NUR 3846 Concorde Career College Foundations of Professional Nursing Worksheet

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kbzrel

Health Medical

NUR 3846

Concorde Career College

NUR

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please fill out entire template that I will provide. I will also provide some basic patient info. You will have to create and make the rest of it on your own. thank you.

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Course: NURS 121L-A PATIENT PROFILE DATABASE Date: ____________________________________________________________________________________ Student Name: Faculty Name: 1. ADMISSION INFORMATION Date of Pt. Name: Admission Care: Date: Age : Reason for Hospitalization/Chief Complaint (in pt’s own words): Surgical Procedures/Date: Admitting Medical Diagnosis: History of Present Illness: Gender: Growth and Development (Erikson): Ethnicit y: Occupa tion: Spiritual Beliefs: 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) ADVANCE DIRECTIVES (Nursing Admission Assessment): Durable Power of Attorney: ☐ Yes Code status : ☐ Full Code ☐ Living Will: ☐ Yes ☐ No DNR (Do Not Resuscitate) ☐ No 2. MEDICATIONS ALLERGIES: Drug Classificatio Dosage Route Frequency Purpose Nursing n (time due) Considerations 3. LABORATORY DATA Test Norms WBC Hemoglobin Hematocrit Page 1 of 7 On admission Current value Test Sodium Potassium Calcium Norms On admissi on Current value Course: NURS 121L-A PATIENT PROFILE DATABASE Platelets PT INR aPTT HA1c BNP BUN Creatinine Magnesium Blood Glucose Urinalysis 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 5. NEUROLOGICAL/SENSORY Orientation: ☐Time ☐Place ☐Person ☐Purpose Admission weight:___________ Yesterday’s weight___________ Today’s weight______________ Height__________ 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 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 PERRLA : #____mm Nystagmus ☐Brisk ☐Sluggish ☐Fixed ☐ 12 3 4 5 6 7 8mm Glascow Coma Scale: Total of all 3 columns__________ Eyes Motor Verbal 4=Open 6=Obeys 5=Oriented spontaneously command 4=Confused 3=To speech 5=Localizes pain 3=Inappropriate 2=To pain 4=Withdraws words 1=None 3=Flexion 2=Incomprehen 2=Extension sible words 1=None 1=None Total_______ Total______ Total________ Page 2 of 7 Course: NURS 121L-A PATIENT PROFILE DATABASE Touch: ☐Normal ☐ Smell: ☐Normal ☐Decreased Hearing: ☐Normal ☐Tinnitus ☐HOH ☐Hearing Aid Decreased ☐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 Skin:☐ Dry ☐Moist ☐Clammy ☐Warm ☐Cold ☐Hot Capillary refill: ☐ 3 seconds Tele monitored rhythm:________________________________ Heart Sounds: ☐S1 ☐S2 Rhythm: ☐Regular ☐ Irregular Implanted Pacemaker: ☐ Yes ☐No Peripheral Edema: ☐None ☐+1 ☐+2 ☐+3 ☐+4 ☐Pitting ☐Non-pitting Location:__________________________________________ ___ 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 Sputum: ☐White/Clear ☐Tan ☐Yellow ☐Green ☐Rusty ☐ Pink ☐Red Cough: ☐None ☐Nonproductive ☐Productive ☐Suctioning required Secretions: ☐Yes ☐No Consistency: ☐Frothy ☐Thick ☐ Thin Suctioning Method: ☐Oral ☐Nasotracheal ☐ETT ☐Trach ☐Bulb Respiratory Comments: Nursing Diagnosis: Page 3 of 7 Pattern: ☐Regular ☐Irregular Character: ☐Full ☐Shallow ☐Deep ☐Labored ☐ SOB Amount: ☐Small ☐Moderate ☐Large Pulse Oximeter: ______% Oxygen: ☐Room air O2 ____L/min. or _____% Mode: ☐N/C ☐Mask ☐Trach O2 ABGs: pH_____ pO2________ pCO2_______ HCO3___________ Course: NURS 121L-A PATIENT PROFILE DATABASE 8. NUTRITION/HYDRATION Diet: ☐NPO ☐Regular ☐Cl. Liquid ☐Full liquid ☐Soft ☐ Pureed ☐Other____________________ Feeding Method: ☐Self ☐Assisted ☐NG ☐G-Tube ☐JTube Parenteral Nutrition: ☐TPN ☐PPN Tube Feeding Formula:_____________ Rate:________mL/hr. Residual: ☐No ☐Yes Amt.______mL. Weight: ☐Gain______# lbs/kg ☐Loss______# lbs/kg ☐No change Intake: Output: PO______ Urine_____ IV______ NG_______ NG______ Emesis________ Blood_______ Stool________ Other_______ Drains________ Other________ 24 hour 24 hour total_________ total_________ Nutrition/Hydration comments: Aspiration Risk: ☐Yes ☐No Nausea: ☐Yes ☐No Vomiting: ☐Yes ☐No Flatus: ☐Yes ☐No Mucous Membranes: ☐Dry ☐Moist Skin Turgor: ☐No problem ☐Tenting ☐Taut 24 hour net I/O: +/-_____ Nursing Diagnosis: 9. GI/FECAL ELIMINATION Bowel Sounds:☐Absent ☐Hypoactive ☐Active ☐ Hyperactive Abdomen: ☐Soft ☐Flat ☐Distended ☐Round ☐Firm ☐ Tender ☐Flatus Last BM: _______Stool: ☐Formed ☐Soft ☐Hard ☐ Liquid #_______ Fecal Elimination Comments: Location: ☐RUQ ☐RLQ ☐ LUQ ☐LLQ ☐ Throughout Ostomy: ☐No ☐Yes Incontinence: ☐Yes Type:______ ☐No Color: ☐Brown ☐Black/Tarry ☐Clay/Gray ☐Yellow ☐Green Nursing Diagnosis: 10. GU/URINARY ELIMINATION Urine: ☐Clear ☐Cloudy ☐Sediment Color: ☐Straw ☐Yellow ☐Amber ☐Pink ☐Red Last void: time____________ Catheter: ☐None ☐In/Out ☐Condom ☐Foley ☐ Suprapubic Insertion date:_________________ Page 4 of 7 amount mL Course: NURS 121L-A PATIENT PROFILE DATABASE Symptoms: Frequency: ☐ Urgency: ☐ Dysuria: ☐ Nocturia: ☐ Incontinence: ☐Yes ☐No Urinary Elimination Comments: Nursing Diagnosis: 11. REST AND EXERCISE Activity: ☐ Bed rest ☐BSC ☐BRP ☐ Chair ☐ Ambulate Functional level: ☐Independent ☐Dependent ☐ Assistance ROM: ☐Active ☐Passive ☐Assistive ☐Limited ☐Full Mobility Aids: ☐Cane ☐W/C ☐Crutches ☐Walker Gait: ☐Steady ☐Unsteady ☐Unable to ambulate Sleep Patterns: ☐Uninterrupted ☐Interrupted ☐ Insomnia ☐Day time sleepiness # hrs sleep/night__________ Restraints: Type_________________ Location_______________ Cast/Brace/Traction: Type___________ Location_______________ Rest and Exercise Comments: Nursing Diagnosis: MORSE FALL SCALE/RISK SCREENING History of Falls within last 12 months Secondary Diagnosis Ambulatory Aids IV or IV access Gait Mental Status Variables No Yes No Yes None/bedrest/nurse assist Crutches/cane/walker Furniture No Yes Normal/bedrest/wheelchair Weak Impaired Know own limits Overestimates or forgets limits Total Rest and Exercise Comments: Nursing Diagnosis: Page 5 of 7 Score 0 25 0 15 0 15 30 0 20 0 10 20 0 15 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 Course: NURS 121L-A PATIENT PROFILE DATABASE 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: Sensory Moisture Activity 1. Completely limited 1. Constantly moist 1. Bedfast Mobility 1. Completely immobile 1. Very poor 1. Problem S B E F Pe P O Surgical site M Burn R Ecchymosis D Fracture/Cast N Petechaie G Pressure ulcer & stage _______________ Other ____________________________ I IV Site Patent Swollen Red Infiltrated Edema Rash Dressing Inflammation Gangrene/Necrosis A Drains None Penrose Hemovac JP Braden Scale 2. Very limited 2. Very moist 2. Chairfast 3. Slightly limited 3. Occasionally moist 3. Walks occasionally Score 2. Very limited 3. Slightly limited 4. No Impairment 4. Rarely moist 4. Walks frequently 4. No limitations Nutrition 2. Probably inadequate 3. Adequate 4. Excellent Friction and 2. Potential problem 3. No apparent Score of 18 or less Shear problem = 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: _______ Page 6 of 7 Course: NURS 121L-A PATIENT PROFILE DATABASE 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 Understands directions: ☐Yes ☐ No Graduate Decision-making: ☐None ☐Concrete ☐Abstract ☐ Judgment: ☐Appropriate ☐Inappropriate ☐Dementia Impaired History/Evidence of: ☐Physical Abuse ☐Neglect ☐Sexual Abuse ☐Thoughts of suicide or self-harm ☐Depression ☐ Psychiatric history Recreational drug use: ☐ Drug long____ How much____ How 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 Psychosocial Comments: Support System: ☐Yes ☐No Living Situation: ___________________________________ Nursing Diagnosis: Narrative Charting: Page 7 of 7
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