Course: NURS 101L
PATIENT PROFILE DATABASE
Student Name:
JACK
Faculty Name: ProfessorJAMES Date: __05-15-2022______
1. ADMISSION INFORMATION
Ethnicity:
Occupation:
Culture
Date of Care: Patient
Admission Age: Gender: Growth and
Development
(Erikson):
/Spiritual
05-15-2022
Initials: N/A
Date: 0550
FEMALE
N/A
Beliefs:
15-2022
Reason for
Surgical
Medical Diagnoses History: (Past Medical History, Physician’s
Hospitalization/Chief
Procedures/Date:
History and Physical notes in the chart, nursing intake
Complaint (in patient’s own
assessment, with length of history if possible)
words):
N/A
Patient has PP in his feet to the level of their ankles secondary to
Burning and tingling
diabetes. His wound is infection
sensation in feet, difficulty
temp differences
Admitting Medical
Diagnosis: Peripheral
neuropathy
History of Present Illness:
Peripheral neuropathy, diabetes.
ADVANCE DIRECTIVES (Nursing Admission Assessment):
Living Will:
Durable Power of Attorney:
☐ Yes ☐ No
☐ Yes ☐ No
2. MEDICATIONS
Drug
Classification
ALLERGIES:
Dosage Route
Code status: ☐ Full Code ☐ DNR
(Do Not Resuscitate)
☐ Modified _____________________
Frequency
(Time due)
Purpose
Test
Normal
Range
Nursing
Considerations
3. LABORATORY DATA
Test
Normal
Range
WBC
Hemoglobin
Hematocrit
Platelets
PT
INR
aPTT
Page 1 of 8
On
admission
Current value
Sodium
Potassium
BUN
Creatinine
Glucose
Calcium
Magnesium
On
admission
Current
value
Course: NURS 101L
PATIENT PROFILE DATABASE
HgA1C
BNP
Albumin
DIAGNOSTIC TESTS
Chest X-ray:
Blood Culture
Sputum Culture
Urine Culture
EKG:
Urinalysis:
ABG:
Abnormal studies:
Abnormal studies:
4. PHYSIOLOGICAL DATA-VITAL SIGNS
Vital Signs: Temp_____ oF / oC ☐Axillary ☐Tympanic ☐Oral
☐ Core ☐Rectal
Pulse______
☐Apical _______ ☐Radial
Respiratory Rate______ ☐Even/regular ☐Labored/SOB ☐Dyspnea on Exertion
BP ______/_______
☐Supine ☐Sitting ☐Standing
Admission weight:
___________
Yesterday’s
weight___________
Today’s
weight______________
Height__________
5. NEUROLOGICAL/SENSORY
Orientation: ☐Time ☐Place ☐Person ☐Purpose
Sensation: ☐Normal ☐Impaired ☐Absent
Pain: Grade ____ /10
Scale used: ☐0-10 Numeric ☐FLACC ☐ Wong-Baker ☐ FACES
Pain Location: _______________
Character: ☐ Sharp ☐Dull ☐Ache ☐Heavy ☐Pinprick ☐Cramp
Other______________
Level of Consciousness: ☐Alert ☐Lethargic ☐Obtunded ☐Stuporous ☐Coma
Coordination: ☐Symmetrical ☐Asymmetrical ☐Unsteady
Strength: ____Right arm _____Left arm _____Right leg
_____Left leg
0=No movement
1=Trace movement
2=Moving, not against gravity
3=Moving against gravity, not against resistance
4=Moving against gravity, some resistance
5=Full power
What makes the pain worse:
______________________________
______________________________
______________________________
What makes the pain better:
______________________________
______________________________
______________________________
Pupil Size ____mm to ____mm
☐ PERRLA ☐Brisk ☐Sluggish ☐Fixed ☐Nystagmus
12 3 4 5 6 7
Glascow Coma Scale:
columns__________
Eyes
4=Open
spontaneously
3=To speech
2=To pain
1=None
Total_______
8mm
Total of all 3
Motor
6=Obeys command
5=Localizes pain
4=Withdraws
3=Flexion
2=Extension
1=None
Total________
Verbal
5=Oriented
4=Confuse
d
3=Inapprop
riate words
2=Incompr
ehensible
words
1=None
Total_____
Touch: ☐Normal ☐Decreased
Page 2 of 8
Smell: ☐Normal
☐Decreased
Hearing: ☐Normal ☐Tinnitus ☐HOH ☐Hearing Aid
☐Deaf
Course: NURS 101L
PATIENT PROFILE DATABASE
Vision: ☐Normal ☐Glasses ☐Contacts ☐Cataracts ☐Glasses ☐Glaucoma ☐Blurred vision ☐ Diplopia
Neurosensory comments:
The client indicate they routinely have a burning and tingling sensation in their feet as well as difficulty sensing Temp
differences
Nursing Problem:
Impaired skin integrity
6. CIRCULATORY/CARDIOVASCULAR
Color: ☐ Pink ☐Pale ☐ Jaundice ☐Flushed ☐Cyanotic
☐Mottled ☐Dusky
Skin:☐ Dry ☐Moist ☐Clammy ☐Warm ☐Cold ☐Hot
Peripheral Edema: ☐None ☐+1 ☐+2 ☐+3 ☐+4
☐Pitting ☐Non-pitting
Location(s): _______________________________________
Capillary refill:
BUE ☐ <3 seconds ☐ >3 seconds
BLE ☐ <3 seconds ☐ >3 seconds
Tele monitored rhythm:
________________________________
Heart Sounds: ☐S1 ☐S2
Rhythm: ☐Regular ☐Irregular
Implanted Pacemaker: ☐ Yes ☐No
Peripheral pulses:
Right radial ☐0 ☐+1 ☐+2 ☐+3 Left radial ☐0 ☐+1 ☐+2 ☐+3
Right pedal ☐0 ☐+1 ☐+2 ☐+3 Left Pedal ☐0 ☐+1 ☐+2 ☐+3
Circulatory Comments:
Nursing Problem:
7. RESPIRATORY/PULMONARY
Breath Sounds:☐Clear ☐Diminished ☐Absent ☐ Crackles
☐Wheezes
Location:☐ Throughout ☐RUL ☐RML ☐RLL ☐LUL ☐LLL
Sputum: ☐White/Clear ☐Tan ☐Yellow ☐Green ☐Rusty
☐Pink ☐Red
Cough: ☐None ☐Nonproductive ☐Productive ☐Suctioning
required
Secretions: ☐Yes ☐No
Consistency: ☐Frothy ☐Thick ☐Thin
Suctioning Method: ☐Oral ☐Nasotracheal ☐ETT ☐Trach
☐Bulb
Respiratory Comments:
Nursing Problem:
Page 3 of 8
Pattern: ☐Regular ☐Irregular
Character: ☐Full ☐Shallow ☐Deep ☐Labored ☐SOB
Amount: ☐Small ☐Moderate ☐Large
Pulse Oximeter: ______%
Oxygen: ☐Room air O2 ____L/min. or O2 _____%
Mode: ☐N/C ☐Mask ☐VM ☐NRB ☐Trach ☐Vent
Course: NURS 101L
PATIENT PROFILE DATABASE
8. NUTRITION/HYDRATION
Diet: ☐NPO ☐Regular ☐Clear Liquid ☐Full liquid ☐Soft
☐Pureed ☐Other____________________
Feeding Method: ☐Self ☐Assisted ☐NG ☐G-Tube ☐J-Tube
Parenteral Nutrition: ☐TPN ☐PPN
Tube Feeding Formula: _____________ Rate:
_____mL/hr.
Residual: ☐No ☐Yes Amt.______mL Water Flush: ________
Weight: ☐Gain______# lbs./kg
☐Loss______# lbs./kg
☐No change
Intake:
Output:
PO______
Urine_____
IV______
NG_______
NG______
Emesis________
Blood_______
Stool________
Other_______
Drains________
Other________
24-hour total_________
24-hour total_________
Aspiration Risk: ☐Yes ☐No
Nausea: ☐Yes ☐No Vomiting: ☐Yes ☐No
Flatus: ☐Yes ☐No
Mucous Membranes: ☐Dry ☐Moist
Skin Turgor: ☐WNL ☐Tenting ☐Taut
24-hour net I/O: +/-___________ml
Breakfast Meal ____________%
Lunch Meal ____________%
Dinner Meal ____________%
Nutrition/Hydration comments:
Nursing Problem:
9. GASTROINTESTINAL
Bowel Sounds:☐Absent ☐Hypoactive ☐Active ☐Hyperactive
Abdomen: ☐Soft ☐Flat ☐Distended ☐Round ☐Firm ☐Tender
☐Flatus
Last BM: _______Stool: ☐Formed ☐Soft ☐Hard ☐ Liquid
Amount: ☐Small ☐Moderate ☐Large ☐______mL
Gastrointestinal Comments:
Location: ☐RUQ ☐RLQ ☐ LUQ ☐LLQ
☐ Throughout
Ostomy: ☐No ☐Yes
Incontinence: ☐Yes
Type:______
☐No
Color: ☐Brown ☐Black/Tarry ☐Clay/Gray ☐Yellow
☐Green
Nursing Problem:
10. GENITOURINARY
Urine: ☐Clear ☐Cloudy ☐Sediment
Color: ☐Straw ☐Yellow ☐Amber ☐Pink ☐Red
☐Other
Last void: time____________
amount
mL
Catheter: ☐None ☐In/Out ☐Condom ☐Foley
☐Suprapubic
Insertion date: _________________
Symptoms: Frequency: ☐ Urgency: ☐ Dysuria: ☐ Nocturia: ☐ Blood in Urine: ☐ Malodorous: ☐
Dysuria: ☐ Burning: ☐ Incontinence: ☐Yes ☐No
Page 4 of 8
Course: NURS 101L
PATIENT PROFILE DATABASE
Genitourinary Comments:
Nursing Problem:
11. MUSCULOSKELETAL AND ACTIVITY
Activity: ☐ Bed rest ☐BSC ☐BRP
☐ Chair ☐ Ambulate
Mobility Aids: ☐Cane ☐W/C ☐Crutches ☐Walker
Functional level: ☐Independent ☐Dependent ☐Assistance
Gait: ☐Steady ☐Unsteady ☐Unable to ambulate
ROM: ☐Active ☐Passive ☐Assistive ☐Limited ☐Full
Sleep Patterns: ☐Uninterrupted ☐Interrupted
☐Insomnia
☐Day time sleepiness # hours sleep/night_______
Restraints: Type______________
Location_______________
Cast/Brace/Traction: Type___________
Location_______________
Rest and Exercise Comments:
Nursing Problem:
MORSE FALL SCALE/RISK SCREENING
Variables
History of Falls within last 12
No
months
Yes
Secondary Diagnosis
No
Yes
Ambulatory Aids
None/bedrest/
nurse assist
Crutches/cane/walker
Furniture
IV or IV access
No
Yes
Gait
Normal/bedrest/
wheelchair
Weak
Impaired
Mental Status
Know own limits
Overestimates or forgets
limits
Total
Musculoskeletal and Activity Comments:
Page 5 of 8
Score
0
25
0
15
0
15
30
0
20
0
10
20
0
15
To obtain the Morse Fall Score add the
score from each category.
Morse Fall Score
☐ High Risk 45 and higher
☐ Moderate Risk 25-44
☐ Low Risk 0-24
Course: NURS 101L
PATIENT PROFILE DATABASE
Nursing Problem:
12. SKIN INTEGRITY/INTEGUMENTARY
Skin Condition: ☐Intact ☐ Skin tear ☐Bruise ☐Rash ☐Burn ☐Wound/Ulcer (complete documentation)
Location_____________ Stage___2________ ☐Incision ☐Other______________
Location#1_____________Type of condition____________ ☐Drainage__________ ☐Odor
Location#2_____________Type of condition____________ ☐Drainage__________ ☐Odor
Location#3_____________Typeof condition____________ ☐Drainage__________ ☐Odor
Indicate location or Intact:
Sensory
1. Completely limited
Braden Scale
2. Very limited
S
B
E
F
Pe
P
O
Surgical site
M
Burn
R
Ecchymosis
D
Fracture/Cast
N
Petechaie
G
Pressure ulcer & stage _______________
Other ____________________________
I
IV Site
Patent
Swollen
Red
Infiltrated
Edema
Rash
Dressing
Inflammation
Gangrene/Necrosis
A Drains
None
Penrose
Hemovac
JP
Score
3. Slightly limited
4. No
Impairment
Moisture
1. Constantly moist
2. Very moist
3. Occasionally moist 4. Rarely moist
Activity
1. Bedfast
2. Chairfast
3. Walks occasionally 4. Walks
frequently
Mobility
1. Completely
2. Very limited
3. Slightly limited
4. No
immobile
limitations
Nutrition
1. Very poor
2. Probably inadequate 3. Adequate
4. Excellent
Friction and
1. Problem
2. Potential problem
3. No apparent
Score of 18 or
Shear
problem
less
= at risk
IV sites: ☐ Patent ☐Swollen ☐Red ☐Infiltrated Location: ____________ Gauge Needle:____________
Start date: ______________
Skin Comments:
_____
Nursing Problem:
13. HORMONE REGULATION/REPRODUCTION/ENDOCRINE
Thyroid Disease: ☐Yes ☐ No Estrogen Use: ☐Yes ☐ No Testosterone use: ☐Yes ☐ No Steroid use: ☐Yes ☐ No
Diabetes: ☐Yes ☐ No ☐Type I ☐Type II Number of year with diabetes: _______
Page 6 of 8
Course: NURS 101L
PATIENT PROFILE DATABASE
14. PSYCHOSOCIAL VARIABLES
Mood/Affect: ☐Cooperative ☐Cheerful ☐Angry ☐Anxious ☐Crying ☐Withdrawn ☐Flat Affect ☐Depressed
☐Fearful ☐Combative
Level of education: ☐None ☐Elementary ☐High School ☐College
Understands directions: ☐Yes ☐ No
☐Postgraduate
Decision-making: ☐None ☐Concrete ☐Abstract
Judgment: ☐Appropriate ☐Inappropriate ☐Dementia
☐Impaired
History/Evidence of: ☐Physical Abuse ☐Neglect ☐Sexual Abuse ☐Thoughts of suicide or self-harm ☐Depression
☐Psychiatric history
Recreational drug use: ☐ Drug
Alcohol use: ☐ How often_____
How much____ How long____
How much_______
Tobacco use: In the last 12 months ☐Yes ☐ No How often ___________ How much_____________
Recent life stress or loss:
☐Yes ☐ No ___________
Coping methods with current illness/hospitalization:
☐Good ☐Fair ☐Poor
Body Image: ☐Positive ☐Negative ☐Changing
Gender: ☐Transgender ☐Transsexual
Ability to write English: ☐Yes ☐No
Ability to read English: ☐Yes ☐No
Language Barrier: ☐None ☐ESL ☐Speech
Impediment ☐Intubated ☐ Trached
Preferred Language___________________
Interpreter Required?
Psychosocial Comments:
Support System: ☐Yes ☐No
Living Situation: ___________________________________
Nursing Problem:
Narrative Charting:
Page 7 of 8
Course: NURS 101L
PATIENT PROFILE DATABASE
Page 8 of 8