Pediatric Admission Assessment: Timothy W.Page 1:
Date: 12/20/95
Time: 11:45 A.M.
Person to Notify in Case of Emergency:
Name: Janet W
Phone: Redacted
Relationship: Mother
Admitted From: Home
Admitted via: Ambulatory
Orientation to Nursing Unit: [All listed are checked off.]
Nurse Call System
Crib/Side Rails
Bathroom
Phone
No Smoking
No leaving children unattended
Bed Controls
ID Bracelet
TV Controls
Visiting Hours
Patient Information
Cribs must have rails up at all times when occupied (Not checked)
No toys or objects to create sparks or friction if in croup tent (not checkted)
Bed/crib must be kept in lowest position at all times (Not checked)
Immunizations Current? Yes
Chief Complaint: Headaches, insomnia, (REDACTED)
Disposition of Valuables (REDACTED)
Caldwell County Hospital (REDACTED, but probably for consistency's sake
since the location isn't right.) will not assume responsibility for lost
or damaged valuables, clothing, or personal itesm kept in the patient's
possession. Valuables should be taken home or secured by the hospital.
Patient/Family Signature:
Witness Signature:
Date: 12/20/95
Time: 12:01 P.M.
Valuables picked up by: Janet W.
Witness: (Cant read)
Date/Time: 12/20/95 12:01 P.M.
Health Profile: Other, Janet W.
Have you been hospitalized at our facility in the past 7 days? No
If yes, has there been any changes in your status since last admission? No (Someone can't read directions...)
Page 2:
Medical History and Previous Surgery:
Ever had a blood transfusion? No
SOcial/Environmental Assessment: (All shown are checked)
1. Patient lives: With family
2. Habits: Tobacco
Member of household uses tobacco
3. Education: Last grade in school attended: 2
Can read? Yes
Can write? Yes
Is Home Health involved in your Care? No
5. Assistance required for Care
Toileting: Goes to bathroom alone, Independent
Medication: Taken best as: Liquid
Who else besides parents might be staying with child? N/A
Emotional Support: Has your family had any recent changes in your life? (moved, divorce, birth, death, new job, etc.): No
6. Abuse/Neglect/Exploitation Screen
Do you feel safe in your home? No (Originally Yes)
Are you afraid of anyone? No (Originally Yes)
Have you ever been physically, sexually, or emotionally abused? No
Within the past year, have you ever been hit, slapped, kicked, or otherwise physically hurt? No (REDACTED)
Have you ever been touched in a manner tham kaes you feel uncomfortable? No (REDACTED)
Evidence of neglect by self? No
Evidence of neglect by caretakers? No
Evidence of abuse by self or others? No
Skin:
Color Impairment: None
Temperature: Warm
Turgor: Good
Page 3:
Oral/Denatal/Nasal
Teeth Condition: Good
Gums: Pink,
Nose: No problems
Hygiene
Bathing: Partial Assist
Condition on arrival: Good
Oral Hygience: Self
Hair Condition: Good
Neuro Status
Conscious
Oriented To: Person, Place (Not Time)
Weakness/Paralysis: None
Range of Motion: Independent
Pupils/Eyes
Pupils: Equal
Eyes:
Vision (All listed here checked)
Adequate
Glasses/Contacts: With Patient
Speech/Sqallowing
Speech: Clear
Swallows: Without Difficulty
Hearing/Ears
Hearing: Adequate
Mobility
ndependent
Respiratory/Cardiovascular
Respiratory Problems:
Cough (Surprise Surprise)
Aids to Respiration: None
Cardiovascular Problems: None
Page 4:
Frequency of BM (REDACTED): Daily
(REDACTED STUFF ABOUT BOWEL MOVEMENTS :O)
Abdomen: Soft
Urinary Status:
Problems: None
GU (REDACTED)
Comfort/Rest/Sleep
Sleep
Unable to fall asleep easily
Avg # Hrs Slept Each Night: 4 #Pillows used: 2
Sleeps with Night Light On (D'aww)
Comfort/Pain
Is the patient currently having pain or admitted a pain related diagnosis? Yes
RATING ON PAIN SCALE: 6
Location: Head
Duration: 2-4 Hrs
Chronic, dull
Relieved by Rest
Aggravated by Talking
Do you have any personal, cultural, spiritual, and/or ethnic beliefs that may affect the way your pain is treated? No
Page 5:
Psychological Status
Body Image/Self Concept Problems: Signs/Symptoms of Depression
Spiritual Needs: No Requests Minister, etc. be notified: No
Observation of Patient Behavior/Interaction: Cooperative, Restless
Developmental/Other Needs Assessment
School Age Child, 6-12 Years
Social
Engages in group activities with same sex peers (UNCHECKED)
Cognitive
Wide Range of Vocabulary
Learns to read
Learning math skills
Begins collections (Hobbies) (UNCHECKED)
Physical
Exhibits physical endurance (plays sports, games) increased time motor ability (writing, painting drawing) (UNCHECKED)
Discharge Needs
Transportation
Plan of Care Reviewed With:
Family
Other Notes: Ran away from home 2 ___(REDACTED)___ ago. Found at Rosswood park.
Page 6:
Is this child's condition affected by the family? No
Is the family affected by this child's hospitalization? No
Fall Risk Assessment
Confused, disoriented, hallucinating, combative - 20
Hx of syncope, seizures (underlined), postural hypotension - 20
Total: 40 (High Risk)
OOG there is another page, but Jay states that it isn't there.
Source:
http://www.hospital-forms.com/704.pdf 
Sat Jul 14, 2012 7:37 pm
