Course: NURS 101L PATIENT PROFILE DATABASE Student Name: Faculty Name: 1. ADMISSION INFORMATION Date of Care: Patient Admission Initials: Date: Age: Gender: Reason for Hospitalization/Chief Complaint (in patient’s own words): Surgical Procedures/Date: Admitting Medical Diagnosis: History of Present Illness: _ Growth and Development (Erikson): Ethnicity: Date: _____________ Occupation: Culture /Spiritual Beliefs: Medical Diagnoses History: (Past Medical History, Physician’s History and Physical notes in the chart, nursing intake assessment, with length of history if possible) 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 HgA1C BNP Albumin Page 1 of 7 On admission Current value Sodium Potassium BUN Creatinine Glucose Calcium Magnesium Blood Culture Sputum Culture Urine Culture On admission Current value Course: NURS 101L PATIENT PROFILE DATABASE DIAGNOSTIC TESTS Chest X-ray: 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 1 2 3 4 5 6 7 8mm Glascow Coma Scale: Total of all 3 columns__________ Eyes Motor 4=Open 6=Obeys command spontaneously 5=Localizes pain 3=To speech 4=Withdraws 2=To pain 3=Flexion 1=None 2=Extension 1=None Total_______ Total________ Verbal 5=Oriented 4=Confuse d 3=Inapprop riate words 2=Incompr ehensible words 1=None Total_____ Touch: ☐Normal ☐Decreased Smell: ☐Normal Hearing: ☐Normal ☐Tinnitus ☐HOH ☐Hearing Aid ☐Decreased ☐Deaf Vision: ☐Normal ☐Glasses ☐Contacts ☐Cataracts ☐Glasses ☐Glaucoma ☐Blurred vision ☐ Diplopia Page 2 of 7 Course: NURS 101L PATIENT PROFILE DATABASE Neurosensory comments: Nursing Problem: 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: 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 Nursing Problem: 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 Page 3 of 7 Aspiration Risk: ☐Yes ☐No Nausea: ☐Yes ☐No Vomiting: ☐Yes ☐No Flatus: ☐Yes ☐No Course: NURS 101L PATIENT PROFILE DATABASE 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_________ 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 Genitourinary Comments: Nursing Problem: Page 4 of 7 Course: NURS 101L PATIENT PROFILE DATABASE 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: Nursing Problem: Page 5 of 7 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 12. SKIN INTEGRITY/INTEGUMENTARY Skin Condition: ☐Intact ☐ Skin tear ☐Bruise ☐Rash ☐Burn ☐Wound/Ulcer (complete documentation) Location_____________ Stage___________ ☐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: S Surgical site M Edema B Burn R Rash E Ecchymosis D Dressing F Fracture/Cast N Inflammation Pe Petechaie G Gangrene/Necrosis P Pressure ulcer & stage _______________ O Other ____________________________ I Sensory 1. Completely limited IV Site Patent Swollen Red Infiltrated Braden Scale 2. Very limited 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: _______ 14. PSYCHOSOCIAL VARIABLES Mood/Affect: ☐Cooperative ☐Cheerful ☐Angry ☐Anxious ☐Crying ☐Withdrawn ☐Flat Affect ☐Depressed ☐Fearful ☐Combative Level of education: ☐None ☐Elementary ☐High School ☐College ☐Postgraduate Page 6 of 7 Understands directions: ☐Yes ☐ No Course: NURS 101L PATIENT PROFILE DATABASE 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 7