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Course: NURS 481L

PATIENT PROFILE DATABASE

Date: ____________________________________________________________________________________

Student Name:

Faculty Name:

1. ADMISSION INFORMATION
Date of Pt. Name: Admission Age Gend Growth and Ethnicit Occupa Spiritual Beliefs:
Care: Date: : er: Development (Erikson): y: tion:

Reason for Surgical Medical Diagnoses History: (Present and past diagnoses, Physician’s
Hospitalization/Chief Procedures/Date: History and Physical notes in the chart, nursing intake assessment,
Complaint (in pt’s own with length of history if possible)
words):

Admitting Medical History of Present Illness:


Diagnosis:

ADVANCE DIRECTIVES (Nursing Admission Assessment):


Durable Power of Attorney: ☐ Yes Code status : ☐ Full Code ☐
Living Will: ☐ Yes ☐ No
☐ No DNR (Do Not Resuscitate)
2. MEDICATIONS ALLERGIES:
Drug Classificatio Dosage Route Frequency Purpose Nursing Considerations
n (time due)

3. LABORATORY DATA
Test Norms On Current value Test Norms On Current value
admission admissi
on
WBC Sodium
Hemoglobin Potassium
Hematocrit Calcium
Platelets BUN
PT Creatinine
INR Magnesium

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Course: NURS 481L
PATIENT PROFILE DATABASE

aPTT Blood Glucose


HA1c Urinalysis
BNP Cultures
blood/sputum
DIAGNOSTIC TESTS
Chest X-ray: EKG: Abnormal studies:

Abnormal studies: Abnormal studies: Abnormal studies:


4. PHYSIOLOGICAL DATA-VITAL SIGNS
Vital Signs: Temp_________ oF / oC ☐Axillary ☐Tympanic ☐Oral ☐ Core Admission weight:___________
☐Rectal Yesterday’s weight___________
Pulse______ ☐Apical _______ ☐Radial Today’s weight______________
Respiratory Rate______ ☐Even/regular ☐Labored/SOB ☐Dyspnea Height__________
on Exertion
BP ______/_______ ☐Supine ☐Sitting ☐Standing
5. NEUROLOGICAL/SENSORY
Orientation: ☐Time ☐Place ☐Person ☐Purpose Sensation: ☐Normal ☐Impaired ☐Absent
Pain: Grade ____ /10 Scale used: ☐0-10 Numeric ☐FLACC ☐ Wong-Baker What makes the pain
FACES worse:_______________
Pain Location:_______________ ________________________________
Character: ☐ Sharp ☐Dull ☐Ache ☐Heavy ☐Pinprick ☐Cramp ☐ _______
Other______________ What makes the pain
better:________________
________________________________
___
Level of Consciousness: ☐Alert ☐Lethargic ☐Obtunded ☐Stuporous ☐Semicomatose ☐Coma
Coordination: ☐Symmetrical ☐Asymmetrical ☐Unsteady PERRLA : #____mm ☐Brisk ☐Sluggish ☐Fixed ☐
Nystagmus

12 3 4 5 6 7 8mm
Strength: ____Right arm _____Left arm _____Right leg Glascow Coma Scale: Total of all 3
_____Left leg columns__________
Eyes Motor Verbal
0=No movement 4=Open 6=Obeys 5=Oriented
1=Trace movement spontaneously command 4=Confused
2=Moving, not against gravity 3=To speech 5=Localizes pain 3=Inappropriate
3=Moving against gravity, not against resistance 2=To pain 4=Withdraws words
4=Moving against gravity, some resistance 1=None 3=Flexion 2=Incomprehensib
5=Full power 2=Extension le words
1=None 1=None

Total_______ Total______
Total________

Touch: ☐Normal ☐ Smell: ☐Normal ☐Decreased Hearing: ☐Normal ☐Tinnitus ☐HOH ☐Hearing Aid ☐
Decreased Deaf

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Course: NURS 481L
PATIENT PROFILE DATABASE

Vision: ☐Normal ☐Glasses ☐Contacts ☐Cataracts ☐Glasses ☐Glaucoma ☐Blurred vision ☐ Diplopia
Neurosensory comments:

Nursing Diagnosis:
6. CIRCULATORY/CARDIOVASCULAR
Color: ☐ Pink ☐Pale ☐ Jaundice ☐Flushed ☐Cyanotic ☐ Capillary refill: ☐ <3 seconds ☐ >3 seconds
Mottled ☐Dusky
Skin:☐ Dry ☐Moist ☐Clammy ☐Warm ☐Cold ☐Hot Tele monitored
rhythm:________________________________
Peripheral Edema: ☐None ☐+1 ☐+2 ☐+3 ☐+4 Heart Sounds: ☐S1 ☐S2 Rhythm: ☐Regular ☐
☐Pitting ☐Non-pitting Irregular
Location:__________________________________________ Implanted Pacemaker: ☐ Yes ☐No
___
Peripheral pulses:
Right radial ☐Present ☐Absent Left radial ☐Present ☐Absent Right pedal ☐Present ☐Absent Left Pedal ☐
Present ☐Absent
Circulatory Comments:

Nursing Diagnosis:

7. RESPIRATORY/PULMONARY
Breath Sounds:☐Clear ☐Diminished ☐Absent ☐ Crackles
Pattern: ☐Regular ☐Irregular
☐Wheezes
Character: ☐Full ☐Shallow ☐Deep ☐Labored ☐SOB
Location:☐ Throughout ☐RUL ☐RML ☐RLL ☐LUL ☐LLL
Sputum: ☐White/Clear ☐Tan ☐Yellow ☐Green ☐Rusty ☐
Amount: ☐Small ☐Moderate ☐Large
Pink ☐Red
Cough: ☐None ☐Nonproductive ☐Productive ☐Suctioning Pulse Oximeter: ______%
required Oxygen: ☐Room air O2 ____L/min. or O2
Secretions: ☐Yes ☐No Consistency: ☐Frothy ☐Thick ☐ _____%
Thin Mode: ☐N/C ☐Mask ☐Trach
Suctioning Method: ☐Oral ☐Nasotracheal ☐ETT ☐Trach
ABGs: pH_____ pO2________ pCO2_______ HCO3___________
☐Bulb
Respiratory Comments:
Nursing Diagnosis:
8. NUTRITION/HYDRATION
Diet: ☐NPO ☐Regular ☐Cl. Liquid ☐Full liquid ☐Soft ☐ Aspiration Risk: ☐Yes ☐No
Pureed
☐Other____________________
Feeding Method: ☐Self ☐Assisted ☐NG ☐G-Tube ☐J-Tube Nausea: ☐Yes ☐No
Parenteral Nutrition: ☐TPN ☐PPN Vomiting: ☐Yes ☐No
Tube Feeding Formula:_____________ Rate:________mL/hr. Flatus: ☐Yes ☐No
Residual: ☐No ☐Yes Amt.______mL.
Weight: ☐Gain______# lbs/kg Mucous Membranes: ☐Dry ☐Moist
☐Loss______# lbs/kg ☐No change Skin Turgor: ☐No problem ☐Tenting ☐Taut
Intake: Output:
PO______ Urine_____ 24 hour net I/O: +/-_____
IV______ NG_______

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Course: NURS 481L
PATIENT PROFILE DATABASE

NG______ Emesis________
Blood_______ Stool________
Other_______ Drains________
Other________
24 hour total_________ 24 hour total_________

Nutrition/Hydration comments:

Nursing Diagnosis:

9. GI/FECAL ELIMINATION
Bowel Sounds:☐Absent ☐Hypoactive ☐Active ☐ Location: ☐RUQ ☐RLQ ☐ LUQ ☐LLQ ☐ Throughout
Hyperactive
Abdomen: ☐Soft ☐Flat ☐Distended ☐Round ☐Firm ☐ Ostomy: ☐No ☐Yes Incontinence: ☐Yes ☐No
Tender ☐Flatus Type:______
Last BM: _______Stool: ☐Formed ☐Soft ☐Hard ☐ Liquid Color: ☐Brown ☐Black/Tarry ☐Clay/Gray ☐Yellow ☐
#_______ Green
Fecal Elimination Comments:

Nursing Diagnosis:

10. GU/URINARY ELIMINATION


Urine: ☐Clear ☐Cloudy ☐Sediment Color: ☐Straw ☐Yellow ☐Amber ☐Pink ☐Red
Last void: time____________ amount Catheter: ☐None ☐In/Out ☐Condom ☐Foley ☐
mL Suprapubic
Insertion date:_________________
Symptoms: Frequency: ☐ Urgency: ☐ Dysuria: ☐ Nocturia: ☐ Incontinence: ☐Yes ☐No
Urinary Elimination Comments:
Nursing Diagnosis:
11. REST AND EXERCISE
Activity: ☐ Bed rest ☐BSC ☐BRP ☐ Chair ☐ Mobility Aids: ☐Cane ☐W/C ☐Crutches ☐Walker
Ambulate
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 # hrs sleep/night__________
Cast/Brace/Traction: Type___________ Restraints: Type_________________
Location_______________ Location_______________
Rest and Exercise Comments:

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Course: NURS 481L
PATIENT PROFILE DATABASE

Nursing Diagnosis:

MORSE FALL SCALE/RISK SCREENING


Variables Scor
e
History of Falls within last No 0
12 months Yes 25
Secondary Diagnosis No 0
Yes 15
Ambulatory Aids None/bedrest/nurse assist 0
Crutches/cane/walker 15
To obtain the Morse Fall Score add the score
Furniture 30
from each category.
IV or IV access No 0
Yes 20
Gait Normal/bedrest/wheelchair 0 Morse Fall Score
Weak 10 ☐ High Risk 45 and higher
Impaired 20 ☐ Moderate Risk 25-44
Mental Status Know own limits 0
☐ Low Risk 0-24
Overestimates or forgets limits 15

Total
Rest and Exercise Comments:

Nursing Diagnosis:

12. SKIN INTEGRITY/INTEGUMENTARY

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Course: NURS 481L
PATIENT PROFILE DATABASE

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 IV Site A Drains
Patent None
Swollen Penrose
Red Hemovac
Infiltrated JP

Braden Scale Score


Sensory 1. Completely limited 2. Very limited 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 limitations
immobile
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 less
Shear problem = at risk _____
IV sites: ☐ Patent ☐Swollen ☐Red ☐Infiltrated Location:____________ Gauge Needle:____________ Start
date:______________
Skin Comments:

Nursing Diagnosis:

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 ☐Post Understands directions: ☐Yes ☐ No
Graduate
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 ☐

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Course: NURS 481L
PATIENT PROFILE DATABASE

Psychiatric history

Recreational drug use: ☐ Drug How much____ How Alcohol use: ☐ How often_____ How
long____ 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 Sexuality: ☐Heterosexual ☐Bisexual ☐Homosexual ☐Transgender
☐Transsexual

Ability to write English: ☐Yes ☐No Ability to read English: ☐Yes ☐No

Language Barrier: ☐None ☐ESL ☐Speech Support System: ☐Yes ☐No


Impediment ☐Intubated ☐ Trached Living Situation: ___________________________________
Psychosocial Comments:

Nursing Diagnosis:

Narrative Charting:

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