Student Name:

6) Reason for hospitalization (face sheet):
Describe reason for hospitalization: (expand
on back of page)
7) Chonic illnesses ( physician’s history and
physical notes in chart; nursing intake
assessment and Kardex)

Medical Dx:

Pathophysiology:

All signs and symptoms: Highlight those your

patient exhibits
8) Surgical procedures (consent forms and
Kardex): Describe surgical procedure (expand
on back of page)

Name of surgical procedure:

Describe surgery:

9) Advanced directives

(NURSE’S ADMISSION ASSESSMENTS):

Living will: Power of attorney: Yes___ Do not resuscitate (DNR) order (Kardex):
Yes___No____ No___ Yes____ No_____

ALLERGIES/PAINS

13) Allergies: 14) When was the last time pain medication given?
(medication administration record)
Type of Reaction:

(medication administration record):

14) Where is the pain? 14) How much pain is the patient in on a scale 0-
10?
(nurse’s notes)
(nurse’s notes, flow sheet):

TREATMENTS

15) List treatments (Kardex): Rationale for treatments

Dressing changes

Ice

Foley
NG

Position changes q2h

Ted Hose

SCDs

IS q1h while awake

C&DB q1h while awake

Tx. Cont.
16) Support services (Kardex) What do support services provide for the patient?

17) What does the consultant do for the patient?

18) DIET/FLUIDS

Type of Diet Restrictions Gag Reflex Appetite: Breakfa Lunch Dinner

(Kardex): (Kardex): intact: st
__Good __Fair ___% ___%
__Yes __No __Poor ___%
What type of diet is this?

What types of foods are included in this diet and what foods should be avoided?

Circle Those Problems That Apply:

Prior 8 hous • Problems: swallowing, chewing, dentures
(nurse’s notes)
Fluid intake: (Oral & IV)
 Fluid Out put • Needs assistances with feeding (nurse’s
notes)
(flow sheet)
• Nausea or vomiting (nurse’s notes)
Tube Feedings:
• Overhydrated or dehydrated (evaluate total
Type and rate (Kardex)
intake and output on flow sheet

• Belching:

• Other:

19) INTRAVENOUS FLUIDS (IV therapy record)

Type and Rate: IV dressing dry, no edema, redness of Other:

site:

___Yes ___No

20) ELIMINATION (flow sheet)

Last bowel movement: Foley/condom catheter:

___Yes ___No
Circle Those Problems That Apply:
• Bowel: constipation diarrhea flatus incontinence belching

• Urinary: hesitancy frequency burning incontinence odor

• Other: _________________________________________________________

• What is causing the problem in

elimination?___________________________________________________________

21) ACTIVITY (Kardex, flow sheet)

Ability to walk Type of Use of assistance devices: Falls-risk assessment

(gait): activity cane, walker, crutches, rating:
orders: prosthesis:

No. of side rails Restraints Weakness Trouble sleeping

required (flow (flow sheet) (nurse’s notes):
___Yes ___No
sheet)
___Yes ___No ___Yes ___No
What does activity order mean?:
___________________________________________________________________

Why isn’t the patient up ad lib?:

____________________________________________________________________
Would the problem cause weakness?:
_______________________________________________________________

PHYSICAL ASSESSMENT DATA

22) BP (flow sheet): 2) TPR (flow 23) Height:_____ Weight:_____ (nursing intake
sheet): assessment)

24) NEUROLOGICAL/MENTAL STATUS:

LOC: alert and oriented to person, place, time (A&O x Speech: clear,
3), confused, etc. appropriate/inappropriate

Pupils: PERRLA Sensory deficits for

vision/hearing/taste/smell

25) MUSCULOSKELETAL STATUS:

Bones, joints, muscles (fractures, Extremity (temperature, edema (pitting vs.

contractures, arthritis, spinal curvatures, nonpitting & sensation
etc):
Motor: ROM x 4 extremities
Ted hose/plexipulses/compression devices: type Casts, splints, collar, brace:

26) CARDIOVASCULAR SYSTEM:

Pulses (radial, pedal) (to touch or with Doppler): Capillary refill (< 3s):

___Yes ___No
Neck vein (distention): Sounds: S1, S2, regular, irregular: Any chest pain:
 Apical rate:

27) RESPIRATORY SYSTEM:

Depth, rate, Use of Cyanosis Sputum Cough: Breath sounds:

rhythm: accessory color, productive clear, rales, wheezes
muscles: amount: nonproductiv
e

Use of oxygen: Flow Oxygen Pulse oximeter: Smoking:

nasal cannula, rate of humidification:
_____% oxygen ___Yes ___No
mask, trach collar:
oxygen: ___Yes ___No saturation

28) GASTROINTESTINAL SYSTEM

Abdominal pain, tenderness, guarding: Bowel sounds x 4 NG tube: describe

distention, soft, firm: quadrants: drainage

Ostomy: describe stoma site and stools: Other:

29) SKIN AND WOUNDS:

Color, turgor: Rash, bruises: Describe wounds Edges Type of

(size, locations): approximated: wound
Pink
drains:
___Yes ___No

Characteristics Dressings (clean, Sutures, staples, Risk for pressure Other:

of drainage: dry, intact): steri-stripe, other: ulcer assessment
rating:

30) EYES, EARS, NOSE, THROAT (EENT):

Eyes: redness, drainage, Ears: drainageNose: redness, Throat: sore

edema, ptosis drainage, edema
Psychosocial and Cultural Assessment
31) Religious preference 32) Marital status (face 33) Health care benefits and
(face sheet) sheet) insurance (face sheet):
34) Occupation (face sheet) 35) Emotional state (nurse’s notes)