BERGEN
COMMUNITY COLLEGE
DEPARTMENT OF
NURSING
Subjective Data (Basic
Conditioning Factors)
Student: Date of Care:
Patient’s Initials: Age:
Room #: Allergies:
Food:
Gender: Medications:
Environmental:
Admitting Diagnosis:
Secondary Diagnosis:
Developmental Stage (Erickson and Havinghurst, see Perry
and Potter):
(List Developmental stage and tasks, assess each task)
History of present illness:
Past medical history (Include Date):
Past surgical history (Include Date):
Medications:
Drug Name Dose Route Frequency Classification
Complementary/Alternative Medical Practices
Herbal Remedies:
Vitamins/Minerals:
Meditation/Yoga
Massage:
Acupuncture/Acupressure:
Aromatherapy:
Other:
Health care system (Current orders and role of health
care members):
Sociocultural / spiritual orientation:
Family system:
Patterns of Living:
A. Employment:
B. Education:
C. Hobbies / interest:
D. ETOH / drug use
Environment (Conditions of living and working):
Available Resources (Economic, personal, agencies):
Laboratory and Diagnostic Test (give results and
significance of abnormals)
Please use Y, N, NA to indicate Yes, No or Not
Applicable
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Day 1 |
Day 2 |
Additional Data |
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Psychosocial |
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Well groomed/Good hygiene |
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Appropriate/Full range affect |
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Maintains eye contact |
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Calm mood |
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Cooperative attitude |
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Able to concentrate |
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Clear speech (volume/tone) |
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Psychomotor retardation |
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Tics/Tremors |
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Hyperactivity/Restlessness/Agitation |
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Hallucinations/Illusions |
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Suicidal/Homicidal Ideations |
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Activity/Rest |
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Well-rested |
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Fatigued |
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Slept through night |
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Neuromuscular |
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Alert and oriented |
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Gait steady |
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Hygiene independent |
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Pain free |
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Hand grasp, |
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Foot push, |
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Smile symmetrical |
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Tongue to midline |
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PERL |
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Meets developmental task |
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Cardiovascular
(air or water)
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Palpable pedal pulses bilaterally |
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Oral mucosa pink |
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Conjunctiva pink |
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Capillary refill within 2 seconds |
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Absence of edema |
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Apical/radial regular rhythm |
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Rate= |
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Blood pressure |
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BP= |
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Telemetry |
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Integument
(prevention of hazards) |
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Temperature |
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Temp= |
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Skin turgor WNL |
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Skin warm to palpation |
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Skin intact |
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Incisions |
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Wounds |
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Day 1 |
Day 2 |
Additional Data |
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Respiratory |
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Resps easy and even |
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Lungs clear |
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Secretions |
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Oxygen in use |
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Oxygen saturation |
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Cough and deep breathe |
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Chest tubes |
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Gastrointestinal |
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Abdomen soft |
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Abdomen non-distended |
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Bowel sounds present |
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Abdominal drains |
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Stomach tubes |
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Bowel movement |
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Nausea/vomiting |
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Feeds self |
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Breakfast (% consumed) |
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Lunch (% consumed) |
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Dinner (% consumed) |
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Tube feeding |
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IV solution (type and rate) |
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IV site (location) |
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IV site without redness or swelling |
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IV dressing dry and intact |
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Chemstick |
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Genitourinary(Fluid
or Elimination) |
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Voids in bedpan or bathroom |
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Foley catheter |
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Suprapubic tube |
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Urine clear |
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Color yellow-amber |
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Amount (cc's) |
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Continuous bladder irrigation |
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Lab Data (explain
abnormal values)
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RANGE |
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WBC: |
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4.5 |
- |
11.0 |
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HGB: |
Men |
14.7 |
- |
16.1 |
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Women |
12.0 |
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16.0 |
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HCT: |
Men |
42.0 |
- |
52.0 |
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Women |
37.0 |
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47.0 |
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Platelet |
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150.0 |
- |
450.0 |
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Glucose |
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70.0 |
- |
110.0 |
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Sodium |
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135.0 |
- |
145.0 |
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Chloride |
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95.0 |
- |
110.0 |
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Potassium |
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3.5 |
- |
5.1 |
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Calcium |
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8.4 |
- |
10.2 |
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Albumin |
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3.4 |
- |
5.0 |
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BUN: |
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7.0 |
- |
20.0 |
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CR: |
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- |
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PT: |
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- |
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PTT: INR: |
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- |
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__________________________________________________ |
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CK: |
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- |
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Troponin ___________________________________
NURSING DIAGNOSIS (USE P
(problem).E (etiology).S (symptoms).FORMAT):
P:
E:
S:
INTERVENTION #1:
INTERVENTION #2
INTERVENTION #3
OR
NURSING DIAGNOSIS IN EACH
AREA BASED ON PATIENT ASSESSMENT:
NEUROMUSCULAR (prevention of
hazards):
CARDIOVASCULAR (air or water):
INTEGUMENT (prevention of
hazards):
RESPIRATORY (air):
GASTROINTESTINAL (food or elimination):
GENITOURINARY (fluid or elimination):