University:
West Coast University
Course:
NURS 103 | Fundamentals of Nursing
Academic year:

2022
Views:

381

Pages:

1
Author:

Edgar Rowe

Start of Care Cheat Sheet Name: Medicare/Advantage PMH: DOB: Authorized Visits: Date: From: Community/Hospital/SNF Following MD/DO: Phone Disciplines Needed: PT/OT/ST/SN/MSW, Aide Diabetes, PAD, or PVD? Temp: Resp: Height: Weight: BP: Vitals: Pulse: Shingles: PNA: Flu: TB: Vaccines: MPOA/Surrogate: DNR/CPR: Posted? Y/N Advanced Directives: Living Will: Limitations: Amputation Dyspnea Paralysis Contracture Legally Blind Incontinent Hearing Endurance Spe Lives: Alone w/Someone ALF Assistance Available: Around Clock Day Night Short Term None Community/Social Screening: Needs resources Sadness Suicidal Suspected Abuse/Neglect For: MSW Needed Home Safety: Stairs No running water Inadequate lighting, heat, or cool narrow or obstructed walkways insects/rodents no fire safety device cluttered/soiled Other: O2 Safety Y/N: NA No Smoking Signs Smoke inside Smoke Detectors Fire Extinguisher Safe Cylinder Storage Cords Intact Evacuation Plan Cleaning Fluids No petroleum products Only water-based lip moisturizers Sensory: Eyes/Vision: Ears: Nose: Pain: Wounds: Lungs: SOB Supplemental O2 O2 Sat Cough Diabetes: Insulin pt/cg draw dose/administer Other Endocrine: Polyuria Cardiac: Chest Pain Polydipsia Dizziness Edema oral hypoglycemic pt/cg indep with glucometer inspect feet Polyphagia Neuropathy Radiculopathy Heart Sounds Peripheral Pulses Cap Refill <3 >3 Urinary: Incontinence Distention Burning Frequency Dysuria Retention Cloudy Odorous Sediment Hematuria Genitalia: Bowels: Incontinent Freq Ostomy Dialysis Hemo Graft/Fistula Site: Nutrition: Dysphagia Decreased Appetite Weight Loss/Gain: Urgency Urostomy CVC Site: Diet: Adequate Y/N Problems: Throat Dental Blood Sugar: Thyroid Problems Pacemaker AIC Catheter Last Changed: Peritoneal Signs of infection Dentures Chewing Other: Neuro: Oriented: Person Place Time Disoriented Forgetful PERRL Seizures Tremors Psychosocial: Poor Environment Poor Coping Agitated Depressed Impaired Decision-Making Anxiety Inappropriate Behavior Irritabilit PHQ-2: Last two weeks, how often bothered by these (# of days)? Little interest or pleasure in doing things Feeling Down, depressed, or hopeless ADL/IADLs: Activities Permitted: Bed Rest Cane Partial Weight Bearing Up as tolerated Walker Crutches Exercise Prescribed Wheelchair Indep at Home Transfer bed<>chair Other: Musculoskeletal: WNL Weakness Amb Difficulty Limited Mobility/ROM Joint Pain/Stiffness Poor Balance Grip Strength R L Bed Bound Chair Bound Contracture Paralysis Assistive Device/s: ADLs: Indep/Setup/Assist/Dep/Device Grooming Dress upper Dress Lower Bathing Toilet Transfer Toilet Hygiene Transfers Amb Eating GG Scoring: 6 – Indep 5 – Setup 4 - Sup/touch 3 – Partial/Mod 2 – Substantial/Max 1 – Dep 7 – Refused 9 – NA 10/88 - No attempt enviro/safety GG Questions: Self Care Eating Oral Hygiene Shower Self Dress Upper Dress Lower Don/Doff Footwear Mobility Roll Sit>Lying Lying>Sit Sit>Stand Chair<>Bed Toilet Transfer Car Transfer Walk 10 50 (+2 turns) Steps 1 4 12 Pick up object WC Assist 50 150 (+2 turns) Medications: Drug Issues: IV Access Y/N Oral: indep/setup/reminder/unable/NA Injecta ble: indep/setup/reminder/unable/NA Additional Notes: Freq/Duration: VO: Next Physician Visit: