Winnebago INPT NURSING ADULT ADMISSION FORM

Each section on the template opens into a dialogue box some information will cross
over from RPMS and RN will assess other data.

Winnebago INPT NURSING ADULT ADMISSION FORM

Sample of the Admission Data dialogue

Sample of the physical assessment dilague box

Winnebago INPT NURSING ADULT ADMISSION FORM

Winnebago INPT NURSING ADULT ADMISSION FORM

Sample of completed note.
TITLE: INPT NURSING ADULT ADMISSION
DATE OF NOTE: JUN 30, 2009@16:10
AUTHOR: NURSE JAYNE
STATUS: COMPLETED

ENTRY DATE: JUN 30, 2009@18:02:03

WINNEBAGO HOSPITAL NURSING ADMISSION FORM, ADULT

ADMISSION DATA
Admitted to: M/S
Admitting diagnosis: Osteomyelitis, right hip
Time of arrival on ward: 30-Jun-2009 15:43
Admission source: Outpatient Clinic
Mode of Admission: Wheelchair
Received report from: Robin Lee, RN
Emergency Contact (include phone): XXXXXXXXXXXXXX
PO BOX 714 WINNEBAGO, NE 68071
Name/Relationship: Frank Zappa
Contact phone: 800-223-8888
Information obtained from: Patient
ADVANCE DIRECTIVES
Patient is not an organ/tissue donor.
Patient does not have a Living Will.
Patient does not have a Durable Power of Attorney for Health Care.
Patient would like to talk to Social Worker about Advance Directives.
Social Worker was notified with a consult.
Copy of Advanced Directives is not on the chart.
PERSONAL BELONGINGS/VALUABLES
Belongings/valuables did not accompany pt to unit.
Glasses: No
Contacts: yes
Dentures/partials: Yes
Hearing Aides: Yes
Disposition of meds: home w/ family
Disposition of belongings: At bedside
Disposition of valuables: At bedside
Pt Property Record Inventory completed. Form FDFM-2-93 Statement of
Waiver of Patient NOT depositing valuables/monies completed.
ORIENTATION TO ROOM/UNIT
Identification band placed on Right wrist
Patient received information on the following:
Yes Patient informed of "Patient's Rights".
Yes Review of Smoking Policy, Visiting Policy, Food Service.
Yes Orientation to nurse call system, bed side rail use, bed controls,
emergency light, bathroom, TV, phone
Yes Safety instructions.
FALL RISK SCREEN
Patient is presently taking medication that causes drowsiness,
dizziness or unsteadiness.
MORSE FALL SCALE
1. History of Fall: 25 (Yes)
2. Secondary DX:
15 (Yes)
3. Ambulatory Aid: 0 (Uses W/C or nurse assists)
4. IV/Heparin Lock: 0 (No)
5. Gait/Transfer:
20 (Impaired: unsteady)
6. Mental Status:
15 (Overestimates ability)
TOTAL SCORE:
75(High Risk >50)
Pt high fall risk per Morse Fall Scale. (score >50).

Winnebago INPT NURSING ADULT ADMISSION FORM

Fall precautions initiated:
orange wristband applied, patient assigned to appropriate
location, orientate pt to surrounding, visual check on patient
fall prevention education completed, provide non-skid footwear,
clutter, maintain clear walk paths, bed in low position, wheels
all high risk fall interventions implemented

bed
q1h ,
minimize
locked,

Pain:
Severity: Severe
Location: left foot
Type: Sharp
Duration: Constant
Sleep problems related to pain? Yes
Activities of Daily Living- problems related to pain? Yes
What relieves the pain? medication, no movement
What worsens the pain? movement
Comfort/pain relief goal? 4
PHYSICAL ASSESSMENT
RESPIRATORY
Clear to auscultation bilaterally. Normal respiratory effort.
CARDIOVASCULAR
Pulse: regular
heart murmur present.
Capillary Refill
Nail bed color: pink
Peripheral edema: left lower leg and foot.
Location: left lower leg and foot.
NEUROLOGICAL
Alert, orientated x 3, co-operative.
Pupils equal, round, reacting to light.
GASTROINTESTINAL
Last BM: 21-Jun-2009
Abdomen soft, bowel sounds present.
No nausea or vomiting, diarrhea or constipation.
GENITOURINARY
Voiding without difficulty.
No bladder distension.
Bladder: non distended
Urinary Care: bath room privileges, urinal
Any discharge? No
Any lesions/sores? No
MUSCULOSKELETAL
Weakness: Yes
Range of Movement: full ROM
Moves extremities X 4
Gait: unsteady
Muscle Tone: moves freely
Amputee: bilateral amputation-left foot all toes amputated.
Paralysis: none
Fall Risk: Yes Fall interventions implemented.
SKIN
WOUND
other - ulcer x 2
Location: left foot
Depth Muscle
Wound odor: foul
Wound drainage: purulent
Wound site not healing well.
Dressing: clean, dry, intact
Wound Staging: Stage 4 - penetrates bones, muscle or joint
Tunneling? Yes
Non-hospital acquired
Infection Prevention
Isolation Precautions: No
Are other family members/siblings currently ill
or have had recent infections? No

Winnebago INPT NURSING ADULT ADMISSION FORM

The Following symptoms are Present draining lesions, wounds
The Following symptoms are Absent Copious secretions, sputum production,
skin rash, diarrhea, catheter, IV, Central Line, PIC LINE, decubiti,
post surgical
FUNCTIONAL ASSESSMENT
Activity level: bed rest, BRP
Assist devices: w/chair
Touch: normal
Physical Limitations: weakness/low energy
Before admission the patient was receiving the following:
No PT, OT, ST therapy
Bed Mobility: Independent
Transfers:
Independent
Ambulation:
Needs help
Bath/Hygiene: Needs help
Oral Hygiene: Independent
Dressing:
Independent
Eating:
Independent
Are you having any difficulty swallowing? No
Have you had a change in your ability to communicate? No
Elimination Stool: self
Usual bowel pattern: Every 1day/s.
Elimination Urine: self
Level of functioning: needs assistance with ADLs
Patient's status now compared with pre admission status is better.
Based on this screen the pt requires assistance with:
amputation care , locomotion/mobility
Per screen a consult should a be considered for:PT
ALLERGIES/IMMUNIZATIONS/MEDICATIONS
ALLERGIES
Allergy Band Placed on patient; Yes
Information from RPMS: Doritos
Food Allergies: Doritos;AdvReac: None found
IMMUNIZATIONS
Information in RPMS:
Immunizations Due: No immunizations due.
MEDICATIONS
Pt takes meds as: Can swallow pills
Pt does take his/her prescribed meds regularly.
If NOT - comment why not? Forgets to take medicines.
Medication information from RPMS:
Active Inpatient Medications (including Supplies):
ACETAMINOPHEN/OXYCODONE TAB 2 TABLETS PO Q4H PRN
AMLODIPINE TAB 5MG PO DAILY
INSULIN ASPART INJ SEE SLIDING SCALE SC AC
INSULIN DETEMIR INJ 55 UNITS SC HS
INSULIN REGULAR 100UNITS/ML INJ 100UNT/1ML SC NOW
LISINOPRIL TAB 40MG PO DAILY
SODIUM HYPOCHLORITE 0.125% SOLN,TOP SMALL AMOUNT TOP BID

PENDING
PENDING
PENDING
PENDING
PENDING
PENDING
PENDING

OTHER PRESCRIBED DRUGS (Non IHS)

Patient does not take any other prescribed non IHS medications.
OTC DRUGS, HERBALS & TRADITIONAL MEDICINES

Winnebago INPT NURSING ADULT ADMISSION FORM

Patient does not take any OTC drugs, herbals, vitamins or
Traditional medications.
MEDICAL HISTORY
Patient says reason for hospital stay is:
left foot ulcers, bad back
Patient's expectations at discharge are:
to be well and healed.
Information in RPMS - Active Problems:
OBESITY (Added on OCT 17, 1980)
CHOLELITHIASIS (Added on MAY 08, 1990)
DIABETES MELLITUS TYPE 2 (Added on JUL 03, 1998)
REPRODUCTIVE HEALTH
Male:Denies
Last prostate exam:
N/A
Do you do testicular self exam?

No

SURGICAL HISTORY
Information from RPMS:
4TH-5TH TOE AMP 12/99, 6/00 [TOE AMPUTATION] - DEC 01,2009 @12:00
METABOLIC/NUTRITION ASSESSMENT
Nutrition Screen completed Yes
Diet Order: 2 gram sodium, 2200 calorie diet
Recent Weight: 147 lb (Jun 21, 2009@16:10)
Recent Height: 64.00 in (Jun 21, 2009@16:10)
BMI: 24.7
Nutrition Labs:
Last HGB & HCT:
HEMOGLOBIN
08.62 JUN 21, 2009@12:00
HEMATOCRIT
25.43 JUN 21, 2009@12:00
Last ALBUMIN

2.69

JUN 21, 2009@12:00

SOCIAL/CULTURAL/LIFESTYLE HISTORY
Marital Status: Married
Employment: Disabled
Tribal affiliation: Navajo
Primary Language: English
RELIGIOUS/SPIRITUAL BELIEF
Religious/Spiritual preference: Catholic
Patient does not have religious, traditional, ethnic, or cultural
practices that should be part of hospital care.
TOBACCO HABITS
Information in RPMS: Last
past
Previous Tobacco User
Age started: 13
Cigarettes pk/day:
1
Quit 21 years ago.
ALCOHOL/DRUG HABITS
Information in RPMS: Last
Has pt ever drunk alcohol

TOBACCO HF: NON-TOBACCO USER - Jun 08, 2009

pack per day for 6 years.

ALCOHOL/DRUG HF: CAGE 0/4 - Jun 08, 2009
or used drugs? Present

Age started: 22
Date last used: 21-Jan-2009
Did you ever share needles with another person? No
Previous ETOH
Age started: 16
Date last used: 21-Nov-2008
DOMESTIC VIOLENCE SCREEN
Current IPV/DV Screen from RPMS: Date: Jun 08, 2009 Results:
NORMAL/NEGATIVE

Winnebago INPT NURSING ADULT ADMISSION FORM

Patient states he does feel safe at home.

Has your partner or someone important to you ever hurt you? No
Has anyone ever forced you to have sexual activities? No
Are you concerned about your safety or the safety of anyone in your
family? No
MENTAL HEALTH HISTORY
EMOTIONAL
Patient does have emotional concerns/recent changes.
anxious , currently being seen by Mental Health , depressed

states he does not CURRENTLY

have thoughts of suicide or suicide ideation.
PATIENT XXX states he does not has not
RECENTLY had thoughts of suicide or suicide ideation.
EDUCATIONAL ASSESSMENT
Patient:
Identified Learning needs: illness/treatment , nutrition intervention, safe/effective
use of equipment, safe/effective use of rehab
techniques, wound care
Current knowledge of disease: Limited
DISCHARGE PLANNING
Current Living Arrangements:
Stairs?
No
Inside running water?
Yes
Electricity?
Yes
Wood stove for cooking?
No
Wood stove for heating?
No
Outdoor toilet?
No
Do you have help at home? Yes
Complete the following questions:
Pt able to care for self under present conditions?

Yes

Does pt need help with shopping, cooking, home maintenance? No

Does the patient have any safety needs?

No

Does the patient have any infection control needs?

wound care

Yes

Does the patient have any special equipment needs?

No

Who will provide transportation at discharge?

Kendra
COMMUNITY RESOURCES
Is the patient currently utilizing community resources?
/es/ Nurse Jayne
Signed: 06/21/2009 18:37

No