Typeof condition____________ ☐Drainage__________ ☐Odor

Indicate location or Intact:

S Surgical site

M Edema

B Burn

R Rash

E Ecchymosis

D Dressing

F Fracture/Cast

Pe Petechaie

N Inflammation

G Gangrene/Necrosis

P Pressure ulcer & stage _______________

O Other ____________________________

I IV Site A Drains

Patent None

Swollen Penrose

Red Hemovac

Infiltrated JP

Braden Scale

Score

Sensory

1. Completely limited

2. Very limited

3. Slightly limited

4. No Impairment

Moisture

1. Constantly moist

2. Very moist

3. Occasionally moist

4. Rarely moist

Activity

1. Bedfast

2. Chairfast

3. Walks occasionally

4. Walks frequently

Mobility

1. Completely immobile

2. Very limited

3. Slightly limited

4. No limitations

Nutrition

1. Very poor

2. Probably inadequate

3. Adequate

4. Excellent

Friction and Shear

1. Problem

2. Potential problem

3. No apparent problem

Score of 18 or less

= at risk

_____

IV sites: ☐ Patent ☐Swollen ☐Red ☐Infiltrated Location:____________ Gauge Needle:____________ Start date:______________

Skin Comments:

Nursing Diagnosis:

13. HORMONE REGULATION/REPRODUCTION/ENDOCRINE

Thyroid Disease: ☐Yes ☐ No Estrogen Use: ☐Yes ☐ No Testosterone use: ☐Yes ☐ No Steroid use: ☐Yes ☐ No

Diabetes: ☐Yes ☐ No ☐Type I ☐Type II Number of year with diabetes: _______

14. PSYCHOSOCIAL VARIABLES

Mood/Affect: ☐Cooperative ☐Cheerful ☐Angry ☐Anxious ☐Crying ☐Withdrawn ☐Flat Affect ☐Depressed ☐Fearful ☐Combative

Level of education: ☐None ☐Elementary ☐High School ☐College ☐Post Graduate

Understands directions: ☐Yes ☐ No

Decision-making: ☐None ☐Concrete ☐Abstract ☐Impaired

Judgment: ☐Appropriate ☐Inappropriate ☐Dementia

History/Evidence of: ☐Physical Abuse ☐Neglect ☐Sexual Abuse ☐Thoughts of suicide or self-harm ☐Depression ☐Psychiatric history

Recreational drug use: ☐ Drug How much____ How long____

Alcohol use: ☐ How often_____ How much_______

Tobacco use: In the last 12 months ☐Yes ☐ No How often ___________ How much_____________

Recent life stress or loss: ☐Yes ☐ No ___________

Coping methods with current illness/hospitalization: ☐Good ☐Fair ☐Poor

Body Image: ☐Positive ☐Negative ☐Changing

Sexuality: ☐Heterosexual ☐Bisexual ☐Homosexual ☐Transgender ☐Transsexual

Ability to write English: ☐Yes ☐No

Ability to read English: ☐Yes ☐No

Language Barrier: ☐None ☐ESL ☐Speech Impediment ☐Intubated ☐ Trached

Support System: ☐Yes ☐No

Living Situation: ___________________________________

Psychosocial Comments:

Nursing Diagnosis:

Narrative Charting: