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Dmr for Nursing Students

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Submitted By jim190
Words 2718
Pages 11
POLK STATE COLLEGE

DEPARTMENT OF NURSING
NURSING HISTORY AND ASSESSMENT
Nursing III

Please asterisk any abnormal data. This abnormal data will need to be reflected in appropriate areas of your DMR.

Personal Information

|Initials: ___JW____ |Age: ___40___ |Gender: _F___ |
|Date of Admission: _10/15/09__ |Date of Assessment: _10/16/09_ |Marital Status: _Married |
|Ethnic/Cultural Background: _Caucasian American_______ |Religious Preference: _Methodist |
|Occupation: _____Cashier_________________ |Education: ______9th Grade_______________ |
|Language Spoken: __English_____ |Any Communication Deficits? No______________________________________ |
|(If other than English, is an interpreter available? __________) | |
|Source and Reliability of Information: __Patient_______________________ |

Admission Data

|Temp _98.6__ |Pulse __105_____ |Resp. __21_______ |BP __105/65____ |
| |
|Reason for hospitalization/ chief complaint (as described by patient/family): Lower Back pain radiating down left leg. |
|

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