Patient Worksheet - Medsurg 2-patient

G ENERAL Allergies:

Dx: PMH: Code: full / dnr / dni

♂ / ♀

Respirations: reg / irreg

G ENERAL Allergies:

Dx: PMH: Code: full / dnr / dni

Age:

O2:

L via

♂ / ♀ Age:

Respirations: reg / irreg

O2:

L via

Skin: elastic / poor // warm / cold Color: Pulses: radial: strong / weak // L / R pedal: strong / weak // L / R Mucous Membranes: pink / moist // dry / chapped Edema: 1+ / 2+ / 3+ / 4+ // pitting // L / R // U / L IV Site: L / R // dorsum / arm / __________________ _______________ warm / cool // clean // edematous / red @ mL/° Expires? pri-tubing / pri-bag / pb-tubing / ∆ In: Out:

Skin: elastic / poor // warm / cold Color: Pulses: radial: strong / weak // L / R pedal: strong / weak // L / R Mucous Membranes: pink / moist // dry / chapped Edema: 1+ / 2+ / 3+ / 4+ // pitting // L / R // U / L IV Site: L / R // dorsum / arm / __________________ _______________ warm / cool // clean // edematous / red @ mL/° Expires? pri-tubing / pri-bag / pb-tubing / ∆ In: Out:

Weight: kg / lb on Dentures? yes / no

Weight: kg / lb on Dentures? yes / no

Feeding: self / assist / total / tube: Diet: normal / soft / diabetic / ↓-Na /

Feeding: self / assist / total / tube: Diet: normal / soft / diabetic / ↓-Na /

Sounds: active / hyper / hypo // x

Flatus? yes / no

Sounds: active / hyper / hypo // x

Flatus? yes / no

Ostomy: red //

Clots? no / yes:

Ostomy: red //

Clots? no / yes:

ADLs: self / partial / total // assist x Activity: bed / BRP / ad lib /

Tone: good / poor / flaccid Devices: walker / w/c /

ADLs: self / partial / total // assist x Activity: bed / BRP / ad lib /

Tone: good / poor / flaccid Devices: walker / w/c /

LOC: A / drowsy / asleep // O x

Language: English /

LOC: A / drowsy / asleep // O x

Language: English /

Xfer: stable / unstable // assist x Amb: stable / w/c / walker / assist x Vision: good / poor / blind glasses / contacts

Fall Risk? yes / no Hearing: good / hoh / deaf // L / R Skin: dry / diaphoretic /

Xfer: stable / unstable // assist x Amb: stable / w/c / walker / assist x Vision: good / poor / blind // glasses / contacts

Fall Risk? yes / no Skin: dry / diaphoretic / Hearing: good / hoh / deaf // L / R

DEVELOPMENTAL

DEVELOPMENTAL

HEALTH DEVIATION

HEALTH DEVIATION

REPORT/NOTES

REPORT/NOTES

Vitals

:

T: o / ax / r

:

report;  meds; vs; “participated” assess;

16-17

P: ap / b / r

report;  meds; vs; “participated” assess;

vs;

: faces / flacc

19-20

SpO2: ra / O2

RN: CNA:

;  I&O; report

20-21

 :

P: ap / b / r R: reg / irreg

18-19

BP: L / R // a / l

Vitals T: o / ax / r

17-18

R: reg / irreg

Pt: Rm:

15-16

BP: L / R // a / l vs;

: faces / flacc SpO2: ra / O2 ;  I&O; report

Student Name: ___________________ Date of Care: __________

RN: CNA:

Pt: Rm:

 :