MEC Nursing Clinical Assessment Tool
Patient Initials:
Admission Date:_
Gender: __
Age: ___
Height:__
Weight: ___
Medical/Surgic:al Diagnosis: ________________
Advanced Directives: Health Care Proxy ONR DNI Other: ______________
Allergy(sJ: ____________
Reaction: ____________
Past Medic:al/Sur&lcal History:
Religious Preference _____ Marital Status ___ Occupation: _____ Ethnicity______
Pain Score: ___ Pain Scale Used: Numeric Wong Baker Faces
Vital Signs: Blood Pressure:
Pulse: (Radial/Apical)
Non-Communicative Patient
Respirations:
Temperature:
(oral/rectal/ tympanic)
IV Site: Location: _____ Solution/Rate: ____________ Catheter Size:._____
Pain: (Yes/No)
Edema: (Yes/No)
Erythema: {Yes/No)
IV dressing:
Neurological
' Gla5'0W Coma Scale: ____
Mental Status:
Awake
Alert
Orientation to Persori
Orientation to Place
Orientation to 11me
Confused
Lethargic:
Obtunded
Behavior:
Affect: ___ ___
Mood: ______
Speec:h/Lan1uage: _______
Clear, appropriate/inappropriate
Pupll Siie: Right:_ left:
+ PERRLA
Seizure Precaution
1:1 Constant Observation
Limb Strength:
Upper Extremities: ___ __
I.Dwer Extremities: _____
Sensory deficits for hearing/vision
Respiratory
Resptratory Rate: _____
Respiratory Depth: ____
Pulse Oidmetry: _____
Breath Sounds:
c Clear IRl&ht Left BIiateraiiy)
□ Craclcles (Right Left BIiateraiiy}
C Wheezing (Rlcht Le�
Bllater.illy}
□ Rhonchl (Right left Bilaterally)
Use of accessory musdes
1' Cough:
� Produc:tlve
_ Nonproductive:
Sputum ________
OxnenType:
c Nasal Cannula: __ Uters
c Non-Breather Mask
'-- Ventl Mask: ___%
_ Trach Callar: __ Uters
;:: Oxygen humtd"rfic:atlon
= Tracheostomy care
Chest Tube:
Dniinage Color: ____
Amount _____
Smoker:
..: 'tes
:..: No
'" Cigarettes
o Other. _____
1
Cardiovascular
Varicose Veins:
� Absent
� Present
Peripheral Pulses:
Palpable, normal
Decreased: ____
j Rate & Rhythm of Pulse: ____
Regular
Irregular
Capillary Refill:
_ < 2-3 seconds
I
!:;
Delayed
1 Pitting Edema: _____
I Where: ________
I
l
::
=
Gastrointestinal
Diet:._______
Amount of Food Eaten: ___%
What types of foods should be
avoided? ________
1-----------Aspiration Precaution
::
Own Teeth
Dentures:
Upper
Bottom
Both
Abdomen:
Soft
:; Non-distended
Firm
Distended
Tender
Last Bowel ·Movement: _____
Bowel Pattern:
Continent
Incontinent
Constipated
Diarrhea
Passing flatus
Bowel Sounds:
Normal
Absent
Hypoactive
Hyperactive
I Finger Stick/Blood Glucose:
I
, Tubes:
-
I Tube feedings:
Type:,__________
Rate: ________
NGT
Salem Sump
r·
PEG
1 Ostomy : ___
! Drainage Amount: ____
1
1
Drainage Color: _____
Consistency: ______
Genitourinary/Reproductive
Voiding:
:; Continent
Incontinent
Dysuria
;: Frequency
Urgency
Urine
Color:
I
Urine Amount: ____
=
I Foley Catheter/Condom Cath:
Amount: ______
Size: _______
Urine Color: _____
Urosotomy:
Bladder Distention
Last Menstrual Period: ______
lntegumentary
Braden Score: ______
Color:
Normal for ethnicity
Pale
Other: _______
Skln Temperature: ____
Skin Turgor: _______
Wound (s):
Pressure Ulcer
Steri-strips
Suture
Staples
Other: _______
Dressings: _________
Describe Wound:
Location: _________
Size: ___________
Edges ap proximated:
- Yes
_ No
Drainage Amount: ______
Drainage Color: ______
_
c:: Odor
I
2
':
Musculosketa I
-
Activity:
Gait:
Assistive Devices:
- Cane
C
Walker
C
Prosthesis
Other:
Steady
Unsteady
Movement:.
□ Moves all extremities
Weakness:
::;
D
Paralysis:
D
0
Why is the isn't the client up ad lib?
ROM:
o Active
- Passive
-
Medications
Name (trade/generic)
I'
I
I
I
!
I
I
I
I
!
I
I
'
I
!
•
II
I
I
I
Dose
I
Route
I
II
I
Frequency
I
I
II
'
I
I
Class
I
I
I
I
I
i
I
I
'
I
I
I
t
II
I
Indications
l
iI
Additional Information: i.e. (SBAR, treatments, significant lab data, diagnostic tests)
MLG-1/2017
3