Totoe Medical Services Nurse's Patient Assessment

Totoe Medical Services Nurse's Patient Assessment

This form needs to be done in the morning at the start of work and in the evening before close of work
Patient's Name*

First NameLast Name
Nurse's Name*

First NameLast Name
Employee Personal Email:*
example@example.com
Nurse:*

Registered Nurse (RN)Licensed Practical Nurse (LPN)Nursing Assistant
Date*

MonthDayYear
Date
Time*

:HourMinutesAM/PM Option
Next MD visit:*
Supplies in Home:*

Hospital BedLiftGlucometerBP kitPulse oximeterOther
Overnight events from family and family Concerns
Overnight events from patient and patient concerns
Vital Signs
Blood Pressure*
BP arm*

LeftRight
Temp*
Temp Location*

OralAxillaryRectalOther
Oxygen saturation %
Resp Rate*
Pulse*
Pulse Location*

RadialApicalOther
Height *
Weight (lbs)*
Blood Sugar*
Albumin Level ( check most recent Liver function test)*
food allergies and Medication allergies *
Mental Status*

AlertOrientedConfusedDisorientedAnxiousForgetfulDepressedLethargicEyes OpenLooks ForwardOther
Sleep habits*

Sleeps wellInsomniaUp FrequentlyNapsRestlessOther
Gait*

SlowUnsteadyAssist neededUnable to Assess / Bed BoundOther
Assistive Devices*

WheelchairWalkerHospital BedMechanical LiftOther
Respirations*

RegularIrregularDeepShallowRetractionsTachypnicDyspneaNasal FlaringGruntingOther
Lung Sounds*

ClearRalesRhonchiDiminishedWheezingCoarseOther
Oxygen Requirements*

Room AirO2 in useNasal CannulaTrach02 MaskNebulizersOther
Skin / Integumentary*

PinkPaleCyanosisWarmDryCoolMoistElasticScalyRednessAbrasionsRashBruisingJaundiceOther
Infection Control*

Standard PrecautionsContact PrecautionsAirborne PrecautionsHand WashingGlovesGownsSterile TechniqueSharps DisposalOther
Cardiovascular*

Regular HRIrregular HRHR WNL (60-100)TachycardiaBradycardiaMurmurStrong pulsesWeak pulsesCap Refill < 3 secCap Refill > 3 secOther
Cough*

ProductiveNon-productiveSputum ClearSputum YellowSputum TanSputum GreenIf Sputum GREEN (check Temp)Other
Abdomen*

FlatRoundDistendedSoftHard/RigidTender to touchPainfulGastric tube in placeOstomy in placeOther
Bowel Sounds (x4 Quad)*

PresentHypoactiveHyperactiveAbsent (call MD?)Other
Bowel Habits*

Bowel ContinentBowel IncontinentWears diaper / briefsDiarrheaFormed stoolConstipatedYellow / Green StoolMalodorous StoolOther
Urinary Habits*

Urinary ContinentUrinary IncontinentStress IncontinentWears diaper / briefsUrinary catheter in placeIn and Out catheter (intermittent)Clear Yellow UrineDark / Amber UrineCloudy UrineConcentrated UrineMalodorous UrineOther
Musculoskeletal*

AmbulatoryNON ambulatoryStrongWeakParesisFull Weight BearingPartial Weight BearingFlaccidCrawlsMAE wellLift requiredOther
Upper Extremeties*

Normal muscle toneFlaccid toneFull ROMLimited ROMContracturesLeft paralysisRight paralysisOther
Lower Extremeties*

Normal muscle toneFlaccid toneFull ROMLimited ROMContracturesLeft ParalysisRight paralysisOther
Treatment Provided:*

AM CarePM CarePeri CareBathOral CareNebulizersCPTStoma careWound CareROMOther
Intake / Diet*

OralEnteralTube Feeding BolusIV NutritionNPOOther
Document and describe in detail food client ate for breakfast, lunch and dinner:*
Skin/Wound Assessment. Upload picture below if applicable:*
List current Medications with Doses and Time administered:*
Additional Assessment Comments:*
Employee Personal Email:*
example@example.com
Nurse Signature*

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Totoe Medical Services Nurse's Patient Assessment

Vital Signs