Course: NURS 101L

PATIENT PROFILE DATABASE

Date: _______

Student Name:

Faculty Name:

1. ADMISSION INFORMATION

Date of Pt. Name: Admission Ag Gend Growth and Ethnicity Occupa Spiritual
Care: Rodney Date: e: er: Development : African tion: Beliefs:
12/7/202 Davis 12/7/2021 54 Male (Erikson): Integrity vs. America Bank N/A
1 Despair n Manage
r

Reason for Surgical Medical Diagnoses History: (Present and past diagnoses,
Hospitalization/Chief Procedures/Date: Physician’s History and Physical notes in the chart, nursing
Complaint (in pt’s N/A intake assessment, with length of history if possible)
own words): Tight
chest / Chest pain / History of blocked arteries, tight chest and the squeezing
Hard to breathe wont go away, dizzy and sick to his stomach,
Hypertension, CAD with Angina, Asthma, Quit smoking a
month ago but chews tobacco occasionally

Admitting Medical History of Present Illness: Tight chest and the squeezing wont go away, dizzy
Diagnosis: and sick to his stomach
Myocardial Infarction

ADVANCE DIRECTIVES (Nursing Admission Assessment):

Code status : (X) Full

Durable Power of Attorney: (X) Yes
Living Will: (X) Yes ☐ No Code ☐ DNR (Do Not
☐ No
Resuscitate)

2. MEDICATIONS ALLERGIES: Penicillin, Peanuts, Sulfa

Drug Classification Dosage Route Frequen Purpose Nursing

cy Considerations
(time
due)
0.9% NS Crystalized 12mL IV Every 8 Hydration Electrolyte
Solution hours Imbalance

0.9% NS Crystalized 250mL IV Continu Maintain arterial Maintain

Solution ous line patency arterial line
using a pressure patency
bag

Albuterol Bronchodilator 2 Puffs Inhaler PRN Treat Difficulty Maintain a

Breathing beta-
adrenergic

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blocker on
standby in
case cardiac
arrhythmias
occur.

0.9% NS Crystalized 1000mL IV For 2 Hydration Electrolyte

Solution at 250 hours Imbalance
ml/hr

Lisinopril ACE Inhibitor 10mg PO Daily at Treat high blood Monitor

0900 pressure patients closely
in any situation
that may lead
to a decrease in
BP secondary to
reduction in
fluid volume

Aspirin NSAID 325mg PO Daily at Anti- Assess pain

0900 Inflammatory and/or pyrexia
one hour before
or after
medication

Clopidogrel Anti Platelet 75mg PO Daily at Anti Platelet Monitor for

0900 Aggregation signs and
symptoms of
bleeding or
signs of
thrombotic
thrombocytope
nic purpura 

Epinephrine alpha- and 0.3mg IM STAT Treat very serious Use extreme
beta-adrenergic allergic reactions  caution when
agonists  calculating and
preparing
doses; epinephr
ine is a very
potent drug;
small errors in
dosage can
cause serious
adverse effects

Morphine Analgesic 0.2mg IV Every 2- Relieve Assess pain

3 min if moderate to levels and
Resp severe pain consciousness
below
10/Min

Naloxone Opoid 0.2mg IV Every 2- Reverse opioid Stay with

Antagonist 3 min if overdose patient and

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Resp assess
below breathing
10/Min

Diphenhydramine antihistamines 25mg IV PRN Relieve itching Administer

every 4 with food if GI
hours upset occurs.

Epinephrine alpha- and 0.3mg IM PRN Treat very Use extreme

beta- Every serious allergic caution when
adrenergic 10-15 reactions  calculating and
agonists  min preparing
doses; epineph
rine is a very
potent drug;
small errors in
dosage can
cause serious
adverse effects

3. LABORATORY DATA

Test Norms On Current Test Norms On Current

admission value admission value

WBC 4.5-11 6,000/mm 6,000/mm Sodium 135-145 140 mEq/L 140

^3 ^3 mEq/L

Hemoglobin 13.5- 15.9 g/dL 15.9 g/dL Potassium 3.6-5.2 3.6 mEq/L 3.6
17.5 mEq/L

Hematocrit 41%-50% 54% 54% Calcium 8.6-10.3 10.2 10.2

mg/dL mg/dL

Platelets 150-450 220,000m 220,000m BUN 7-21 18 mg/dL 18

m^3 m^3 mg/dL

PT 11-12.5 12 12 Creatinine 0.74- 0.8 mg/dL 0.8

seconds 1.35 mg/dL

INR 1.1 0.9 0.9 Magnesium 1.7 to 1.6 mEq/L 1.6

below 2.2 mEq/L
mg/dL

aPTT 30-40 34 34 Blood Glucose Less than 118 mg/dL 118

seconds 140 mg/dL

HA1c 5.7% 7% 7% Urinalysis Pale Pale Pale

below Yellow Yellow Yellow

BNP 125 or 100 100 Cultures None None None

less blood/sputum

DIAGNOSTIC TESTS

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Chest X-ray: No Fluid or EKG: ST-Elevation MI or STEMI Abnormal studies: MI

Pneumothorax , Normal

Abnormal studies: Abnormal studies: Abnormal studies:

4. PHYSIOLOGICAL DATA-VITAL SIGNS

Vital Signs: Temp___99______ oF / oC ☐Axillary (X)Tympanic ☐Oral ☐ Admission

Core ☐Rectal weight:_242lbs_______
Pulse___104___ ☐Apical _______ (X) Radial _
Respiratory Rate__26____ ☐Even/regular (X) Labored/SOB Yesterday’s
☐Dyspnea on Exertion weight___________
BP __100____/___96____ (X) Supine ☐Sitting Today’s
☐Standing weight______________
Height___168cm______
_

5. NEUROLOGICAL/SENSORY

Orientation: (X) Time (X) Place (X) Person (X) Sensation: (X) Normal ☐Impaired
Purpose ☐Absent

Pain: Grade __8__ /10 Scale used: (X) 0-10 Numeric ☐FLACC ☐ What makes the pain
Wong-Baker FACES worse:____Hard breathing
Pain Location:______Chest_________ and activity ___________
Character: (X) Sharp ☐Dull ☐Ache ☐Heavy ☐Pinprick ☐Cramp What makes the pain
☐Other______________ better:___Lying
Still_____________

Level of Consciousness: (X) Alert ☐Lethargic ☐Obtunded ☐Stuporous ☐Semicomatose ☐Coma

Coordination: (X) Symmetrical ☐Asymmetrical PERRLA : #__3__mm (X) Brisk ☐Sluggish

☐Unsteady ☐Fixed ☐Nystagmus

12 3 4 5 6 7 8mm

Strength: __5__Right arm __5___Left arm __5___Right Glascow Coma Scale: Total of all 3
leg ___5__Left leg columns____15______

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Eyes Motor Verbal

0=No movement 4=Open 6=Obeys 5=Orient
1=Trace movement spontaneously command ed
2=Moving, not against gravity 3=To speech 5=Localizes pain 4=Confu
3=Moving against gravity, not against resistance 2=To pain 4=Withdraws sed
4=Moving against gravity, some resistance 1=None 3=Flexion 3=Inapp
5=Full power 2=Extension ropriate
1=None words
2=Incom
Total___4___ prehensi
Total____6____ ble
words
1=None

Total__5
____

Touch: (X) Normal Smell: (X) Normal Hearing: (X) Normal ☐Tinnitus ☐HOH
☐Decreased ☐Decreased ☐Hearing Aid ☐Deaf

Vision: ☐Normal (X) Glasses ☐Contacts ☐Cataracts ☐Glasses ☐Glaucoma ☐Blurred vision ☐
Diplopia

Neurosensory comments: Everything within normal range

Nursing Diagnosis: Acute Pain r/t myocardial injury, ischemia,

6. CIRCULATORY/CARDIOVASCULAR

Color: ☐ Pink (X) Pale ☐ Jaundice ☐Flushed Capillary refill: ☐ <3 seconds (X) >3
☐Cyanotic ☐Mottled ☐Dusky seconds

Skin:☐ Dry (X) Moist ☐Clammy ☐Warm ☐Cold Tele monitored

☐Hot rhythm:___Yes________________________
_____

Peripheral Edema: (X) None ☐+1 ☐+2 ☐+3 ☐+4 Heart Sounds: ☐S1 ☐S2 Rhythm:
☐Pitting ☐Non-pitting ☐Regular (X) Irregular
Location:_______________________________________
______ Implanted Pacemaker: ☐ Yes (X) No

Peripheral pulses:
Right radial (X) Present ☐Absent Left radial (X) Present ☐Absent Right pedal (X) Present
☐Absent Left Pedal (X) Present ☐Absent

Circulatory Comments: Poor circulation due to artery blockage causing pale/cyanotic skin

Nursing Diagnosis: Risk for decreased Cardiac output: Risk factors: alteration in heart rate, rhythm, and
contractility

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7. RESPIRATORY/PULMONARY

Breath Sounds: (X) Clear ☐Diminished ☐Absent ☐

Pattern: ☐Regular ☐Irregular
Crackles ☐ Wheezes
Character: ☐Full ☐Shallow ☐Deep ☐Labored
Location: (X) Throughout ☐RUL ☐RML ☐RLL ☐LUL
(X) SOB
☐LLL

Sputum: (X) White/Clear ☐Tan ☐Yellow ☐Green

Amount: (X) Small ☐Moderate ☐Large
☐Rusty ☐Pink ☐Red

Cough: (X) None ☐Nonproductive ☐Productive Pulse Oximeter: __94____%

☐Suctioning required Oxygen: ☐Room air O2 __2__L/min. or
Secretions: ☐Yes (X) No Consistency: ☐Frothy O2 _____%
☐Thick ☐Thin Mode: ☐N/C (X) Mask ☐Trach

Suctioning Method: (NA) ☐Oral ☐Nasotracheal ABGs: pH__7.35___ pO2____88 mm Hg____ pCO2___40
☐ETT ☐Trach ☐Bulb mm Hg____ HCO3____26 mEq/L_______

Respiratory Comments: Trouble breathing due to the chest pain

Nursing Diagnosis: Risk for decreased Cardiac tissue perfusion: Risk factors: coronary artery spasm,
hypertension, hypotension, hypoxia

8. NUTRITION/HYDRATION

Diet: (X) NPO ☐Regular ☐Cl. Liquid ☐Full liquid Aspiration Risk: ☐Yes (X) No
☐Soft ☐Pureed
☐Other____________________

Feeding Method: ☐Self (X) Assisted ☐NG ☐G-Tube Nausea: ☐Yes (X) No
☐J-Tube Vomiting: ☐Yes (X) No
Parenteral Nutrition: (N/A) ☐TPN ☐PPN Flatus: ☐Yes (X) No

Tube Feeding Formula:____N/A_________ Rate:

mL/hr.
Residual: ☐No ☐Yes Amt.______mL

Weight: ☐Gain______# lbs./kg Mucous Membranes: ☐Dry (X) Moist

☐Loss______# lbs./kg (X) No change
Skin Turgor: (X) No problem ☐Tenting
☐Taut

Intake: Output:
PO__0____ Urine__0___ 24 hour net I/O: +/-_____
IV___0___ NG__0_____
NG__0____ Emesis____0____
Blood___0____ Stool____0____
Other__0_____ Drains___0_____
Other___0_____
24 hour total____Non 24 hour total_____Non at
at Admission_____ Admission____

Nutrition/Hydration comments: Patient is hydrated

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Nursing Diagnosis: Risk for ineffective peripheral Tissue Perfusion: Risk factor: sedentary lifestyle

9. GI/FECAL ELIMINATION

Bowel Sounds:☐Absent ☐Hypoactive (X) Active Location: ☐RUQ ☐RLQ ☐ LUQ ☐LLQ (X)
☐Hyperactive Throughout

Abdomen: (X) Soft ☐Flat ☐Distended ☐Round Ostomy: (X) No ☐Yes Incontinence:
☐Firm ☐Tender ☐Flatus Type:______ ☐Yes (X) No

Last BM: __This Morning_____Stool: (X) Formed Color: (X) Brown ☐Black/Tarry ☐Clay/Gray
☐Soft ☐Hard ☐ Liquid #_____ ☐Yellow ☐Green

Fecal Elimination Comments: Normal bowl movements up to admission

Nursing Diagnosis: None

10. GU/URINARY ELIMINATION

Urine: (X) Clear ☐Cloudy ☐Sediment Color: ☐Straw (X) Yellow ☐Amber ☐Pink
☐Red

Last void: time___In the AM_________ amount Catheter: (X) None ☐In/Out ☐Condom
200 mL ☐Foley ☐Suprapubic
Insertion date:_________________

Symptoms: Frequency: ☐ Urgency: ☐ Dysuria: ☐ Nocturia: ☐ Incontinence: ☐Yes (X) No

Urinary Elimination Comments: Normal Urination Patterns

Nursing Diagnosis: None

11. REST AND EXERCISE

Activity: (X) Bed rest ☐BSC ☐BRP ☐ Chair ☐ Mobility Aids: (N/A) ☐Cane ☐W/C
Ambulate ☐Crutches ☐Walker

Functional level: ☐Independent ☐Dependent (X) Gait: (X) Steady ☐Unsteady ☐Unable to
Assistance ambulate

ROM: (X) Active ☐Passive ☐Assistive ☐Limited Sleep Patterns: (X) Uninterrupted
☐Full ☐Interrupted ☐Insomnia
☐Day time sleepiness # hrs
sleep/night___8_______

Cast/Brace/Traction: Type____N/A_______ Restraints: Type_____N/A_________

Location_______________ Location_______________

Rest and Exercise Comments: Patient should remain on bed rest due to activity causing more chest
pain and heart work load

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Nursing Diagnosis: Activity Intolerance Due to Cardiovascular Disease

MORSE FALL SCALE/RISK SCREENING

Variables Scor
e

History of Falls within last 12 No 0

months Yes 25

Secondary Diagnosis No 0
Yes 15

Ambulatory Aids None/bedrest/nurse assist 0

Crutches/cane/walker 15

Furniture 30 To obtain the Morse Fall Score

add the score from each
IV or IV access No 0
category.
Yes 20

Gait Normal/bedrest/wheelchair 0
Morse Fall Score
Weak 10 ☐ High Risk 45 and higher
☐ Moderate Risk 25-44
Impaired 20 (X) Low Risk 0-24
Mental Status Know own limits 0

Overestimates or forgets 15
limits

Total 20

Rest and Exercise Comments: Patient has no known risk falls but should be on bed rest

Nursing Diagnosis: None

12. SKIN INTEGRITY/INTEGUMENTARY

Skin Condition: (X) Intact ☐ Skin tear ☐Bruise ☐Rash ☐Burn ☐Wound/Ulcer (complete
documentation) Location_____________ Stage___________
☐Incision ☐Other______________
Location#1_____________Type of condition____________ ☐Drainage__________ ☐Odor
Location#2_____________Type of condition____________ ☐Drainage__________ ☐Odor
Location#3_____________Typeof condition____________ ☐Drainage__________ ☐Odor

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Braden Scale Score

Sensory 1. Completely limited 2. Very limited 3. Slightly limited 4. No 4

Impairment

Moisture 1. Constantly moist 2. Very moist 3. Occasionally moist 4. Rarely moist 3

Activity 1. Bedfast 2. Chairfast 3. Walks occasionally 4. Walks 1

frequently

Mobility 1. Completely 2. Very limited 3. Slightly limited 4. No limitations 4

immobile

Nutrition 1. Very poor 2. Probably inadequate 3. Adequate 4. Excellent 3

Friction and 1. Problem 2. Potential problem 3. No apparent Score of 18 or

Shear problem less _20_
= at risk

IV sites: (X) Patent ☐Swollen ☐Red ☐Infiltrated Location:____Hand________ Gauge Needle:_____20_______

Start date:_____12/7/2021_________

Skin Comments: Skin in tact and appears normal

Nursing Diagnosis: Risk for impaired Skin integrity

13. HORMONE REGULATION/REPRODUCTION/ENDOCRINE

Thyroid Disease: ☐Yes (X) No Estrogen Use: ☐Yes (X) No Testosterone use: ☐Yes (X) No Steroid use:
☐Yes (X) No

Diabetes: (X) Yes ☐ No ☐Type I (X) Type II Number of year with diabetes: ___15____

14. PSYCHOSOCIAL VARIABLES

Mood/Affect: (X) Cooperative ☐Cheerful ☐Angry (X) Anxious ☐Crying ☐Withdrawn ☐Flat Affect ☐Depressed
☐Fearful ☐Combative

Level of education: ☐None ☐Elementary (X) High School ☐College Understands directions: (X) Yes ☐
☐Post Graduate No

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Decision-making: ☐None (X) Concrete ☐Abstract Judgment: (X) Appropriate ☐Inappropriate ☐Dementia
☐Impaired

History/Evidence of: (N/A) ☐Physical Abuse ☐Neglect ☐Sexual Abuse ☐Thoughts of suicide or self-harm
☐Depression ☐Psychiatric history

Recreational drug use: ☐ Drug N/A How much____ How Alcohol use: ☐ How often__None___ How
long____ much_______

Tobacco use: In the last 12 months (X) Yes ☐ No How often ___Everyday________ How much____1 pack a
day_________

Recent life stress or loss: ☐Yes (X) No Coping methods with current illness/hospitalization: ☐Good
___________ (X) Fair ☐Poor

Body Image: ☐Positive (X) Negative Sexuality: (X) Heterosexual ☐Bisexual ☐Homosexual
☐Changing ☐Transgender ☐Transsexual

Ability to write English: (X) Yes ☐No Ability to read English: (X) Yes ☐No

Language Barrier: (X) None ☐ESL ☐Speech Support System: (X) Yes ☐No
Impediment ☐Intubated ☐ Trached Living Situation: __Lives with
wife_________________________________

Psychosocial Comments: Patients seems to be handling the current situation as well as anyone can. Weary of
health but handling it fairly as new information is received.

Nursing Diagnosis: Death Anxiety r/t seriousness of medical condition

Narrative Charting: Davis Rodney, 54 year old African American who is admitted for chest pains which started this
afternoon. His wife gave him three doses of nitroglycerin when it started and then 325 mg of aspirin one hour later.
His vitals and admission were a pulse of 104 respiration of 26 and a BP of 100/96, Pulse OX of 94 and we start him on
2L nasal cannula. He was having episodes of dyspnea and when being active it was aggravating his angina. I believe
the patient may have suffered a Myocardial Infarction but further testing will be needed to confirm this. We should
order him a X-ray, EKG along with a blood panel and ABG and assess his cardiac output. Also an angiogram to see
extent of artery blockage.

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