LSSC NURSING- CLINICAL DATABASE
Today’s Date:
Student Name:
Patient Initials:
Date and Time of
Admission:
Age:
Primary Diagnosis:
Sex:
Secondary Diagnosis:
Surgical Procedures this Admission:
Living Will:
YES
NO
Power of Attorney:
YES
NO
DNR:
YES
NO
Allergies
Medicines: Food: Latex:
Date
Medications/IV’s
(include dose, route, frequency)
NU: Sp ‘14 Adopted. REV’d 01/5/15.
Times
Of TX
Treatments (Dsg Changes, TED’s,
SCD’s)
Page 1
Chief Complaint on
Admission:
Past Medical
History:
Past Surgical
History:
Home Medications:
Continued During Hospital
Stay?
Social History:
Family History:
Client Assessment
Vital Signs:
AM
BP
Pulse
Respirations
Temp.
PM
Activity Ordered:
Diet:
Intake:
24 hour
mL
Intake:
POIV-
mL
mL
NU: Sp ‘14 Adopted. REV’d 01/5/15.
% Eaten
Output:
Output:
O2 Sats.
Pain
%@
0/10
RA or L/min
%@
0/10
RA or L/min
Telemetry:
YES
NO
Rhythm:
mL
mL
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Ht/Wt:
Subjective
Objective
HEENT:
Head:
HEENT:
Head:
Eyes:
Eyes:
Ears:
Ears:
Nose:
.
Nose:
Tongue:
Throat:
.
Tongue:
Throat:
Cardiovascular:
Cardiovascular:
Rate: Apical
Radial
Rhythm: Regular
Irregular
Pulse Quality/Strength: (0, 1+, 2+, 3+)
Right
Left
Brachial
Femoral
Popliteal
Pedal
Post-Tibial
Carotids
Carotid Bruit: Yes___No___R____L____
S-1 S-2
Murmurs:
Capillary Refill: R seconds L seconds
PMI Location:
Peripheral-Vascular:
Legs: Color R
(Pink, Pale, Cyanotic) L
Temperature: R
(Cool, Warm, Hot)
L
Trace:
R
R
L
L
(1+, 2+, 3+, 4+) Present Absent Present Absent
Pedal Edema
Pitting Edema
Leg Edema above ankle (Describe locations, amount,
bilateral/unilateral):
Respiratory:
NU: Sp ‘14 Adopted. REV’d 01/5/15.
Lesions: R
L
Describe:
Respiratory:
Rate: /min
Ease/Effort: Non-labored
Labored
Depth: Shallow
Normal
Deep
Character: Quiet/Silent
Noisy
Chest Expansion: Symmetrical
Asymmetrical
Intercostals: Bulging
Retraction
Normal
Breath Sounds:
Clear
Wheezes
Ronchi
Crackles
Anterior:
Posterior:
R-Lateral:
L-Lateral:
Bilaterally
Page 3
Cough: None
Describe: N/A
Non-Productive
Productive
Odor:
Color:
Gastrointestinal:
.
Genitourinary:
.
Musculoskeletal:
Integumentary:
Neurological:
Psychosocial (Erikson):
NU: Sp ‘14 Adopted. REV’d 01/5/15.
Gastrointestinal:
Oral Mucosa: Pink
Pale
Dry
Moist
Intact
Lesions
Dentures: None
Upper
Lower
Partial Plate
Teeth Condition:
None
Abdominal Contour: Flat
Rounded
Scaphoid
Protuberant
Bowel Sounds: Normoactive
Hypoactive
Hyperactive
Location: RLQ
RUQ
LLQ
LUQ
Abdominal Aortic Bruit: Present
Not Present
Illiacs Bruit: (R) Present
Not Present
(L) Present
Not Present
Renal Bruit: (R) Present
Not Present
(L) Present
Not Present
Abdomen: Soft
Firm
Tense
Distended
Tender
Location:
Presence of surgical incision:
Umbilicus:
Genitourinary:
Urine Output: YES
NO
Color: Amber
Light
Dark Amber
Bloody
Blood Tinged
Clear
Sediment
Odor: YES
NO
Describe:
Musculoskeletal:
Movement/Gait: Erect
Steady
Smooth and Coordinated
Weak
Flacid
Strength: (5+, 4+. 3+, 2+, 1+, 0) =
Able to turn self
Bears own weight
ROM: Full
Limited
Describe:
Assistive Devices: None
Walker
Cane
Wheelchair
Crutches
Integumentary:
Color: Pink
Pale
Cyanotic
Jaundiced
Temperature: Cold
Cool
Warm
Hot
Condition: Dry
Moist
Clammy
Diaphoretic
Integrity: Intact
Rash
Wound
Describe:
Turgor: Immediate
Remains Peaked
Taut
Neurological:
Response: Alert
Lethargic
Stuporous
Comatose
Orientation: Person
Place
Time
Situation
PERRLA: Right
Left
Hand Grips: Weak
Strong
Bilaterally
Mood: Appropriate
Not Appropriate
Attitude/Behavior: Cooperative
Hostile
Combative
Withdrawn
Psychosocial (Erikson):
Page 4
Lab Values:
Na
HGB
BUN
Glucose
PLT
WBC
HCT
CCC
CCC
CCC
CCX
CC
Cl
\
K
HCO
CR
jhjhjhjkj
1. Lab Values Interpretation.
2. Prioritize Actual problems (Problem + related to AEB).
3. List Interventions that you provided this shift for the above problems.
4. List teaching given to this patient (written, video, demonstration).
5. List diagnostic test.
Critical Thinking Assignment:
Answer the questions below based on your above assessment and data collection from your
patient.
1. What are you alert for today with your patient?
2. What are the important assessments to make?
3. What complications may occur? What could go wrong?
4. What interventions will prevent complications?
NU: Sp ‘14 Adopted. REV’d 01/5/15.
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