7/17/2019 N126 Student Worksheet

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Nursing 126 Student Worksheet HAIR  

  oily

  normal

 

dry

  any recent hair loss

 

style hair special

NAILS  

unusual nail breakage

   blanching

SKIN 

  normal

 

dry

  oily

  use any special lotions

 

how often do you shower

 

scars

NEUROLOGICAL    blackouts/fainting

  seizures

 

headaches

  loss of memory

 

mood swings

 

hallucinations

  weakness

 

numbness/tingling

  tremors

  loss of coordination

 

difficulty speaking

SIGHT 

 

glasses/contacts (how long_____)

   blurry vision

 

loss of vision

  swelling/redness

  drainage

 

double vision (diplopia)

HEARING 

 

hearing aid(s) (how long______)

  earaches

 

drainage 

loss of hearing

TASTE, TOUCH & SMELL 

  change in sense of taste

 

loss of ability to taste

  any problems with sense of touch

  change of feeling in hands or feet

 

change in sense of smell

RESPIRATORY 

  changes in breathing

  shortness of breath (dyspnea)

 

wheezing

  coughing anything up (color_________)

 

 painful breathing

  activities that cause shortness of breath

 

number of pillows used at night (orthopnea)

CARDIOVASCULAR  

  chest pain

 

swelling in hands or feet (edema)

  shortness of breath when lying flat

   palpitations/fluttering

 

cold hands or feet

 

change in color of hands or feet

GASTROINTESTINAL 

 

dentures/partials

  trouble chewing

 

sores in mouth

 

trouble swallowing

  sore throat

 

loss of appetite

  vomiting, nausea

  heartburn

 

indigestion

 

abdominal pain   problems with bowel movements

 

constipation

  use laxative/enemas

 

diarrhea

   pain or itching around rectum

  water

 

coffee B decaf/caffeinated

  tea B decaf/caffeinated

  soft drinks B  sugar-free/decaffeinated

 

fruit juices

  alcohol

BEHAVIOR  

  anxiety

 

irritability

 

depression

  sleep disturbances

7/17/2019 N126 Student Worksheet

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HEMATOLOGY

  anemic (low hemaglobin)

 

 bruise easily

  unusual bleeding

   blood transfusion in past

 

any lymph node swelling

GENITOURINARY

 

how often do you urinate

 

do you urinate during the night (nocturia)

 

cloudy or dark urine

   blood in urine (hematuria)

   painful urination

 

diminished urination

  excessive urination

ENDOCRINE

  diabetes

  thyroid problems

 

temperature changes

  excessive thirst

 

excessive hunger

 

excessive sweating

   problems with breast/nipples

 

 breast tenderness

  lumps

  last breast exam

 

self exam

MUSCULO/SKELETAL

 

 joint pain

   joint stiffness

 

 joint weakness 

muscle pain or cramps (claudication)

   back pain/stiffness

 

neck pain

Client initials:

Age:

Sex

Birth date:

Date of admission:

Initial impressions

G:Nsg\pkts\N120-126-clinicalWord-NsgStudWkst.2013

What brings you to the hospital?

What has the physician said about your condition?

Do you have any chronic/recurring diseases?

Have you had any surgeries in the past? Dates?

Do you have any allergies?

Latex-food - medications - environmental

Do you take any medication at home?

What do you do to stay healthy?

How do you cope with stress?

Do you smoke?

What are your health goals?

Rank your own health, good, fair, bad. (1-10)

How do you feel about being in the hospital?

What is most important to you at the moment?

Have you experienced any life changes, eg., births,

deaths, retirement: How have they affected you?

Place of residence (home, apt.)

Is your home environment safe:

 Number of children and their ages

Who do you turn to in time of need?

Race National origin

Religion Occupation

Education Insurance

Financial concerns Marital status

Sexuality Role in family

BP T P R Ht Wt

Hgb Hct WBC Platelet I/O

 Na K C1 CO2 BUN Pro/al

CR U/A Blood sugar Chest X-ray EKG

ABGs