BOROUGH OF MANHATTAN COMMUNITY COLLEGE
Department of Nursing
Student Name: Name
Date:
Course: NUR313.511
Clinical Instructor: Prof.
PATIENT PROFILE DATABASE
ADMISSION INFORMATION
1. Date of Care:
2. Patient Initials:
3. Age:
6. Reason (s) for Hospitalization:
4. Gender:
5. Admission Date:
7. Medical Diagnoses: (present diagnoses,
past diagnoses):
8. Surgical Procedures:
9. ADVANCE DIRECTIVES (NURSE’S ADMISSION ASSESSMENTS):
Living will:
Yes
No
Power of attorney:
Yes
No
Do not resuscitate (DNR) order:
Yes
No
10. LABORATORY DATA
Test
White blood cells
Norms
On Admissions
4.8-10.8
Current Value
Other
Creat
Differential
Norms
0.8-2.0
Albumin
3-5
Hemoglobin
14-18
AST
0-40
Hematocrit
42-52
MCV
80-94
130-400
MCH
27-31
Prothrombin
time (PT)
MCHC
33-37
International
normalized
ratio (INR)
RBC
4.7-6.1
Activated
partial
thromboplastin
Time (aPPT)
T Prot
6.0-8.5
Platelets
Blood glucose
65-115
Other:
Sodium
135-147
Other:
Potassium
3.5-5.3
Other:
Chloride
95-108
Other.
Calcium
8.5-10.5
Other:
8-26
Other:
Blood urea
nitrogen
On Admissions
11. DIAGNOSTIC TESTS
Chest x-ray:
EKG:
Other:
Other:
Other:
Other:
Current Value
BOROUGH OF MANHATTAN COMMUNITY COLLEGE
Department of Nursing
12. MEDICATIONS List medications, times of administration, and therapeutic use
Medication/Time of
Therapeutic Use/Side or
of
administration. and therapeuticAdverse
use
Administration/Assessment
Effects
Medication/Time of
Therapeutic Use/Side of
Administration/Assessment Adverse Effects
ALLERGIES/PAIN
13. Allergies
14. Where is the pain?
14. Patient pain on scale from 0-10?
14. When was the last pain medication given?
TREATMENTS
15. Treatments:
16. Support Services:
17. Consultations:
18. DIET/FLUIDS
Type of Diet:
Restrictions:
Gag reflex intact:
Yes
No
Appetite: Breakfast
%
Lunch
Dinner
%
%
Check those problems that apply
• Problems swallowing, chewing, dentures
• Needs assistance with feeding
• Nausea or vomiting
• Over hydrated or dehydrated (evaluate total intake and
output on I & O sheet)
• Belching
• Other
Fluid Intake:
8 hours:
24 hours:
Tube feedings:
Type and rate:
19. INTRAVENOUS FLUIDS (IV therapy record)
Type and rate:
Location:
Other:
IV dressing dry, no edema, redness of
site:
Yes
No
20. ELIMINATION
Last bowel movement:
8-hour urine output:
24-hour urine output:
Foley/condom catheter
Yes
Check those problems that apply
• Bowel:
• Urinary:
• Other:
constipation
hesitancy
diarrhea
frequency
flatus
burning
incontinence
Incontinence
belching
odor
No
BOROUGH OF MANHATTAN COMMUNITY COLLEGE
Department of Nursing
21. ACTIVITY
Ability to walk (gait):
Type of Activity orders:
Use of assistive devices (cane,
walker, crutches, prosthesis):
Falls-risk assessment
rating:
No. of side rails req:
Yes
No
Restraints:
Yes
No
Weakness:
Yes
No
Trouble sleeping:
Yes
No
22. PHYSICAL ASSESSMENT DATA
Temperature:
BP:
Pulse:
Height:
Respirations:
Weight:
REVIEW OF SYSTEMS: Write WNL (within normal limits) if normal and
Describe abnormalities in space provided:
24. NEUROLOGICAL/ MENTAL STATUS:
LOC: alert and oriented to person, place, time (ADO x 3),
confused, etc.
Motor: ROM x 4 extremities
Sensations: 4 extremities
Speech: clear, appropriate/inappropriate
Sensory deficits
vision/hearing/taste/smell:
Pupils: PERRLA
Other:
25. MUSCULOSKELETAL SYSTEM:
Bones, joints, muscles (fractures, contractures,
arthritis, spinal curvatures, etc.):
Extremity circulation checks (pulses, temperature,
sensation, edema):
TED hose/compression devices: type:
Casts, splints, collar, brace:
Other:
26. CARDIOVASCULAR SYSTEM:
Pulses (radial, pedal, etc.) (to touch
or with Doppler):
Capillary refill (<23 sec):
Yes
No
Edema, pitting vs. nonpitting:
Neck veins (distention):
Sounds: regular, irregular
Any chest pain?
Other:
27. RESPIRATORY SYSTEM:
Rate, rhythm, depth: Breath sounds: Skin color: Cough
(clear, crackles,
wheezes):
Use of oxygen: nasal Flow rate of
cannula, mask, trach oxygen:
collar:
Sputum
Use of accessory muscles:
(productive,
(amount, color,
nonproductive): odor,consistency):
Pulse oximeter
% oxygen
saturation
Smoking:
Yes
No
If yes: number of cigarettes/packs
per day and number of years of
smoking:
Other:
BOROUGH OF MANHATTAN COMMUNITY COLLEGE
Department of Nursing
28. GASTROINTESTINAL SYSTEM :
Abdominal pain, tenderness,
guarding, distention, soft, firm:
Bowel sounds x 4 quadrants:
NG tube: describe drainage
Other:
Ostomy: describe stoma site and stools:
Other:
29. SKIN AND WOUNDS:
Color, turgor:
Characteristics of
drainage:
Rash, bruises:
Dressings (dry,
clean, intact):
Describe wounds
(size, location):
Edges approximated: Type of wound drains:
Sutures, staples,
steri-strips, other:
Risk for pressure ulcer-assessment rating:
Yes
No
Other:
30. EYES, EARS, NOSE, THROAT (EENT)
Eyes: redness, drainage
Ears: drainage
Nose: redness, drainage
Throat: sore
Other:
PSYCHOSOCIAL AND CULTURAL ASSESSMENT
31. Religious
preference:
32. Marital status:
AND
CULTURAL
ASSESSMENT
Psychosocial and cultural assessment tool:
See next sheet
33. Occupation:
34. Emotional state:
BOROUGH OF MANHATTAN COMMUNITY COLLEGE
Department of Nursing
METHOD DAILY TEACHING PLAN
Patient Name:
Diagnosis:
Teaching Technique(s):
One-to-one discussion. Therapeutic communication.
M (Medications):
E (Environment):
T (Treatments):
H (Health knowledge of disease):
O (Outpatient/inpatient referrals):
D (Diet):
BOROUGH OF MANHATTAN COMMUNITY COLLEGE
Department of Nursing
SUPPLEMENTAL MEDICATION SHEET
Generic Name:
Brand Name:
Drug Classification:
Reason your patient is receiving medication:
Usual Dosage:
Route:
What you will need to assess before, during, and after giving medication:
Evaluate effectiveness of medication:
Rate of flow and time of administration for IV medication:
Generic Name:
Brand Name:
Drug Classification:
Reason your patient is receiving medication:
Usual Dosage:
Route:
What you will need to assess before, during, and after giving medication:
Evaluate effectiveness of medication:
Rate of flow and time of administration for IV medication:
Generic Name:
Brand Name:
Drug Classification:
Reason your patient is receiving medication:
Usual Dosage:
Route:
What you will need to assess before, during, and after giving medication:
Evaluate effectiveness of medication:
Rate of flow and time of administration for IV medication:
2003-2004 NANDA-Approved Nursing Diagnoses
Activity Intolerance
Activity Intolerance, Risk for
Adaptive Capacity: Intracranial Decreased
Adjustment, Impaired
Airway Clearance, Ineffective
Anxiety
Anxiety, Death
Aspiration, Risk for
Attachment, Parent/Infant/Child, Risk for
Impaired
Body Image, Disturbed
Body Temperature: Imbalanced, Risk for
Bowel Incontinence
Breastfeeding, Effective
Breastfeeding, Ineffective
Breastfeeding, Interrupted
Breathing Pattern, Ineffective
Cardiac Output Decreased
Caregiver Role Strain
Caregiver Role Strain, Risk for
Communication, Readiness for Enhanced
Communication: Verbal, Impaired
Confusion, Acute
Confusion, Chronic
Constipation
Constipation, Perceived
Constipation, Risk for
Coping: Community Ineffective
Coping: Community, Readiness for Enhanced
Coping, Defensive
Coping: Family, Compromised
Coping: Family, Disabled
Coping: Family, Readiness for Enhanced
Coping (Individual), Readiness for Enhanced
Coping, Ineffective
Decisional Conflict (Specify)
Denial, Ineffective
Dentition, Impaired
Development: Delayed, Risk for
Diarrhea
Disuse Syndrome, Risk for
Diversional Activity, Deficient
Dysreflexia, Autonomic
Dysreflexia, Autonomic, Risk for
Energy Field, Disturbed
Environmental Interpretation Syndrome, Impaired
Failure to Thrive, Adult
Falls, Risk for
Family Processes, Dysfunctional: Alcoholism
Family Processes, Interrupted
Family Processes, Readiness for Enhanced
Fatigue
Fear
Fluid Balance, Readiness for Enhanced
Fluid Volume, Deficient
Fluid Volume, Deficient, Risk for
Fluid Volume, Excess
Fluid Volume, Imbalanced, Risk for
Gas Exchange, Impaired
Grieving, Anticipatory
Grieving, Dysfunctional
Growth, Disproportionate, Risk for
Growth and Development, Delayed
Health Maintenance, Ineffective
Health-Seeking Behaviors (Specify)
Home Maintenance, Impaired
Hopelessness
Hyperthermia
Hypothermia
Identity: Personal, Disturbed
Infant Behavior, Disorganized
Infant Behavior: Disorganized, Risk for
Infant Behavior Organized, Readiness for
Enhanced
Infant Feeding Pattern, Ineffective
Infection, Risk for
Injury, Risk for
Knowledge, Deficient (Specify)
Knowledge (Specify), Readiness for Enhanced
Latex Allergy Response
Latex Allergy Response, Risk for
Loneliness, Risk for
Memory, Impaired
Mobility: Bed, Impaired
Mobility: Physical, Impaired
Mobility: Wheelchair, Impaired
Nausea
Neurovascular Dysfunction: Peripheral, Risk for
Noncompliance (Specify)
Nutrition, Imbalanced: Less than Body
Requirements
Nutrition, Imbalanced: More than Body
Requirements
Nutrition, Imbalanced: More than Body
Requirements, Risk for
Nutrition, Readiness for Enhanced
Oral Mucous Membrane, Impaired
Pain, Acute
Pain, Chronic
Parenting, Impaired
Parenting, Readiness for Enhanced
Parenting, Risk for Impaired
Perioperative Positioning Injury, Risk for
Poisoning, Risk for
Post-trauma Syndrome
Post-trauma Syndrome, Risk for
Powerlessness
Powerlessness, Risk for
Protection, Ineffective
Rape-Trauma Syndrome
Rape-Trauma Syndrome: Compound Reaction
Rape-Trauma Syndrome: Silent Reaction
Relocation Stress Syndrome
Relocation Stress Syndrome, Risk for
Role Conflict, Parental
Role Performance, Ineffective
Self-Care Deficit: Bathing/Hygiene
Self-Care Deficit: Dressing/Grooming
Self-Care Deficit: Feeding
Self-Care Deficit: Toileting
Self-Concept, Readiness for Enhanced
Self-Esteem, Chronic Low
Self-Esteem, Situational Low
Self-Esteem, Risk for Situational Low
Self-Mutilation
Self-Mutilation, Risk for
Sensory Perception, Disturbed (Specify:
Visual, Auditory, Kinesthetic, Gustatory,
Tactile, Olfactory)
Sexual Dysfunction
Sexuality Patterns, Ineffective
Skin Integrity, Impaired
Skin Integrity, Risk for Impaired
Sleep Deprivation
Sleep Pattern Disturbed
Sleep, Readiness for Enhanced
Social Interaction, Impaired
Social Isolation
Sorrow, Chronic
Spiritual Distress
Spiritual Distress, Risk for
Spiritual Well-Being, Readiness for Enhanced
Spontaneous Ventilation, Impaired
Sudden Infant Death Syndrome, Risk for
Suffocation, Risk for
Suicide, Risk for
Surgical Recovery, Delayed
Swallowing, Impaired
Therapeutic Regimen Management:
Community, Ineffective
Therapeutic Regimen Management, Effective
Therapeutic Regimen Management: Family,
Ineffective
Therapeutic Regimen Management, Ineffective
Therapeutic Regimen Management, Readiness
for Enhanced
Thermoregulation, Ineffective
Thought Processes, Disturbed
Tissue Integrity, Impaired
Tissue Perfusion, Ineffective (Specify:
Renal, Cerebral, Cardiopulmonary,
Gastrointestinal, Peripheral)
Transfer Ability, Impaired
Trauma, Risk for
Unilateral Neglect
Urinary Elimination, Impaired
Urinary Elimination, Readiness for Enhanced
Urinary Incontinence, Functional
Urinary Incontinence, Reflex
Urinary Incontinence, Stress
Urinary Incontinence, Total
Urinary Incontinence, Urge
Urinary Incontinence, Risk for Urge
Urinary Retention
Ventilatory Weaning Response, Dysfunctional
Violence: Other-Directed, Risk for
Violence: Self-Directed, Risk for
Walking, Impaired
Wandering
Source, NANDA Nursing Diagnoses:
Definitions and Classification, 2003-2004.
Philadelphia: North American Nursing
Diagnosis Association. Used with
permission