Date: __________ Room#: ________ Pulse Rate: _____bpm Pain: Yes  No 

Patient: ________ Gender: M  F  Body Temp.: ________ (Norm. 60-100 bpm)

1 2 3 4 5 6 7 8 9 10
D.O.B.: ________ Age: __________ (Norm. Range 96.8-100.4) Rhythm: Reg.  Irreg. 
Location: ________________
Site: _______________ Quality: Bounding 
Height: ________ Weight: ________ Description: ______________

5 VITAL SIGNS
Strong 
Date Admitted: ____________________ F= 1.8 (C) + 32 Thready  Constant? Yes  No 
Diagnosis: ________________________ C= F – 32/1.8 Weak  Radiating? Yes  No 
_________________________________ All present? ___________ Pain Since: _______________
Weak/Strong Bilaterally?
Allergies: _________________________
_________________________________ Respiration Rate: _____ Blood Pressure: ________
_________________________________ (Norm. 12-20 resp./min) Norm.  120/80
_________________________________ Depth: Shallow  Deep  Prehyp. 120-139/80-89
Rhythm: Reg.  Irreg.  Hyp. I 140-159/90-99
Pulse Ox %:______________ Hyp. II 160/100

Responsiveness
____________________________________________________________________________________
Alert  Awake  Responsive  Non-responsive  ________________________________________________________________________________________________
Is Client Oriented?: Name  Location  Date  ________________________________________________________________________________________________
NEUROLOGICAL

Sensory Perception Musculoskeletal

Speech Clear  Unclear  Preferred Language? ______________________ Movement in all Extremities? Yes  No  Equal Movement? Yes  No 
Literate  Illiterate  Eyeglasses?  Contacts?  ________________ ___________________________________________________________________
Eye Discharge? _______________________________________ PERRLA  ___________________________________________________________________
Ears Aligned? Yes  No  Hearing  Hard of Hearing (HOH)  ___________________________________________________________________
Hearing Apparatus? ___________________________________________________ Ambulates: With Assistance?  Without Assistance?  Devices: _____________
Discharge from Ears? Yes  No  Color/Amount: ________________________ Gait: Steady?  Unsteady? 
Sensitivity to Touch? Temperature? ______________________________________ Strength in all 4 Extremities: Equal?  Unequal?  ________________________
___________________________________________________________________ ADLs: _____________________________________________________________
___________________________________________________________________ ___________________________________________________________________
CIRCULATORY

Skin Nails: Intact  Cracked  Uneven 

Color: Brown  Tan  Olive  Pink  Jaundiced  Cyanotic  Pale  Ecchymotic  Bruised  Capillary Refill: Rapid  Slow 
Turgor: Elastic  Non-elastic  Temperature: Cold  Clammy  Warm  Hot  Diaphoretic  Dry  ________________________________________
Integrity: Open Area? Yes  No  Where?________________________ How big? ________cm ________________________________________
Edema? No  Non-pitting  Pitting +1 +2 +3 +4
Mucous Membranes of Lips, Gums, & Tongue: Pink  Cyanotic  Dry  Moist 
____________________________________________________________________________________________
____________________________________________________________________________________________
Hair: Clean  Dry  Brittle  Intact 
____________________________________________________________________________________________ ________________________________________
____________________________________________________________________________________________ ________________________________________
Intravenous
Solution: _____________________________________ Flow Rate: _____________________ Pump  Gravity 
Site: _________________________________________ Dry & Intact  Pale  Inflamed  Swollen  Red  Cool  Painful 
_____________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________
RESPIRATION

Oxygen Therapy Cough Breath Sounds

Cough Present? Yes  No  Present  Or Absent  In both lungs? Symmetrical? 
Equipment: ____________________________ Occasional  Frequent  Clear  Unclear  Labored  Unlabored 
______________________________________ Productive  Non-productive  _____________________________________________
______________________________________ Sputum Color: _________________ _____________________________________________
Amount of O2: ______________________ Amount: _______________ _____________________________________________
Pulse Ox. %: _____________ Thick  Thin  Frothy  _____________________________________________
GASTROINTESTINAL

Diet ________________________________________________________________________
Breakfast % Fluid mL: _______
_________________________________________________________________________
Height: ____________ _________________________________________________________________________
Weight: ____________ Lunch % Fluid mL: _______ _________________________________________________________________________
BMI: ______________ _________________________________________________________________________
Dinner % Fluid mL: _______ Nauseated?  Vomit?  Amount/Description: _______________________________
_________________________________________________________________________
Oral Cavity Teeth Present  Absent  Condition? _____________________ Dentures Partial  Full  Implants  Condition? ________________________
Bowel Abdomen
Frequency: _________________________ Bowel Sounds in All 4 Quadrants? Yes  No 
Amount: ___________________________ If not, where are they present/absent?
Color: _____________________________
Consistency: Hard  Formed  Liquid 
________________________
Foul Smelling? Yes  No 
Colostomy  Ileostomy  Other 
Is device intact? Yes  No 
Describe stoma: ________________________________________________________ Soft  Firm 
Drainage: _____________________________________________________________ Distended  Non-distended 
Tender  Non-tender 
Drainage Devices Nasogastric  Gastric Tubes 
Feeding Tube Type of Tube: _____________________________ Type of Feeding: ______________________________________
Strength of Solution: ________________________ Pump: _______________________________________________
mL/hour: _________________________________ Site Condition: ________________________________________
 GENITOURINARY
Elimination Drainage Devices
Color: Yellow  Amber  Pink  Red  Other: ___________________________ Foley Catheter  Ileal Conduit  Other: _________________________________
Amount: ________________mL Is Device Intact? Yes  No 
Odor: Ammonia  Strong  Foul  Other: _______________________ Describe Stoma: _____________________________________________________
Frequency: _________________________________________________ Describe Drainage: ___________________________________________________
Problems with Urination? ______________________________________ ___________________________________________________________________
Perineal Area Sexual Concerns
Area Intact? Yes  No  _____________________________________ Sexual Problems r/t Med Condition: _____________________________________
Any Drainage? Yes  No  Patient Questions Regarding Intimate Relationships: ________________________
Describe Drainage: ___________________________________________ ___________________________________________________________________
___________________________________________________________________
WOUNDS/DRESSINGS

Wound/Incision Site Tubes/Drains

Size: ________cm Type of Tube: ____________________________________
Tissue color: Red  Pink  Black  Other: __________ Site: ____________________________________________
Drainage? Yes  No  Collection Device: _________________________________
Describe Drainage: Serous=Yellow  Describe Drainage: ___________________________________________________
Serosanguinous=Pink  Tube Attached to Suction? Yes  No 
Sanguinous=Red/Bloody  Suction Operating Correctly? Yes  No 
Odor? Pungent  Foul  No Odor  Wound Vac? Yes  No 
Dressings
Dry & Intact? Yes  No  Any Action Taken? __________________________________________________________________________________________________
Document Drainage on Dressing: ________________________________________________________________________________________________________________
PSYCHOLOSOCIAL

Psychological
Maslow’s Stage: _______________________________________ Erikson’s Stage:
Trust vs. Mistrust  Autonomy vs. Shame & Doubt 
Explanation: ____________________ Initiative vs. Guilt  Industry vs. Inferiority 
Identity vs. Role Confusion  Intimacy vs. Isolation 
Generativity vs. Stagnation  Integrity vs. Despair 

Explanation: ________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Emotional
Describe Patient’s Behavior & Mood: ____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________\
___________________________________________________________________________________________________________________________________________
Support System
People: ____________________________________________________________________________________________________________________
Organizations: _______________________________________________________________________________________________________________________________
Etc.: _______________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Patterns of Coping ___________________________________________ _________________________________________________
___________________________________________ _________________________________________________
___________________________________________ _________________________________________________

Defense Mechanisms Culture

Describe Client Behaviors/Statements: _______________ Cultural Group: ______________________________________________________
Denial  ______________________________________________ Race: ____________________ Ethnic Origin: __________________________
Displacement  ______________________________________________ Childhood: __________________________________________________________
Projection  ______________________________________________ Home Life: _________________________________________________________
Rationalization  ______________________________________________ Work: ______________________________________________________________
Rxn Formation  ______________________________________________ Education: __________________________________________________________
Regression  ______________________________________________ Impact of Culture on Health: ____________________________________________
___________________________________________________________________
Repression  ______________________________________________
___________________________________________________________________
Sublimation  ______________________________________________
Needs or Problems/Interventions: ________________________________________
Suppression  ______________________________________________ ___________________________________________________________________
___________________________________________________________________
Spiritual/Religion Socioeconomic
Affiliation: __________________________ Type of medical/health insurance? _______________________________________
Relationship b/t beliefs and illness? ______________________________________ Financial Concerns? __________________________________________________
Needs or Problems/Interventions: ________________________________________ Can client safely return home? Yes  No  ______________________________
___________________________________________________________________ ___________________________________________________________________
___________________________________________________________________ Needs or Problems/Interventions: ________________________________________
___________________________________________________________________ ___________________________________________________________________
___________________________________________________________________

ADDITIONAL NOTES: _____________________________________________________________________________________________________________

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