SYSTEMS (continued) Adaptive Equipment Note: Musculoskeletal Comments: (Include duration frequency and severity of any signs / symptoms. Include current / past treatment and how issues may have affected client’s quality of life). (If yes listen to bowel sounds and single select from bowel Gastrointestinal client’s sounds list).   Abdominal Distention: No Yes Date of Last Bowel Movement:     Bowel Sounds: Absent Faint Hyperactive Present Gastrointestinal: Constipation Diarrhea Encopresis    Heartburn   Flatus  GERD Nausea  Hemorrhoids Hiatal hernia    Ostomy Rectal bleeding   Other  Vomiting No known difficulty   Gastrointestinal Comments: (Include location of active or absent bowel sounds (per quadrant). Include frequency, duration and severity of issues. Include how issues may have affected client’s quality of life). Endocrine Endocrine: Hyperthyroidism Hypothyroidism No known difficulty Other     (specify) Endocrine Comments: (Include duration and current /past treatment if known).    Does Client Have Diabetes? No Yes Unknown Diabetes Treatment:  Byetta  Diet  Insulin Insulin Pump Oral Medication Other    (specify) Diabetes Comments: (Include duration, severity and factors known to affect blood sugar. What is usual blood sugar range). client’s 7
SYSTEMS (continued) Adaptive Equipment Note: Musculoskeletal Comments: (Include duration frequency and severity of any signs / symptoms. Include current / past treatment and how issues may have affected client’s quality of life). Gastrointestinal Date of Last Bowel Movement: (If yes listen to client’s bowel sounds and single select from bowel sounds list). Abdominal Distention:  No  Yes Bowel Sounds:  Absent  Faint  Hyperactive  Present Gastrointestinal:  Constipation  Flatus  Hemorrhoids  Ostomy  Vomiting  Diarrhea  GERD  Hiatal hernia  Rectal bleeding  No known difficulty  Encopresis  Heartburn  Nausea   Other Gastrointestinal Comments: (Include location of active or absent bowel sounds (per quadrant). Include frequency, duration and severity of issues. Include how issues may have affected client’s quality of life). Endocrine Endocrine:  Hyperthyroidism  Hypothyroidism  No known difficulty  Other (specify) Endocrine Comments: (Include duration and current /past treatment if known). Does Client Have Diabetes?  No  Yes  Unknown Diabetes Treatment:  Byetta  Insulin Pump  Diet  Oral Medication  Insulin  Other (specify) Diabetes Comments: (Include duration, severity and factors known to affect blood sugar. What is client’s usual blood sugar range). 7
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