please fill out entire template that I will provide. I will also provide some basic patient info. You will have to create and make the rest of it on your own. thank you.
Course: NURS 121L-A
PATIENT PROFILE DATABASE
Date: ____________________________________________________________________________________
Student Name:
Faculty Name:
1. ADMISSION INFORMATION
Date of
Pt. Name: Admission
Care:
Date:
Age
:
Reason for
Hospitalization/Chief
Complaint (in pt’s own
words):
Surgical
Procedures/Date:
Admitting Medical
Diagnosis:
History of Present
Illness:
Gender:
Growth and
Development
(Erikson):
Ethnicit
y:
Occupa
tion:
Spiritual Beliefs:
Medical Diagnoses History: (Present and past diagnoses, Physician’s
History and Physical notes in the chart, nursing intake assessment,
with length of history if possible)
ADVANCE DIRECTIVES (Nursing Admission Assessment):
Durable Power of Attorney:
☐ Yes
Code status : ☐ Full Code ☐
Living Will: ☐ Yes ☐ No
DNR (Do Not Resuscitate)
☐ No
2. MEDICATIONS
ALLERGIES:
Drug
Classificatio Dosage
Route
Frequency Purpose
Nursing
n
(time due)
Considerations
3. LABORATORY DATA
Test
Norms
WBC
Hemoglobin
Hematocrit
Page 1 of 7
On
admission
Current value
Test
Sodium
Potassium
Calcium
Norms
On
admissi
on
Current value
Course: NURS 121L-A
PATIENT PROFILE DATABASE
Platelets
PT
INR
aPTT
HA1c
BNP
BUN
Creatinine
Magnesium
Blood Glucose
Urinalysis
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
☐Rectal
Pulse______
☐Apical _______ ☐Radial
Respiratory Rate______ ☐Even/regular ☐Labored/SOB ☐Dyspnea
on Exertion
BP ______/_______
☐Supine ☐Sitting ☐Standing
5. NEUROLOGICAL/SENSORY
Orientation: ☐Time ☐Place ☐Person ☐Purpose
Admission weight:___________
Yesterday’s weight___________
Today’s weight______________
Height__________
Sensation: ☐Normal ☐Impaired ☐Absent
Pain: Grade ____ /10 Scale used: ☐0-10 Numeric ☐FLACC ☐ Wong-Baker
FACES
Pain Location:_______________
Character: ☐ Sharp ☐Dull ☐Ache ☐Heavy ☐Pinprick ☐Cramp ☐
Other______________
What makes the pain
worse:_______________
______________________________
_________
What makes the pain
better:________________
______________________________
_____
Level of Consciousness: ☐Alert ☐Lethargic ☐Obtunded ☐Stuporous ☐Semicomatose ☐Coma
Coordination: ☐Symmetrical ☐Asymmetrical ☐Unsteady
Strength: ____Right arm _____Left arm _____Right leg
_____Left leg
0=No movement
1=Trace movement
2=Moving, not against gravity
3=Moving against gravity, not against resistance
4=Moving against gravity, some resistance
5=Full power
PERRLA : #____mm
Nystagmus
☐Brisk ☐Sluggish ☐Fixed ☐
12 3 4 5 6 7
8mm
Glascow Coma Scale:
Total of all 3
columns__________
Eyes
Motor
Verbal
4=Open
6=Obeys
5=Oriented
spontaneously command
4=Confused
3=To speech
5=Localizes pain 3=Inappropriate
2=To pain
4=Withdraws
words
1=None
3=Flexion
2=Incomprehen
2=Extension
sible words
1=None
1=None
Total_______
Total______
Total________
Page 2 of 7
Course: NURS 121L-A
PATIENT PROFILE DATABASE
Touch: ☐Normal ☐
Smell: ☐Normal ☐Decreased
Hearing: ☐Normal ☐Tinnitus ☐HOH ☐Hearing Aid
Decreased
☐Deaf
Vision: ☐Normal ☐Glasses ☐Contacts ☐Cataracts ☐Glasses ☐Glaucoma ☐Blurred vision ☐ Diplopia
Neurosensory comments:
Nursing Diagnosis:
6. CIRCULATORY/CARDIOVASCULAR
Color: ☐ Pink ☐Pale ☐ Jaundice ☐Flushed ☐Cyanotic ☐
Mottled ☐Dusky
Skin:☐ Dry ☐Moist ☐Clammy ☐Warm ☐Cold ☐Hot
Capillary refill: ☐ 3 seconds
Tele monitored
rhythm:________________________________
Heart Sounds: ☐S1 ☐S2 Rhythm: ☐Regular ☐
Irregular
Implanted Pacemaker: ☐ Yes ☐No
Peripheral Edema: ☐None ☐+1 ☐+2 ☐+3 ☐+4
☐Pitting ☐Non-pitting
Location:__________________________________________
___
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
☐Wheezes
Location:☐ Throughout ☐RUL ☐RML ☐RLL ☐LUL ☐LLL
Sputum: ☐White/Clear ☐Tan ☐Yellow ☐Green ☐Rusty ☐
Pink ☐Red
Cough: ☐None ☐Nonproductive ☐Productive ☐Suctioning
required
Secretions: ☐Yes ☐No Consistency: ☐Frothy ☐Thick ☐
Thin
Suctioning Method: ☐Oral ☐Nasotracheal ☐ETT ☐Trach
☐Bulb
Respiratory Comments:
Nursing Diagnosis:
Page 3 of 7
Pattern: ☐Regular ☐Irregular
Character: ☐Full ☐Shallow ☐Deep ☐Labored ☐
SOB
Amount: ☐Small ☐Moderate ☐Large
Pulse Oximeter: ______%
Oxygen: ☐Room air
O2 ____L/min. or
_____%
Mode: ☐N/C ☐Mask ☐Trach
O2
ABGs: pH_____ pO2________ pCO2_______ HCO3___________
Course: NURS 121L-A
PATIENT PROFILE DATABASE
8. NUTRITION/HYDRATION
Diet: ☐NPO ☐Regular ☐Cl. Liquid ☐Full liquid ☐Soft ☐
Pureed
☐Other____________________
Feeding Method: ☐Self ☐Assisted ☐NG ☐G-Tube ☐JTube
Parenteral Nutrition: ☐TPN ☐PPN
Tube Feeding Formula:_____________
Rate:________mL/hr.
Residual: ☐No ☐Yes Amt.______mL.
Weight: ☐Gain______# lbs/kg
☐Loss______# lbs/kg
☐No change
Intake:
Output:
PO______
Urine_____
IV______
NG_______
NG______
Emesis________
Blood_______
Stool________
Other_______
Drains________
Other________
24 hour
24 hour total_________
total_________
Nutrition/Hydration comments:
Aspiration Risk: ☐Yes ☐No
Nausea: ☐Yes ☐No
Vomiting: ☐Yes ☐No
Flatus: ☐Yes ☐No
Mucous Membranes: ☐Dry ☐Moist
Skin Turgor: ☐No problem ☐Tenting ☐Taut
24 hour net I/O: +/-_____
Nursing Diagnosis:
9. GI/FECAL ELIMINATION
Bowel Sounds:☐Absent ☐Hypoactive ☐Active ☐
Hyperactive
Abdomen: ☐Soft ☐Flat ☐Distended ☐Round ☐Firm ☐
Tender ☐Flatus
Last BM: _______Stool: ☐Formed ☐Soft ☐Hard ☐
Liquid #_______
Fecal Elimination Comments:
Location: ☐RUQ ☐RLQ ☐ LUQ ☐LLQ ☐ Throughout
Ostomy: ☐No ☐Yes
Incontinence: ☐Yes
Type:______
☐No
Color: ☐Brown ☐Black/Tarry ☐Clay/Gray ☐Yellow
☐Green
Nursing Diagnosis:
10. GU/URINARY ELIMINATION
Urine: ☐Clear ☐Cloudy ☐Sediment
Color: ☐Straw ☐Yellow ☐Amber ☐Pink ☐Red
Last void: time____________
Catheter: ☐None ☐In/Out ☐Condom ☐Foley ☐
Suprapubic
Insertion date:_________________
Page 4 of 7
amount
mL
Course: NURS 121L-A
PATIENT PROFILE DATABASE
Symptoms: Frequency: ☐ Urgency: ☐
Dysuria: ☐
Nocturia: ☐
Incontinence: ☐Yes ☐No
Urinary Elimination Comments:
Nursing Diagnosis:
11. REST AND EXERCISE
Activity: ☐ Bed rest ☐BSC ☐BRP ☐ Chair ☐
Ambulate
Functional level: ☐Independent ☐Dependent ☐
Assistance
ROM: ☐Active ☐Passive ☐Assistive ☐Limited ☐Full
Mobility Aids: ☐Cane ☐W/C ☐Crutches ☐Walker
Gait: ☐Steady ☐Unsteady ☐Unable to ambulate
Sleep Patterns: ☐Uninterrupted ☐Interrupted ☐
Insomnia
☐Day time sleepiness
# hrs
sleep/night__________
Restraints: Type_________________
Location_______________
Cast/Brace/Traction: Type___________
Location_______________
Rest and Exercise Comments:
Nursing Diagnosis:
MORSE FALL SCALE/RISK SCREENING
History of Falls within last
12 months
Secondary Diagnosis
Ambulatory Aids
IV or IV access
Gait
Mental Status
Variables
No
Yes
No
Yes
None/bedrest/nurse assist
Crutches/cane/walker
Furniture
No
Yes
Normal/bedrest/wheelchair
Weak
Impaired
Know own limits
Overestimates or forgets limits
Total
Rest and Exercise Comments:
Nursing Diagnosis:
Page 5 of 7
Score
0
25
0
15
0
15
30
0
20
0
10
20
0
15
To obtain the Morse Fall Score add the
score from each category.
Morse Fall Score
☐ High Risk 45 and higher
☐ Moderate Risk 25-44
☐ Low Risk 0-24
Course: NURS 121L-A
PATIENT PROFILE DATABASE
12. SKIN INTEGRITY/INTEGUMENTARY
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:
Sensory
Moisture
Activity
1. Completely limited
1. Constantly moist
1. Bedfast
Mobility
1. Completely
immobile
1. Very poor
1. Problem
S
B
E
F
Pe
P
O
Surgical site
M
Burn
R
Ecchymosis
D
Fracture/Cast
N
Petechaie
G
Pressure ulcer & stage _______________
Other ____________________________
I
IV Site
Patent
Swollen
Red
Infiltrated
Edema
Rash
Dressing
Inflammation
Gangrene/Necrosis
A Drains
None
Penrose
Hemovac
JP
Braden Scale
2. Very limited
2. Very moist
2. Chairfast
3. Slightly limited
3. Occasionally moist
3. Walks occasionally
Score
2. Very limited
3. Slightly limited
4. No Impairment
4. Rarely moist
4. Walks
frequently
4. No limitations
Nutrition
2. Probably inadequate 3. Adequate
4. Excellent
Friction and
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: _______
Page 6 of 7
Course: NURS 121L-A
PATIENT PROFILE DATABASE
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 ☐
Psychiatric history
Recreational drug use: ☐ Drug
long____
How much____ How
Alcohol use: ☐ How often_____ How
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
Impediment ☐Intubated ☐ Trached
Psychosocial Comments:
Support System: ☐Yes ☐No
Living Situation: ___________________________________
Nursing Diagnosis:
Narrative Charting:
Page 7 of 7
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