BASE AND HISTORY ‘Name of Patient: Civil Stat Date Admission: Chief Complaint and History of Present Illness Type of Previous Illness Date Type of Previous Illness Date Pregnancy/Delivery Pregnancy/Delivery Has received blood in the past: Yes No; If yes, list dates Reaction__Yes No Medication | Dose / Time of Name of Dose/ | Time of Last Name Frequency | Last Dose _| Medication | Frequency Dose Admitting diagnosis: Attending Physician: Score: Grade:NURSING SYSTEM REVIEW CHART ‘Name: Date: Vital Signs: Pulse: BP: Temp: Height: Weight: INSTRUCTIONS: Place an (X) in the area of abnormality, Write comment on the space provided. Indicate the location of the problem in the figure using (X). EENT: [ Jimpaired vision [ ] blind [ ] pain reddened [ ] drainage [ Jbuming [ Jedema [ ] lesion teeth [ Jassess eyes, ears, and nose [ ] throat for abnormality [ ] no problem RESPIRATION [ ] asymmetric [ ]tachypnea [ ] barrel chest [Japnea —[ J rales { Jeough { ] bradypnea [ ]shallow — [ ] rhonchi [ ]sputum — [ ] diminished [ ] dyspnea [ Jorthopnea [ ]labored — [ ] wheezing [ } pain [ Jeyanotic [ ] assess resp. rate, rhythm, depth, pattem [ ] breathe sounds, comfort [ ]no problem GASTRO INTESTINAL TRACT [ obese [ ] distention [ ]mass [ ] dysphagia [ Jrigidly — [ ]pain [ ] assess abdomen, bowel habits, swallowing [_] bowel sounds, comfort —_[ ] no problem GENITO-URINARY and GYNE [J pain [ Jurine color [ ] vaginal bleeding [ Jhermaturia [ ]discharge [ ]noctoria [ J assess urine freq., control, color, odor, comfort {J gyn-bleeding [ ] discharge [ ] no problem NEURO ‘ []paralysis [ ]stuporous [ ] unsteady [ ] seizures [ Jlethartic [ comatose [ ] vertigo [ ] tremors [ Jconfused [ ]vision — [ ]grip [ ] assess motor function, sensation, LOC, strength [ J rip, gait, coordination, speech [ Jno problem MUSCULOSKELETAL and SKIN [ Jappliance [ ]stiffness [ Jitching [ ] petechiae { ] hot [ Jdrainage [ ] prosthesis [ ] swelling [ Jlesion [ ]poorturgor{ Jcool —_[ ] deformity {atrophy [J pain [ Jecchymosis [ ] diaphoretic moist { ] assess mobility, motion, gait, alignment, joint function [ ] skin color, texture, turgor, integrity [ ] no problemNURSING ASSESSMENT 2 SUBJECTIVE I OBJECTIVE COMMUNICATION: Healing loss Comments: 2 Glasses Languages Visual changes Contact lens CO Hearing aide 0 Denied L O Speech difficulties OXYGENATION: Dyspnea Comments: ‘Smoking history Cough ‘Sputum Denied Olrregular | oooo0 CIRCULATION: Chest pain ‘Comments: Leg pain Numbness of 0 o Heart Rhythm Regular 1 Irregular Ankle Edema: Carotid. Radial Dorsalis Pedis Femoral R L Comments: extremities —— Denied ——— ‘Comments: “IF applicable NUTRITION: Diet None oN OV Recent change in weight an appetite © Difficulty in SS swallowing G_Denied ELIMINATION: Usual bowel pattern G_ Urinary frequency ‘With Patient ‘Comments: 1D Constipation Urgency Present 0 Yes, ONO remedies Q Dysuria Urine* (color, 0 Hematuria consistency, odor) Date of last BM O_ Incontinence O. Polyut 0 Diarrhea character Foley in place ‘if foley bag catheter is in D_Denied place MGT. OF HEALTH & ILLNESS: G_ Alcohol O Denied (amount, frequency) Briefly describe the patient's ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). SBE Last Pap Smear: LMP:SUBJECTIVE OBJECTIVE O Limited motion of joints Limitation in ability to Ambulate Bathe self Other Denied aqooa | SKININTEGRITY: Diary Teold Cpale 0 Dy ‘Comments O flushed warm Itching moist Deyanotic, O Other “rashes, uleers, decubitus (describe size, location, O Denied ——_______._ | drainage). ACTIVITY / SAFETY: GLOC and orientation: . Convulsion Comments: - Dizziness Gait: walker Geare_ Gother Osteady ( unsteady Sensory and motor losses in face or extremities ROM imitations: ‘COMFORT / SLEEP / AWAKE. Pain (location, frequency, remedies) © Noeturia Comments: O facial grimaces O guarding other signs of pain side rail release form signed (60+ years) (Observed non-verbal behavio Occupation Members of household: Person (Phone Number) Most supportive person: ‘SPECIAL PATIENT INFORMATION (USE LEAD PENCIL) Daily Weight PT/OT BP Shift Irradiation ‘Neuro VS Urine Test CVP/SG Reading 24 hour Urine Collection [Date Ordered] Disgnowtc Taboraton | Date Done | Date] IV. Flisds/ Blood] Date Die. Exams Ordered [| i]PATHOPHYSIOLOGY Name of Patient: Diagnosis: Score: Grade:‘apes ss400g T PS] —] | — ; a | vonneseig | saya 21:01 itmpaus) | wonyso | 20 pormpig | (pag) suouan Sus : wssumgpary | Seber Jwowmusen| PeG? | “Guo sum AGALS SNUG "uated Jo oueNropty, 19409 —}——| Gas uonnesag | stoayyg ax0,| uonespur | st Brup Aya) Buysmy | /saya opis | -enuoy | uonvorpuy aytoads poxapig | (puerg) ou2099 ord ‘Brug Jo aureN, wonoy jo asta woneaysse[D, Tyuatieg JO SWeN AGOLS SNUGrepr 12109¢ i | parapIo uopnesarg | sioagg orxoy | uonesmput | strap Ay) | uonsy jo now ap I ‘uous: ausmy | /sisaya opis | -enu0p wsrueysoyy fononbend soneouisseig | Pe” Goeeosome. AGALS Ona “uated Jo owenreper 194096, NOILLVOTVAR aTVNOILVa SNOILNAAUSLNI| SHALLOaAO NV1Id FAV) ONISHON SISONOVIG ONISMON: sano Tuspeg Jo surenySISONDVIC SNOILLNSAUSINI}| SHALLOSLAO. ‘ONISUAN sano Tuaneg Jo ouleNy NOLLVN TVA ATVNOILVY NV1d Fav) ONISUNNrapuiy 12409 — NOLLVNTVAT ATVNOILVY | SNOILNSAUSLNI} SHALLOSLAO SISONOVIG ONISUON ‘used Jo sureNy NV 1d TaVO ONISHYANpty 194095, | + NOLLVATWA ATVNOILVY | SNOLLNSAUSLNI NVTd FAV) ONISHON SNISHON saauoarao | SISONSvIG sano TuTeg Jo Sue,ape 12409 SISONOVIG NOLLVNTVAS ATWNOILVY | SNOILNSAUSLNI} SHALLOGLaO ONISUAN Tuaned JO owen NV1Td FAV) ONISUNNHEALTH TEACHINGS Name of Patient: MEDICATION EXERCISE TREATMENT OUT-PATIENT (Check-up) DIET Score: Grade:KARDEX ~_ [Diet Case No. Chief Complaint: ‘Med () Non Med() ‘Admitting Dx: Rel: Adres Wer Surgical Procedure/Delivery: Date & Time Admitted: “AP/ApS: I IWF/BT ‘SPECIAL CONSIDERATION | LABORATORY REMARKS = DOSEROUTE TSettsimin = 1.00ce/min = 60coThr 20gtts/min = 1.33ce/min = 80cofhr 2sghs/min = 1.66cc/min = 100ce/nr 30gttsmin = 2.00ec/min = 120ce/hr 35gttsimin = 2.33cc/min = 140ce/nr 4ogtts min = 2.66cc/min = 160ce/nr ASgtts/min = 3.00ce/min = 180cc/hr 10mgtts/min = 10ce/ne [Smgtts/min = 1Sce/hr = 20cehhr 30mgtts/min = 30cc/hr LEVEL [IVF & RATE. “TIME | ORAL. — c