WALLACE STATE COMMUNITY COLLEGE

NURSING DATABASE: Nursing Home

Student Name: Enger Steger
Date of Care: Age/Gender: Race: Growth and Development: Marital Admission
Status: Date:
Reason for NH Placement: Flu vaccine history:
Pneumococcal vaccine history:
TB:
Medical Diagnoses:

Surgical History:

ADVANCE DIRECTIVES
Living Will Yes No Power of Attorney Yes No Do Not Resuscitate (DNR) Yes No
DIAGNOSTIC TESTS (List test, date, and findings)

MEDICATIONS (May list on back)

Brand/Generic Times Route Action Nursing Implications
Due Dose
ALLERGIES/Pain
Allergies (Reactions): Last time pain medication given:

BASELINE VITAL SIGNS

T: P: R: BP: O2 Sat: Pain:

Follow up Vital Signs

Date:
T: P: R: BP: O2 Sat: Pain:

Follow up Vital Signs

Date:
T: P: R: BP: O2 Sat: Pain:

TREATMENTS
List treatments/rationales (Example: dressing change)

Support Services (clergy, nutritional, etc.)

Consultants (Dietician, PT, OT, Speech Therapy)

DIET/FLUIDS
Diet Restrictions: Appetite: Breakfast % Lunch % Supper %
Good Fair Poor
Rationale for diet? Types of foods included and any foods to be avoided:
 Circle Those Problems That Apply:
Current Intake/Output * Problems: swallowing chewing dentures
Fluid Intake: PO: * Needs assistance with feeding
Fluid Output: * Nausea or vomiting
Tube Feedings: NG PEG * Overhydrated or dehydrated (Fluid Balance)
Type of Feeding and Rate: * Other

Current Shift Intake: Oral ______ Tube :______________

Output: Urine Stool : ______________
ELIMINATION
Last Bowel Movement: Voids: Yes No Foley: Yes No Type:
Bowel Assessment: Size:
Assessment of Urine: Assessment of Urine:

Circle problems that apply:

 Bowel: constipation diarrhea flatus incontinence belching
 Urinary: hesitancy frequency burning incontinence odor
 Other:
 Any problems of elimination and causes?

ACTIVITY
Ability to walk (gait): Activity orders: Use of assistive devices: Fall-Risk Assessment
Rating/Type Used:

Number of siderails Restraints: Weakness: Trouble sleeping:

required: Yes No Yes No Yes No
What does activity order mean?

PHYSICAL ASSESSMENT DATA

Weight:
Height:
BMI

HEAD, EYES, EARS, NOSE, THROAT (HEENT) Explain any assessment abnormalities.
Head Eyes: redness, drainage, Ears: drainage Nose: redness, drainage, Throat: sore
edema, ptosis edema, deviations

NEUROLOGICAL STATUS
LOC: alert and oriented to person, place, time (A&O Speech: clear, appropriate/inappropriate
x3), confused, etc.

Pupils: PERRLA Sensory Deficits for vision/hearing/taste/smell

MUSCULOSKELETAL STATUS
Bones, joints, muscles (fractures, contractures, arthritis, Extremity (temperature, edema (pitting vs. nonpitting) &
spinal curvatures, etc: sensation:

Motor: ROM x4 extremities, active, passive:

Ted Hose/foot board/etc Casts, splints, collar, brace:

CARDIOVASCULAR SYSTEM
Pulse Grade (+1 - +4) Right Left
Carotid
Brachial
Radial
Femoral
Pedal
Posterior Tibial
Neck vein (distention): Capillary Refill:

RESPIRATORY SYSTEM
Depth Use of Cyanosis Sputum: Cough: Breath sounds: clear,
Rate accessory Color Productive rales, wheezing, etc.
Rhythm muscles Amount Nonproductive

Use of oxygen Flow rate of oxygen Oxygen Pulse oximeter: Smoking History:
humidification? Continuous Yes No
Method Intermittent How Long?
Sat %_______

GASTROINTESTINAL SYSTEM
Abdominal pain, tenderness, Bowel sounds x4 quadrants NG tube:
guarding; distention, soft, firm: Drainage (describe)
Suction
Amount
Ostomy: describe stoma site, location, stools: Other:

GENITOURINARY SYSTEM
Voiding: (with/without difficulty, Bladder palpation (distended/not Drainage: (vaginal, urethral)
urgency, pain, hesitancy; nocturia) felt) Amount
Ileostomy: describe stoma site, location, urine: Other:

SKIN AND WOUNDS

Color, turgor: Rash, bruises Describe wound Edges of wound Type of wound
(size, locations) approximated: drains:
Yes No

Characteristics of Dressings: (where, Sutures, staples, Braden scale score: Other:

drainage: appearance) steri-strips, other

PSYCHOSOCIAL AND CULTURAL ASSESSMENTS

Religious Preference Health care benefits: Yes No
Occupation Mental Health History (Depression, Anxiety, etc)

Current Emotional State: Coping Mechanisms:

Possible Nursing Concerns:

DIABETIC ASSESSMENT
Baseline blood glucose: Pattern blood sugars:
0700 1100 1600 2100
Type of sliding scale and insulin used:

How long has patient been a Compliance: Complications related to diabetes:

diabetic?

Expected physical findings:

PATIENT TEACHING/LEARNING NEEDS (M* E *T* H* O* D)

Medications: (What med, what would you teach?)

Environment: (Based on environmental survey)

Treatments: (Any treatments received)

Knowledge of Disease (What does client know about disease?)

Outpatient/Inpatient Referrals: (Types of therapies needed?)

Diet: (Type of teaching needed related to diet)

NURSING DIAGNOSIS (list in order of importance)

1. Substantiating info—S &/or O:
1.
2.
3.

2. Substantiating info—S &/or O:

1.
2.
3.

3. Substantiating info—S &/or O:

1.
2.
3.

BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK

1 2 3 4
SENSORY Completely limited: Very limited: Slightly limited: No impairment:
PERCEPTION Unresponsive (does not Responds only to Responds to verbal Responds to verbal
Ability to respond to moan, flinch, or grasp) painful stimuli. Cannot commands but cannot commands. Has no
meaningfully to to painful stimuli, due to communicate always communicate sensory deficit which
pressure-related diminished level of discomfort except by discomfort or need to would limit ability to
discomfort consciousness or moaning or be turned. OR feel or voice pain or
sedation, OR restlessness, OR Has a sensory discomfort.
Limited ability to feel Has a sensory impairment which
 pain over most of the impairment which limits ability to feel
body surface. limits the ability to feel pain or discomfort in 1
pain or discomfort over or 2 extremities
½ of the body
Constantly Moist: Moist: Occasionally Moist: Rarely Moist:
MOISTURE Skin is kept moist Skin is often but not Skin is occasionally Skin is usually dry;
Degree to which skin almost constantly by always moist. Linen moist, requiring an linen requires changing
is exposed to perspiration, urine, etc. must be changed at extra linen change only at routine
moisture Dampness is detected least once a shift. approximately once a intervals.
every time patient is day.
moved or turned.
Bedfast: Chairfast: Walks Occasionally: Walks Frequently:
ACTIVITY Confined to bed Ability to walk Walks occasionally Walks outside the
Degree of physical severely limited or during day but for very room at least twice a
activity nonexistent. Cannot short distances, with or day and inside room at
bear own weight without assistance. least once every 2
and/or must be assisted Spends majority of hours during walking
into chair or each shift in bed or hours
wheelchair chair
Completely Immobile: Very Limited: Slightly Limited: No limitations:
MOBILITY Does not make even Makes occasional Makes frequent though Makes major and
Ability to change and slight changes in body slight changes in body slight changes in body frequent changes in
control body position. or extremity position or extremity position or extremity position position without
without assistance but unable to make independently. assistance.
frequent or significant
changes independently
Very poor: Probably Inadequate: Adequate: Excellent:
NUTRITION Never eats a complete Rarely eats a complete Eats over half of Eats most of every
Usual food intake meal. Rarely eats more meal and generally eats meals. Eats a total of 4 meal. Never refuses a
pattern than 1/3 of any food only about ½ of any servings of protein meal. Usually eats a
offered. Eats 2 servings food offered. Protein (meat, dairy products) total of 4 or more
or less of protein (meat intake includes 3 each day. Occasionally servings of meat and
or dairy products) per servings of meat or will refuse a meal, but dairy products.
day. Takes fluids poorly. dairy products per day. will usually take a Occasionally eats
Does not take a liquid Occasionally will take supplement if offered. between meals. Does
dietary supplement, is a dietary supplement, OR Is on a tube not require
NPO and/or maintained OR Receives less than feeding or TPN supplementation
on clear liquids or IVs optimum amount of regimen, which
for > 5 days liquid diet or tube probably meets most of
feeding. nutritional needs.
Problem: Potential Problem: No Apparent Total Points:
FRICTION AND Requires moderate to Moves feebly or Problem:
SHEAR maximum assist in requires minimum Moves in bed and in
moving. Complete assistance. During a chair independently
lifting without sliding move skin probably and has sufficient
against sheets is slides to some extent muscle strength to lift
impossible. Frequently against the sheets, up completely during
slides down in bed or chair, restraints, or move. Maintains good
chair, requiring frequent other devices. position in bed or chair
repositioning with Maintains relatively at all times.
maximum assistance. good position in chair
Spasticity, contractures, or bed most of the time
or agitation leads to but occasionally slides
almost constant friction. down.
 Fall Risk Assessment Form

Circle appropriate score for each section and total score at bottom.

Parameter Score Patient Status/Condition

A. Level of 0 Alert and oriented X3

Consciousness/ Mental 2 Disoriented X 3 at all times
Status 4 Intermittent confusion
B. History of Falls 0 No falls
(past 3 months) 2 1-2 falls
4 3 or more falls
C. Ambulation/ 0 Ambulatory & continent
Elimination Status 2 Chair bound & requires assist w/ toileting
4 Ambulatory & incontinent
D. Vision Status 0 Adequate (w/ or w/o glasses)
2 Poor (w/ or w/o glasses)
4 Legally blind
E. Gait and Balance ------ Have patient stand on both feet w/o any type of assist then have walk: forward,
thru a doorway, then make a turn. (Mark all that apply.)
0 Normal/safe gait and balance.
1 Balance problem while standing.
1 Balance problem while walking.
1 Decreased muscular coordination.
1 Change in gait pattern when walking through doorway.
1 Jerking or unstable when making turns.
1 Requires assistance (person, furniture/walls or device).
F. Orthostatic 0 No noted drop in blood pressure between lying and standing.
No change to cardiac rhythm.
Changes 2 Drop<20mmHg in BP between lying and standing.
Increase of cardiac rhythm <20.
4 Drop >20mmHg in BP between lying and standing.
Increase of cardiac rhythm >20.
G. Medications ------ Based upon the following types of medications: anesthetics, antihistamines,
cathartics, diuretics, antihypertensives, antiseizure, benzodiazepines,
hypoglycemics, psychotropics, sedative/hypnotics.
0 None of these medications taken currently or w/in past 7 days.
2 Takes 1-2 of these medications currently or w/in past 7 days.
4 Takes 3-4 of these medications currently or w/in past 7 days.
1 Mark additional point if patient has had a change in these medications or doses in past
5 days.
H. Predisposing ------ Based upon the following conditions: hyptension, vertigo, CVA, Parkinsons
Disease, loss of limb(s), seizures, arthritis, osteoporosis, fractures.
Diseases 0 None present.
2 1-2 present.
4 3 or more present.
I. Equipment Issues O No risk factors noted.
1 Oxygen tubing.
1 Inappropriate or client does not consistently use assistive device.
1 Equipment needs:
1 Other:
 TOTAL SCORE A score of 10 or more indicates high risk for falls. If score is 10 or more,
complete back page.

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