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Client Name: Sex:

Room #: DOB/Age:
Doctor: Height:
Report Data: Weight:
Ethnicity:
Education Level:
Occupation:
Religion:

Precautions/Isolation: Oriented: to person⃞ place⃞ time⃞


Allergies: Activity: gait_____ mobile⃞ bed bound⃞ 1- or 2-assist⃞
Diet: walker⃞ cane⃞ wheelchair⃞ splint⃞ crutches⃞ cast⃞
lift________ contractured⃞ amputation⃞ total care⃞
Admitting date & Dx:
ADLs: ____________
Body build: grossly obese⃞ overweight⃞ average⃞ slim⃞
Additional Dx: Mental Status: lethargic⃞ calm⃞ anxious⃞ irritable⃞
fearful⃞ depressed⃞ other⃞
Family Hx:
Other Info:

T: P: R: B/P: SaO2: Pain:


I&O:

Head: symmetrical⃞ asymmetrical⃞ masses⃞ non-tender ⃞


Hair: evenly distributed⃞ shiny⃞ dry scalp⃞ balding⃞ lesions⃞ dandruff⃞ lice⃞
Eyes: PERRLA⃞ symmetrical⃞ drainage⃞ edema⃞ drooping lid⃞ glasses⃞ contacts⃞
Ears: symmetrical⃞ drainage⃞ lesions⃞ tenderness⃞ HOH⃞ hearing aid⃞
Nose: symmetrical⃞ drainage⃞ sense of smell⃞ tenderness⃞
Mouth: lips dry⃞ lips moist⃞ mucous membranes moist⃞ dry⃞ lesions/sores⃞ teeth missing⃞ gingivitis⃞ dentures
upper ⃞dentures lower⃞ teeth grinding⃞
Pulse: regular⃞ irregular⃞ weak⃞ strong⃞ bounding⃞ pulses equal⃞
Grips: weak⃞ strong⃞ equal⃞
ROM: (Head, neck, arms, hands, hips, legs, & feet)
Respirations: asthma⃞ inhaler⃞ Depth: normal⃞ deep⃞ shallow⃞ Effort: labored⃞ unlabored⃞ Sounds: clear⃞
congested⃞ crackles⃞ wheezing⃞ Cough: productive⃞ non-productive⃞ frequent⃞ occasional⃞ describe sputum:
Heart sounds: strong⃞ weak⃞ normal (S1 & S2) ⃞ abnormal (S3 or S4)⃞
Bowel sounds: all 4 quad?⃞ normal⃞ sluggish⃞ hyperactive⃞ high pitch⃞ low pitch⃞ last elimination________
Abdomen: pain⃞ non-tender⃞ distended⃞ non-distended⃞ soft⃞ firm⃞
Bladder: distended⃞ non-distended⃞
Joints: arthritis⃞ spinal curvature⃞ pain⃞
BM: continent⃞ incontinent⃞ constipated⃞ diarrhea⃞ soft⃞ formed hard ⃞ loose⃞ bloody⃞ brown⃞
Urine: continent⃞ incontinent⃞ clear⃞ cloudy⃞ yellow⃞ amber⃞ bloody⃞ sediment⃞ UTI⃞
Voids: with⃞ without difficulty⃞
Skin: Characteristics: abnormal moles⃞ rashes⃞ bruising⃞ ulcers⃞ lacerations⃞ diaphoretic⃞ warm& dry⃞
cool & clammy ⃞ Integrity: good⃞ scars⃞ tears⃞ stitches⃞ risk for impaired⃞ Color: pink⃞ ruddy⃞ pale⃞
flush⃞ Edema: yes⃞ no⃞ non-pitting⃞ pitting⃞ grading (+1- +4) __ TED hose⃞ Turgor: elastic⃞ tenting⃞
Capillary Refill: brisk⃞ sluggish⃞ < 3 sec⃞ how long if > 3 sec______
Pain: Location_______ Intensity (0-10) ____ Quality_____ Duration______ Pain Reliever(s)_____________
Wound: Location__________ Condition: pink⃞ red⃞ necrotic⃞ Drainage: sanguinous⃞ serosanguinous⃞ serous⃞
purulent⃞ Drain condition_______ Drain type________ Amount: ____mL Dimensions: _____________
Stoma: type__________ location____________ skin integrity________
O2: Rate_________ Nasal Cannula⃞ Mask⃞ Reason__________
IV: location___________ condition_______ fluid__________ rate________
G-Tube/NG Tube: intake_____ output______ infusion rate_____ formula______ skin integrity________
Catheter: condition______ size____ amount_____ color_______ reason_______ cloudy⃞ clear⃞ milky⃞ sediment⃞
Trade Name Generic Name Class. Dose Route Freq. Reason

Date Performed: Lab: Result:

Nursing Dx Problem #1: Nursing Dx Problem #2:

Nursing Dx Problem #3: Nursing Dx Problem #4:

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