

Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
A form for nurses to be filled by asking all the questions from patient
Typology: Cheat Sheet
Limited-time offer
Uploaded on 04/23/2021
4.5
(15)233 documents
1 / 2
This page cannot be seen from the preview
Don't miss anything!
On special offer
POLST/Code Status VS 7:30 Temperature Pulse Respirations BP / Pain / VS 11:30 Temperature Pulse Respirations BP / Pain /
How does the client look?
Age___________ Male/Female Body Build: Thin Cachectic Obese WNL Height___________ Weight____________ Well groomed Poorly Groomed Facial Expression: Anxious Happy Sad Angry
(LOC) Level of Consciousness
Alert Awake Lethargic Obtunded Stuper Comatose Confused Decerebrate Decorticate Oriented x 4: Person Place Time Event Response to touch/voice Eyes Unaided sight Glasses Contact lens Implants Prosthesis Snellen 20/ Blind
Pupils Equal^ Round^ Reactive to light^ Accommodates^ Sluggish^ Brisk^ Nonreactive to light^ Consensual Pupil size before light ______mm Pupil size after light ______mm Ears Unaided hearing Hard of hearing Deaf Hearing aid Implant Cerumen Drainage Extremities Hand grips +1 +2 +3 +4 +5 equal unequal Foot pushes +1 +2 +3 +4 +5 equal unequal
Cranial Nerves - intact
I(smell) II(vision) III+IV+VI(eye movement) V(sensation of face/oral) VII (facial movement/taste) VIII (hear/balance) IX (taste/swallow) X (chew/gag/speech) XI (shrug/turn head) XII(tongue movement) Pain Character Onset Location Duration Severity Pattern Associated Factors COLDSPA
Skin / Mucous Membranes Pink Pale Cyanotic Jaundiced Ruddy Flushed Diaphoretic Radial and Pedal Pulses Radial: Palpable (L/R) Absent (L/R) Pedal: (DP PT) Palpable (L/R) Absent (L/R) Apical Radial Pulses (2 people simultaneously) Apical and Radial Pulse Deficit Carotid Pulses (DO NOT TAKE AT SAME TIME) Right Left Thrill Bruit Capillary Refill Normal (<3 Sec) ______sec Jugular Neck Veins Not visible Visible Edema Absent Present: location +1 +2 +3 +4 Anasarca Pitting Non Pitting Calf Tenderness Denies Positive Homan’s sign R L calf size R____ L_____ (team leader or charge nurse notified) Heart Rhythm/ Sounds – S1S
Regular Irregular Murmur Extra sounds Strong Faint Muffled Telemetry: rhythm ___________________ Pacemaker Defibrillator location
Solution_______________ Rate ____ml/hr Pump Site location (be specific) ______________________________________ Site appearance: Clear Edema Erythema Tender Pallor Dialysis access: type __________ Thrill Bruit Location:___________ Appearance:____________
Respirations Regular Irregular Even Uneven Unlabored Labored Symmetrical Asymmetrical
Lung Sounds
Clear LUL RUL LLL RLL RML Anterior Posterior Wheezes location__________ Rales/crackles location__________ Rhonchi location ________ Nasal flaring Sternal retraction Intercostal retraction Do lung sounds improve with cough and deep breath? If no, report to team leader Cough None Nonproductive Dry Moist Productive Sputum:amount color frequency
Oxygen Room air^ Pulse ox ______^ O2 at_____L/min^ Nasal Cannula^ Mask Tent CPAP BIPAP
Respiratory Treatments
Incentive Spirometer (IS): ml______ frequency _______hold for ___ seconds # of times______ HHN medication Bipap Ventilator? TV rate 02% other
Oral Teeth Dentures Caries Dysphagia Mucous Membranes: intact moist dry pale leukoplakia Abdomen: Inspect Auscultate Percuss Palpate
Soft Round Flat Scaphoid Obese Firm Hard Nondistended Distended Tender Non Tender Location: Bowel Sounds RLQ RUQ LUQ LLQ Normoactive Hypoactive Hyperactive Absent
NG/ GT/ JT
None Type of tube _____ patent nonpatent Suction: low high Color of drainage amount Bowel Movement Continent Incontinent last BM Color Size Consistency Ostomy Stool
Nutrition
Diet___________ % eaten Breakfast____ Lunch_____ NPO? Why___________ Self feed Needs assistance Thickened liquids: honey nectar pudding Tube Feed_________________
Urine Continent^ Incontinent^ Catheter type _______________^ Patent^ Nonpatent________________ Color_________________ Clear Cloudy Sediment Burning Frequency
Intake and Output PO/Oral/Tube Feed intake____________^ IV intake____________^ Urine output_________^ Other output Fluid restriction Total I&O + /- ________________ Genitalia Male Female vaginal discharge LMP post partum
Mobility ADLs independent or assisted with _________________________________________________ Muscle treatment None Cast Brace Splint Location Elevate Traction - type traction wt:
CMST Circulation: color, pulses, cap refill^ Motion^ Sensation^ Temperature RA LA RL LL Antiembolitic Hose:knee/thigh Contractures Not present Present – which extremity? What % decreased? Amputation No Yes Location _______________________________ ROM AROM AAROM PROM CPM Limited location___________________
Mobility
Turns self Sits independently Dangles Stands independently Walks independently Ambulatory assistance: Gait belt Cane Walker Crutches Braces Wheelchair Gerichair Walks: distance frequency tolerance PT OT RNA Risk for Falls Bed alarm Chair alarm 1 or 2 Person Transfer Floor pad Side Rails Mechanical Lift Slide Board
Appearance
Intact Color___________ Pallor Rash Bruise Lesions Scar Location _________________________ Turgor_____seconds Site___________ Skin Warm Hot Cool Cold Dry Moist Wound Dressing
Pressure Ulcers
None Surgical site – Location Well approximated Sutures Staples Steristrips Dressing: Dry/intact Non-intact Change: yes no Drainage: Color Amount___________ Odor_________ Wound appearance Drain type _________ Amount______ Stage Location Size Tunneling Eschar Slough Stage Location Size Tunneling Eschar Slough Stage Location Size Tunneling Eschar Slough
Type Culture Site Type Culture Site
Behavior Cooperative Uncooperative Pleasant Withdrawn Combative Other_______________
Restraints
None Chemical Physical: type location CMST of extremity RA LA RL LL Frequency Checked________________ See Restraint Form Language spoken English = speaks and understands other_________________ Interpreter
STUDENT(printed) __________________________________________________ Date _________ Client initials ________ Room Number _______ NANDA DX ____________________________________________________________________________________________________________
Medical DX_____________________________________________________________________________________________________________