A
• Does the person have known allergies • Medications • Environmental • Food • Latex • Iodine • Soaps, Lotions • Other •
• How do allergies affect their overall health and lifestyle? • Does the person have current orders for PRN or routine medications for allergies?
Al lergies
What reaction has the patient
had in the past?
• Does the person have respiratory diagnosis or issues? • Is breathing a problem? •
1
Ai r
• Does the person take any medications for respiratory issues? • How often? • Effective? • Any special nursing considerations?
Does the person use oxygen or other assistive devices?
• Are there any potential toxins in the room/outside environments? • What are your significant respiratory assessment findings • O 2 Flow Rate • Mask, • Cannula • Lung sounds • Respiratory Rate & Quality, • Skin color • Cap refill • SpO2
• What is the recommended dietary intake for this person? • Does the person require a special diet related to a medical diagnosis? •
2
Food
• Where does the person eat their meals? • Is this a safe environment? • Do they require assistance with preparation of meal tray or consuming of meals? • Does the person require assistive devices or special set up for meals? • Does the person have orders for dietary supplements? • Why?
ADA, AHA, Edentulous, Aphagia, Renal, etc. • Why?
• Does the person eat well (50%> of meals served)? • Does the person have food preferences? • Any cultural considerations regarding foods or meals?
3
• What is the recommended amount of water intake for this person? • What sources of water has the person had to drink today? • How often did you offer fluids? • How much did they drink (intake)? • Are there any potential toxins or pollutants in the environment that could
Wa t e r
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