Pt Age: _________Primary
Nurse______________________________
Date of admission ____________ Language: ________
MRP___________
Isolation MRSA/ VRE/ ESBL/C-diff No ________ Yes
____________
Allergies: ________________Code status___________
Admitting Diagnosis:
________________________________________
___________________________________________________
________
Past Medical History:
________________________________________
_________________________________________________________
__
_________________________________________________________
_________________________________________________________
____
Psychosocial
No verbal or emotional concerns expressed by client and/or family
Treatments (O2, Enteral Feeds, Wound Care, IV, etc…)
 G-tube feeds
_________________________________________
 G-tube site _________________________________

Formula __________Rate____________


Flushes__________

Wounds/ulcers___________________________________
Dressing change Yes__________ No_______________
Type dressing___________________________________


IV Yes____ No_____ Solution ___________Rate:
_____cc/hr
Check IV; site inspection, correct solution/rate.
Oxygen: Delivery Type _____________@ _______ L/ min
 Other:
_______________________________________________
Diagnostic Tests results: _______________________________

___________________________________________________
PT appointment
OT appointment
Diet:
_____________________Texture________________________
Fluids: regular___________ Thickened
_________________________
Hygiene: Self__________ Assisted: _________ Complete:
________
Transfer: Self__________ Assisted:
_________Complete:_________
Lab Tests: Please include Normal values beside your patient lab
values
Elimination: urine :
incontinent______ voiding ________Foley______
Neurological
Alert & oriented to person, place and time. Pupils equal bilaterally, round,
reacting briskly to light and accommodation (PERRLA). Behavior and
verbalization appropriate to situation. Moving all limbs spontaneously,
symmetry of strength in all limbs.
Last day of BM: _________________ Bowel Sounds:
_____________
Vital Signs:
1) Temp______ HR ______ RR ______ BP ______ O2Sat
______%
2) Temp______ HR ______ RR ______ BP ______ O2Sat
______%
Pain Scale: (Scale 0 – 10) __________Location: ________________
Your Nursing interventions if patient reports pain:
_________________________________________________________
________________________________________________
Medications Administered for pain
---------------------------------------------------------------------------------------
HgPlt
WBCHctK-
CrUreaINR
AlbuminMg-
NaCaClBS-
Respiratory
Ant/Post diameter < transverse
Symmetric chest expansion, normal palpation, percussion Ant/Post air
entry normal and audible to all lobes, no wheezing, crackles or stridor.
Gastrointestinal
Bowel sounds present, normal x 4 quadrants. Abd non-distended, soft,
non-tender. Absence of nausea/vomiting. No recent weight gain/loss.
Normal appetite, bowel patterns.
Genito-Urinary
Genitalia; no redness, edema, abnormal discharge Able to void
independently; urine clear, pale yellow, no odor, normal output, no pain
or burning on voiding.
Musculoskeletal Full range of motion in all limbs. Nil weakness,
paralysis, joint stiffness.
Medication name, dose, route, time of administration
Time
Drug Name/Action
Plan of Care for Patient/Nursing Interventions
Side Effects
Patient Education
PRN Medications:
Other