Health Perceptions-Health Management

Nutrition-Metabolic Pattern

Reason for seeking health care:

Treated at home:
Past medical hx:
Past surgical hx:
Allergies:
Code status:
Advance Directives:
Medical Durable Power of Attorney:
Family hx:

Ht:
Wt:
Recent change in wt(amt/time):
Diet:
Appetite:
Bkft:
% Lunch:
% Dinner:
%
Problems eating: difficulty swallowing/nausea/vomiting/ abdominal
pain/ antacid use
Dentition/Dentures:
Taste sensation: normal/impaired
Tests blood glucose at home: yes/no
Tube feeding: Type of feeding: _______ Residual: ________
NG/PEG/PEJ Rate: _________
IV Site: peripheral/PICC/central line/port appearance: __________
I:
O:
Nails:
Skin:
Braden Scale

Elimination Pattern

Activity-Exercise Pattern

Usual bowel habits: ___________ Last BM: ____________

Diarrhea/Constipation/Incontinent/_________ Color: _________
Consistency:
Ostomy:
Rectum:
Bladder function:
Bladder distention:
Urine: Color___________ Clarity__________

Tobacco Use: yes/no How long: __________ PPD ________ Quit

smoking? _______
Respiratory effort:
Respiratory depth:
DIB:
Cough:
Sputum: Color ______ Consist. _____ Amt _____
ADL- eat/toilet/ambulate/bath/bed mobility/dress/transfer
Response to ADL:
Gait: steady/unsteady/Posture______
Assistive devices:
Participates PT:
Hx of falls:

Sleep-Rest Pattern

Sexuality-Reproductive Pattern

Home sleep: _______ hrs/night

Naps: _____________
Hospital sleep: ________ hrs/night
Naps: _____________
Insomnia/Sleep Apnea/Other _________ Sleep Aids _______

Verbalized impact of illness, meds, tx: _____________________

Breasts: _______________________ Hx of STDs: _________
Genitalia: _____________________ Prostate: ____________
Sexually Active: ________ GYN/Mammogram: ___________

Cognitive-Perceptual Pattern

Role-Relationship Pattern

Memory: intact/recent memory deficit/remote memory deficit

Thought process: appropriate/poor historian/ __________
Restraints: ______________ Alternatives: __________________
Verb. understand illness: _____________ Glasses: yes/no
Barriers to learning: _________________ Hearing Aids: yes/no
Heat/cold intolerance: yes/no numbness/tingling: yes/no
Pain: __/10 Longer than 6 months: yes/no Desired pain: ___/10
What makes it worse: __________________________________
What makes it better: __________________________________

Occupation (current or retired): _____________________

Support Systems: married/widowed/divorced/single/life partner
Identified support systems/individuals: ____________________
Socialization: phone calls/visitors/cards
Verbalized Fear of Violence

Self-Perception/Self-Concept Pattern

Coping-Stress Tolerance Pattern

Ericksons Age related Developmental Stage: _______________

Clients Developmental Stage ___________________ AEB
____________________
Verbalized identification with cultural group: _______________
Indicators of culture: __________________________________
Identified/Verbalized major losses/life changes: _____________
Emotional/Behavioral State: calm/happy/sad/depressed/agitated/
combative/angry/anxious/other: ______________

Behaviors/Statements indicating adjustment to stressors/illness:

Values-Belief Pattern

Vital Signs:
BP
8am
Noon

Verbalization of that which is most valued in life: ____________

Verbalization of self as a spiritual/religious person: ___________
Request for spiritual support while hospitalized: _____________
Environmental spiritual cues: ____________________________
Behavioral/Verbalized cues of spiritual distress: _____________
Diagnostic Studies Done: yes/no
X-rays/Scans:
Procedures:
EKG:
Other:

Behaviors/Statements indicating impaired adjustment:

Drugs/Alcohol for coping: yes/no
Interest in alternative coping strategies: yes/no

PO

Pain

Labs: Date: ___________

RBC: ____ HGB: _____ HCT: _____Platelets: ____ WBC:____
Na: ____K: ____ Cl: ____ CO2: ____ Mg: ____ Ca: ____ P: ___
Others:

Initials: ________ Room Number: _______ Age: ______ M/F

Admission Date: __________ From: home / ECF / assisted living
Medical DX: _________________________________________
Surgical Procedure: ____________________________________

7.8 Collect data & come up with plan for day & nursing diagnosis Pre-conference 8-9 Vitals then chart, AM Care, start
baseline assessment 9-10 Activities of Daily Living and chart, finish baseline assessment 10-11 Ongoing Adult
Assessment (should be on task list) 11-12 Activities of Daily Living 12-1 Vitals and chart 1-2 Activities of Daily
Living 2-3 Post Conference

Head
LOC: clear/confused (oriented to person, place, time)
alert/lethargic
PERRL: pupils __ mm at rest, equal/round/ reactive to light
MUCOUS MEMBRANES: dry/moist, pink/pale/cyanotic,
intact/fissured
Thorax
SHAPE: (1:2), (1:1)
BREATH SOUNDS: clear/crackles/wheezing,
effortless/DIB
HEART: regular/irregular, rate ______ bpm
Abdomen
CONTOUR: flat/round, soft/firm, distended, tender
OTHER: stoma________ drains_________ scars_________
BOWEL SOUNDS: present x 4 quadrants/absent
Limbs
UPPER: radial pulse (0, +1, +2, +3) capillary refill </> 3 sec
Hand Grasps = / R < > L
ROM full/restricted explain: _________________________
LOWER: pedal pulse (0, +1, +2, +3) = / R < > L
Edema absent/present, firm/pitting (+1, +2, +3, +4)
ROM full/restricted explain: _________________________
Skin
COLOR: pink / pale / cyanotic / jaundiced
CONDITION: dry / moist, cool / warm
TURGOR: elastic / tents
INJURY: contusion / abrasion / laceration / ulceration /
excoriation / descriptors: Size ________________
Color _______________ Dry/Drainage_________________
Equipment
FOLEY: urine color ___________ clarity ____________
Amount__________
IV: Site Infiltration (cool, pale, pain) Phlebitis (warm, red,
pain)
Solution: ___________________ Rate: ________________
OXYGEN THERAPY: device _________ L/min ________
OTHER: Pain: no ______ yes _____ Pain scale: _____/10
NOC: ___________________________________________
________________________________________________

Name: ___________________________________
Room #: _____________
Diagnosis/Surgery: ________________________________
________________________________________________
________________________________________________
Vital Signs (how often): ____________________________
Activity (what needs to happen today): ________________
________________________________________________
________________________________________________
Diet (any restrictions):
I&O (has to be monitored regardless of whether or not it
was ordered): _____________________________________
________________________________________________
O2/Resp Tx (what kind & how much): _________________
________________________________________________
IV & rate (what solution, site, rate in gtts/min): __________
________________________________________________
________________________________________________
Treatments (dressings, SCDs, trach care, etc.): __________
Accucheck (how often?): ___________________________
________________________________________________
Labs (what needs to be drawn? Results to view today?): ___
________________________________________________
________________________________________________
________________________________________________
Priority Assessment Data: ___________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
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Nursing Dx: _____________________________________
________________________________________________
________________________________________________
________________________________________________
Nursing Interventions: ______________________________

________________________________________________
Medications: 0800 _________________________________
________________________________________________
________________________________________________
0900 ____________________________________________
________________________________________________
________________________________________________
1000 ____________________________________________
________________________________________________

Medications: 1200 _________________________________

________________________________________________
________________________________________________
1300 ____________________________________________
________________________________________________
________________________________________________
1400 ___________________________________________
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