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SN Chart

This document is a patient assessment form that includes sections for personal information, vital signs, neurological status, respiratory and cardiovascular assessments, dietary information, elimination details, integumentary status, fall risk assessment, and treatment procedures. It provides a comprehensive overview of the patient's current health status and care needs. Additionally, it includes space for nurses' notes and patient education details.

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sufeyahsegurabalawag
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6 views1 page

SN Chart

This document is a patient assessment form that includes sections for personal information, vital signs, neurological status, respiratory and cardiovascular assessments, dietary information, elimination details, integumentary status, fall risk assessment, and treatment procedures. It provides a comprehensive overview of the patient's current health status and care needs. Additionally, it includes space for nurses' notes and patient education details.

Uploaded by

sufeyahsegurabalawag
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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j.

jacobe_2024

PT. LAST NAME, FIRST NAME M.I. AGE/SEX: ATTENDING PHYSICIAN:


DATE OF BIRTH:
BED NUMBER: SHIFT:
TIME RECEIVED: ALLERGIES: [ ] NO KNOWN ALLERGIES
DATE:
ADL INTAKE AND OUTPUT
[ ] Activity as Tolerated [ ] CBR with BRP ORAL IVF TOTAL URINE OTHERS TOTAL

[ ] High Back Rest [ ] CBR w/o BRP

Neuro
[ ] Concious Responsive to:
[ ] Alert [ ] Verbal Stimuli
[ ] Coherent [ ] Painful Stimuli VITAL SIGNS MONITORING
[ ] Incoherent Pupils __________________________ TIME TEMPERATURE PULSE RATE RESPIRATORY RATE BLOOD PRESSURE O2 SATURATION
[ ] Aphasia Reflexes ________________________

[ ] Stuporous Others _________________________

[ ] Comatose

Pulmo
Respiration Intubated IV FLUID/BLOOD LINE/SIDE DRIP
[ ] Eupneic [ ] Endotracheal Bottle Number/Name/Volume/Rate Level

[ ] Dyspneic [ ] Apneic [ ] Tracheostomy

Breath Sounds: __ ET SIZE __ RR

[ ] Clear [ ] Rales __ PIP __ TV

Location: ______________ __ PEEP __ IE

[ ] Oxygen _________ LPM __ LIP LEVEL __ MODE


[ ] Nasal Canulla __ FIO2 SPECIAL ENDORSEMENT
[ ] Multivent Mask
Cardio
Pulses [ ] Regular [ ] Irregular [ ] Weak

[ ] Bounding [ ] Chest Pain

Character: ________________________ NURSES' NOTES


Location: _________________________ Date FDAR [ FOCUS, DATA, ACTION, RESPONSE ]

Others: __________________________
Gastro
Diet: _________________

[ ] Oral [ ] NGT/OGT [ ] Trans Abdominal

Size: ______ Level: _____

Insertion Date: _________ Time: ______


Elimination
[ ] Voiding Freely Color:

[ ] With Foley Catheter

[ ] With Condom Catheter Amount:


Others:

Integumentary
LIPS [ ] Intact [ ] Moist [ ] Broken [ ] Dry

SKIN [ ] Intact [ ] Edematous [ ] Dry

Skin Turgor [ ] Good [ ] Poor

Pressure Injury [ ] Yes [ ] No Stage: ___ Size: ____

Location: ____________________________________

Drainage: ___________________________________

Surgical Site: _________________________________


Others: _____________________________________
FALL RISK [ ] LOW [ ] MODERATE [ ] HIGH PROCEDURE / TREATMENT DONE
Side Rails Up: [ ] Yes [ ] No ACTUAL TIME PROCEDURE REMARKS

Education to Patient and Watcher: [ ] Yes [ ] No

STUDENT NURSE IN-CHARGE:

j.jacobe_2024

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