Professional Documents
Culture Documents
Age: __________________________
Height: __________________________
Sex: __________________________
Weight: __________________________
Pain: __________________________
Allergies: __________________________
Chief Complaint:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
History of Present Illness:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Past Medical History:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Current Orders:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Diet: ________________________________________________________________________________
1
TCD/10-07
Activity: _____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Treatments:___________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
ASSESSMENT
(Please be specific)
Neurologic:
Respiratory:
Color:
Tubes:
O2 and SATs:
Difficulties: SOB, accessory muscles, retractions, anxiety
Cry for age: strong for age/weak/high pitched
Upper Airway:
(reassess if an intervention was performed)
Cardiovascular:
HR:
Rhythm: (regular, weak, or strong)
Apical pulse: normal for age and what is normal for age of your patient?
capillary refill: < 3 sec
Heart sounds 1-5 points:
Artificial devices:
Peripheral Pulses (+2-+3 intensity): (distal, pedal, equal, strong, or weak)
Pitting/Edema 1+, 2+, 3+: (present at torso or extremity)
Insertion sites, tubes, lines:
Skin turgor: (assess mucus membranes)
(reassess if an intervention was performed)
Musculoskeletal: ROM: (active, passive) paralysis, strengths, weaknesses, grips, gait, appearances,
skeletal muscle defects)
Peripheral Pulses: (tubes/lines, casts,)
Muscle strength: (reflexes, coordination, sensations)
Vertebral column: (symmetry, normal curvature, Scoliosis, Lordosis, etc)
Mobility: Good muscle tone in all 4 extremities including tone with age appropriate
gross and fine motor skills
(reassess if an intervention was performed)
Integumentary:
3
Skin: (color, integrity, temp, moisture, texture, turgor, insertion sites, dressings,
TCD/10-07
DEVELOPMENTAL ASSESSMENT
PIAGETS STAGE: (defn/citation)
EVIDENCE: (list/identify)
ERIKSONS STAGE: (defn/citation)
EVIDENCE: (list/identify)
Cultural and Spiritual Beliefs: (What is clients/family stated religion? Where is
client from? Be alert of their ethnicity, customs, traditions and background. Tell us
how your clients cultural and spiritual belief effects their nursing care.)
Document:
Family dynamics: (patient/family complaints, concerns) (parental/guardian
interactions with pt, healthcare interest, home situations, Does pt feel safe in the
home?)
Substances: Any excessive alcohol use, or excessive drug use, prescription or nonprescription, smoking or family issues with the above)
Behavior: (mood and affect)
Appearance: (hygiene, age, position, posture, expression)
Significant Relationships:
Support Systems:
(reassess if an intervention was performed)
Nutritional:
Diet: (Special diets, appetite, percentage of food eaten, ability to feed self, breast feed,
breastfeeding feeding tubes, formula, feeding schedule. TPN food allergies)
Nutritional Supplements: (ensure, etc.)
Significant weight loss or gain in last 30 days:
(reassess if an intervention was performed)
Drug
Doseage
MEDICATIONS
Route
Indication
TCD/10-07
CBC
Name
WBC (K/ul)
RBC (M/ul)
Hemoglobin (g/dl)
Hematocrit (%)
MCV (Fl)
MCH (PG)
MCHC (g/dl)
RDW (%)
Platelet (K/ul)
MPV (Fl)
Granulocytes
Lymphocytes
Monocytes
Eosinophils
Basophils
Ab. Granulocytes
Ab. Lymphocytes
Ab. Monocytes
DATE:
Pt. Values
4
1
Ab. Eosinophils
Ab. Basophils
Ab. Granulocytes
DATE:
Pt. Values
Normal values
136-145
3.5-5.5
100-108
21-32
5-15
74-99
7-18
0.6-1.3
12-20
>60
>60
8.4-10.4
6.4-8.3
3.5-5.0
2.0-4.0
1.1-2.6
0.2-1.2
25-115
10-37
5-40
136-145
1.
2.
TCD/10-07
3.
4.
5.
Notes: __________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
________________
TCD/10-07