UCN/UM Joint BN Program
Course Number ______________________
CLIENT PROFILE DATABASE
Student Name _____________________
ADMISSION INFORMATION
Date of Care
Client Initials
Age
Growth & Development
Sex
Admission Date
Medical Diagnoses (present diagnoses, past diagnoses; physician’s
history and physical notes in chart; nursing database; kardex)
Reason For Hospitalization\Placement
Surgical Procedures (consent forms and kardex)
ADVANCE DIRECTIVES (Nurse’s Admission Assessments)
Living Will :
□ Yes □ No Power of Attorney: □ Yes □ No Do Not Resuscitate (DNR) Order □
Yes
□ No
LABORATORY DATA
Test
Red Blood
Cells (RBC)
Hemoglobin
(Hgb)
Hematocrit
(HCT)
Mean
Corpuscular
Vol. (MCV)
White Blood
Cells (WBC)
Differential
Platelets
(PLT)
Prothrombin
time (PT)
International
normalized
Ratio (INR)
Activated
Partial
Thromboplastin
time (APTT)
Potassium (K+)
Norms
Current
Value
Interpretation/Why
Test
Norms
Current
Value
Interpretation/Why
Sodium (Na+)
Chloride (Cl-)
Calcium
(Ca 2+)
Blood Glucose
Circle type
FBS RBS ACCU
Glycohemoglobin
(Hgb A1C)
Urine Analysis
(UA)
Lipid Profile:
Cholesterol
LDL
Triglycerides
Adapted from Shuster, P. (2002). Concept mapping: a critical-thinking approach to care planning by Fraser, K. & Kellett, P. (2004)
DIAGNOSTIC TESTS
Including all X-Ray, CT Scan, MRI, EEG, Ultrasound, Bone Scan, and other studies
Chest X-Ray
EKG
ALLERGIES/PAIN
Allergies (MAR)
When was last pain Medication given? What was given? (medication administration record)
Where is the Pain? Quality? Any radiation? (nurse’s
notes)
How much pain is the client in on a scale of 0-10? (nurses notes)
TREATMENTS
List Current Treatments
Consultations and Support Services
DIET/FLUID BALANCE
Type of Diet (kardex):
Restrictions (kardex):
Gag Reflex Intact
□
Yes
Appetite:
Breakfast
Lunch
Supper
□ No
______% _____% _____%
Circle Those Problems That Apply:
 Problems swallowing, chewing, dentures (nurse’s notes)
 Needs Assistance with feeding (nurse’s notes)
 Nausea or vomiting (nurse’s notes)
 Overhydrated or dehydrated (evaluate total intake and output)
 Belching
 Other ________________________________________________
Fluid Intake:
24 hours
(I&O Sheet)
Tube Feedings:
Type & Rate
(kardex)
Intravenous Fluids (IV therapy record; kardex)
Solution and Rate:
IV dressing dry, no edema, redness of site
□
Yes
Other:
□ No
Adapted from Shuster, P. (2002). Concept mapping: a critical-thinking approach to care planning by Fraser, K. & Kellett, P. (2004)
ELIMINATION (flow sheet, I&O)
Last Bowel Movement
24- hour urine output (I&O)
Foley/Condom Catheter
□



Circle those problems that apply
Bowel:
constipation
Urinary:
hesitancy
Other _________
diarrhea
frequency
Yes
flatus
burning
Size
□ No
incontinence
incontinence
belching
odor
ACTIVITY (ADL’s) (Kardex, flow sheet)
Ability to walk (gait)
Number of side rails
required (kardex):
Type of activity orders:
Restraints and type
(kardex)
□
Yes
□ No
Use of assistive devices: cane,
Walker, crutches, prosthesis:
Falls-risk assessment rating:
Weakness
Location
□
□L □R
Trouble Sleeping (nurse’s
notes)
Yes
□ No
□
Yes
□ No
PHYSICAL ASSESSMENT DATA
BP (flow sheet):
TPR (flow sheet):
Height: _______
T= _____
REVIEW OF SYSTEMS
P= _____
Weight: _______ (nsg. intake assessment)
R= _____
Write WNL (within normal limits) if normal and describe abnormalities in the space provided. (Check nurse’s
notes and shift assessments for the latest information you can get)
NEUROLOGICAL/MENTAL STATUS ________
LOC: alert and oriented to person, place, time (A&O x3), confused etc.
Motor: ROM x4 extremities
Sensation: 4 extremities
Speech: clear, appropriate/inappropriate
Pupils: PERRLA
Sensory deficits for vision/hearing/taste/smell
MUSCULOSKELETAL SYSTEM _______
Bones, joints, muscles (fractures, contractures, arthritis,
spinal curvatures, etc.)
Extremity circulation checks (pulses, temperature, sensation,
edema):
TED hose/ plexi pulses/ compression devices: type:
Casts, splint, collar, brace:
CARDIOVASCULAR SYSTEM ________
Pulses (radial, pedal) (to touch or with
Doppler):
Neck vein (distension):
Capillary refill (<3 s):
□
Yes
Edema, location, pitting vs nonpitting
□ No
Heart Sounds: S1, S2, regular, irregular:
Any chest pain:
Adapted from Shuster, P. (2002). Concept mapping: a critical-thinking approach to care planning by Fraser, K. & Kellett, P. (2004)
RESPIRATORY SYSTEM _______
Depth, rate, rhythm
Use of accessory
muscles
Use of oxygen: nasal
cannula, mask, trach collar
Cyanosis:
Flow rate of O2
Sputum: color, amount
Oxygen humidification
□
Yes
□ No
Cough: Productive,
nonproductive
Pulse oximeter:
Breath sounds: clear, rales,
wheezes
Smoking
_____% O2 saturation
□
Yes
□ No
GASTROINTESTINAL SYSTEM _______
Abdominal pain, tenderness, guarding; distension, soft, firm:
Bowel sounds x4 quadrants:
Ostomy: describe stoma site and stools:
Other:
NG tube: describe drainage
SKIN AND WOUNDS ________
Color, turgor:
Rash, bruises
Describe wounds (size, location)
Edges approximated
□
Characteristics of drainage
Dressings (clean, dry, intact):
Yes
Sutures, staples, steristrips, other:
Type of wound drain
□ No
Risk for decubitus
ulcer rating:
Other:
EYES, EARS, NOSE, THROAT (EENT): ______
Eyes: redness, drainage,
edema, ptosis
Ears: drainage
Nose: redness, drainage, edema
Throat: sore
PSYCHOSOCIAL AND CULTURAL ASSESSMENT
Religious preference: (face
sheet)
Marital Status (face sheet)
Occupation (face sheet)
Emotional State (nurse’s notes):
RELEVANT SOCIAL HISTORY ______
Adapted from Shuster, P. (2002). Concept mapping: a critical-thinking approach to care planning by Fraser, K. & Kellett, P. (2004)
DISCHARGE PLANNING_______
Expected Discharge Date:
Discharge Planning Meeting Date
Referrals needed for discharge:
Discharge Plans:
ADDITIONAL RELEVANT INFORMATION:
Adapted from Shuster, P. (2002). Concept mapping: a critical-thinking approach to care planning by Fraser, K. & Kellett, P. (2004)
MEDICATIONS: ROUTINE & PRN
* Note: Students may attach drug printouts which contain the appropriate information, but relevant information must be highlighted or circled
Dose, Route Frequency
(generic name)
Class/ Mechanism of
Action
Why is this client on this
medication?
Pertinent nursing
implications
Evaluation of drug’s
effectivness
Adapted from Shuster, P. (2002). Concept mapping: a critical-thinking approach to care planning by Fraser, K. & Kellett, P. (2004)
PATHOPHYSIOLOGY: TEXTBOOK EXPLANATION-CITE REFERENCE
Priority Health Problem
Etiology (What Causes the Problem?)
Risk Factors that contribute to the development of the
problem
List and lab or diagnostic Studies that may be utilized to evaluate this condition
List Clinical Manifestations (Signs & Symptoms) and potential complications with a pathophysiological explanation for why
they occur :
Adapted from Shuster, P. (2002). Concept mapping: a critical-thinking approach to care planning by Fraser, K. & Kellett, P. (2004)
POTENTIAL NURSING DIAGNOSES
(List in priority order and give rationale as to why you have prioritized in this manner)
ORGANIZATIONAL PLAN FOR DAY (Optional except in year 2)
Time
Plan
Supplies and Equipment Needed
Adapted from Shuster, P. (2002). Concept mapping: a critical-thinking approach to care planning by Fraser, K. & Kellett, P. (2004)