PATIENT DATA SHEET

Patient Initials & Room #_______

Admitting Diagnosis:

Age/Sex_______

Other Medical Problems (PMH):

Surgeries (significant PSH):
Significant Psychiatric History:

Student___________ RN__________ BNA__________

Admission Date_______
Allergies_____________________
Code Status_________________
Vital Signs: B/P_______ HR_______ RR_______ Temp
_______
Current Pain Rating: __________

GENERAL APPEARANCE:

RESPIRATORY[ ] see nursing notes

Activity-Exercise Pattern

[ ] male [ ] female DOB:_____________

Age_________Ethnicity_________
Occupation _________________ Religion_______________
[ ] awake [ ] cheerful [ ] crying [ ] sleeping [ ]
lethargic
[ ] calm [ ] agitated [ ] anxious [ ] combative [ ]
fearful
SKIN
[ ] (see wound care sheet)[ ] see nursing
notes
Nutritional-Metabolic Pattern

Braden scale score: ________

breakdown

RESPIRATIONS: Rate______ O2_________ SPO2______%

[ ]reg [ ] even [ ] irreg [ ] labored
[ ] uses accessory muscles [ ] cough
BREATH SOUNDS:
RIGHT: [ ] clear [ ] crackles [ ] wheezes [ ]
rhonchi

[ ] risk skin

COLOR: [ ]acyanotic [ ] pale [ ] ruddy [ ] jaundiced

[ ] decreased [ ] absent
[]

cyanotic
TEMP: [ ] warm/dry [ ] hot [ ] cool [ ]cold/clammy [ ]
diaphoretic
TURGOR: [ ]<3 sec
[ ] > 3 sec
HAIR: [ ] shiny [ ]dry/faking [ ]balding [ ] lesions [ ] lice

NEUROLOGICAL[ ] see nursing notes

Cognitive-Perceptual Pattern

Left:

[ ] clear [ ] crackles [ ] wheezes [ ]

rhonchi
[ ] decreased [ ] absent
THORAX: [ ] even expansion [ ] uneven expansion
SMOKING: [ ]cigarettes pk/day ____________ [ ] cigars [ ]
marijuana
[ ] cocaine
GASTROINTESTINAL/NUTRITION [ ] see nursing
notes
Elimination Pattern & Nutritional-Metabolic Pattern

ORIENTATION: [ ] person [ ] place [ ] time

APPEARANCE: [ ] flat [ ] round [ ] obese [ ] soft [ ]gravid

[ ] Disoriented: [ ] confused [ ] impaired

memory
RESPONDS TO: [ ] name [ ] stimuli [ ] non-responsive
SPEECH: [ ] clear [ ] garbled [ ] slurred [ ] aphasic
[ ] inappropriate [ ] cannot follow conversation

BOWEL SOUNDS: [ ] active [ ] hypoactive [ ] hyperactive [ ]

absent
PALPATION:
[ ] non-tender [ ] tender (location)__________
[ ] mass (location) _____________

FACE: [ ] symmetrical [ ] drooping [ ] drooling

LAST BM:________[ ] incontinent

EYES: [ ] PERRLA [ ] unequal [ ] drooping lid

[ ] constipation [ ] diarrhea [ ] mucous [ ] blood

Diet:______________ [ ] impaired swallowing [ ]
choking
[ ] NG tube Color drainage______________[ ] Feeding tube

SIGHT: [ ] no correction [ ] glasses [ ] contacts [ ] blind

HEARING: [ ] WNL [ ] HOH [ ] hearing aid
Hx: [ ] seizures [ ] CVA [ ] brain injury [ ] spinal injury [ ]
other
MUSCULOSKELETAL[ ] see nursing notes
Activity-Exercise Pattern
GAIT: [ ] steady [ ] unsteady [ ] non-ambulatory
ACTIVITY: [ ] up ad lib [ ] walker [ ] cane [ ] crutches [ ]
wheelchair
Assist: [ ] x1 [ ] x2 [ ] lift [ ] bed bound
HAND GRIPS:
RIGHT: [ ] strong [ ] weak [ ] flaccid [ ] contractures

Oosterhouse 2013

[ ] stoma- _______

[ ] tube feeding Type: ______________ Rate:_________

GENITOURINARY[ ] see nursing notes

Elimination Pattern

[ ] Voids [ ] catheter [ ] stoma

APPEARANCE OF URINE:
[ ] clear [ ] light yellow [ ] amber [ ] brown
[ ]cloudy [ ] sediment [ ] red/wine [ ] clots
BLADDER: [ ] soft [ ] firm/distended [ ] incontinent

LEFT: [ ] strong [ ] weak [ ] flaccid[ ]

contractures
ROM:
ARMS: [ ] full [ ] weak [ ] flaccid [ ]
contractures
LEGS: [ ] full [ ] weak [ ] flaccid [ ]contractures [ ]TED
AMPUTATION: [ ] right [ ] left [ ] BKA [ ] AKA [ ]
other
SPINE: [ ]kyphosis [ ] scoliosis [ ] osteoporosis
OTHER: [ ] Cast location:___________ [ ]
Traction_____________

CARDIOVASCULAR[ ] see nursing notes

Activity-Exercise Pattern
HEART SOUNDS: [ ] normal S1-S2 [ ] Abnormal S3-S4 [ ]
murmur
PULSE: APICAL: [ ]reg [ ] irreg [ ] strong [ ] faint
RADIAL: [ ]reg [ ] irreg [ ] strong [ ] faint [ ] nonpalpable
PEDALIS: [ ]reg [ ] irreg [ ] strong [ ] faint [ ]
nonpalpable
EXTREMITY COLOR & TEMP:
[ ] warm [ ] cool [ ] cold [ ] acyanotic [ ] cyanotic [ ]
discolor
EDEMA: [ ] none [ ] generalized (anasarca)

Sexuality-Reproductive Pattern
FEMALES: LMP: _________ [ ] WNL [ ] dysmenorrheal
Birth control:[ ] yes [ ] no [ ] BSE monthly
[ ] menopause [ ] taking estrogen
SEXUALITY: [ ] sexually active [ ] safe sex
MED HX: [ ] urinary retention [ ] BPH [ ] Frequent UTI

PAIN ASSESSMENT: [ ] see nursing notes [ ] see

MAR
Cognitive-Perceptual Pattern

PRECIPITATING:_____________________________________
QUALITY:___________________________________________
REGION:____________________________________________
SEVERITY 0-10/10: Now _____ at worst ______at best _______
TIMING:

SAFETY:[ ] see nursing notes [ ] Fall risk

Site #1________________

PRECAUTIONS: [ ] side rails x_______ [ ] bed down [ ] call

light

Site #2 ________________

DISCHARGE/TEACHING:

CAPILLARY REFILL: Fingers [ ] brisk [ ] slow

Toes: [ ] brisk [ ] slow
Hx: [ ] Pacemaker [ ] HTN [ ] CAD [ ] CHF [ ] PVD
Other:_______

FLUID BALANCE

[ ] see nursing notes

Nutritional-Metabolic Pattern
INTAKE: [ ] PO [ ] IV: Solution: ____________Rate_______
ml/hr
SITE LOCATION: _____________ [ ] clean [ ] patent
[ ] redness [ ] swelling [ ]cool [ ] hot [ ] pain
[ ] tubing change [ ] dressing change
MUCOUS MEMBRANES: [ ] moist [ ]pink [ ]dry [ ]sticky [ ]
coated
Todays wt:______________ Yesterdays
wt:__________________

Scheduled Medication or Treatment Times

0800 0900 1000 1100 1200 1300 1400
1600 1700 1800 1900 2000 2100 2200

[ ] see nursing notes

NEEDS:_____________________________________________________
____________________________________________________________
________________________________________
TYPE OF LEARNER: [ ] visual [ ] auditory [ ] kinesthetic
Educational level _____________Family present: [ Y] [N]
NURSE SIGNATURE:

Time completed:
REASSESSMENT:
TIME ________ [ ] no change [ ] see nurses notes [ ]
initials___
TIME ________ [ ] no change [ ] see nurses notes[ ]
initials___
TIME ________ [ ] no change [ ] see nurses notes[ ]
initials___
LAB VALUES
BMP
CBC

---------I----------I----------<
>--------------<

PT/INR and PTT _____________________

________________

Other

Brief Pathophysiology of Current Condition (Knowledge):

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Oosterhouse 2013

Impact of condition on patient:

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Clinical Reflection (Attitude):
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Skill List
Skill Attempted

Oosterhouse 2013

How I did

How I can improve

Instructor Feedback

Head to Toe Narrative:

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Patient Priorities:
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SBAR Report:
Situation
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Background
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Oosterhouse 2013

Assessment
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Recommendation
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Oosterhouse 2013