Nursing Assessment Worksheet



Daily Assessment Worksheet*

Date _____________ Patient # 1, 2, 3 Primary Nurse ________________SN:________________

IV Site/Gauge/Fluids/Rate___________________________SL/Gauge/Site_____________________

Pain Level___ Goal___ Braden Score_____/_____ Morse Scale____/_____ Careplan Y/N

Vital Signs (AM) B/P HR Resp Sat% (PM) B/P Pulse Resp Sat%

|Primary Medical Diagnosis: |Allergies: |Wt: |

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| | |Ht: |

|Neurological (Consciousness, orientation, pupils speech, |Awake/alert/oriented/confused/lethargic/ unresponsive/sedated. |

|sensation) |Eyes: clear/redness/discharge__________ |

| |Pupils: ___________, non-reactive, sluggish |

| |Speech: clear,/slurred/non-audible |

| |Sensation: Intact/Tingling/Numbness |

|Cardiovascular (Heart sounds, rate, rhythm, pulses, capillary |S1/S2 Extra Sounds Rate/Rhythm: Regular, Irregular |

|refill, neck veins, edema) |Pacemaker Y/N Implanted Defibrillator: Y/N |

| |Pulses: Radial Pedal Carotid (+1 +2 +3) |

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| |Cap refill: UE/LE_______________ JVD: Y/N |

| |Edema: Non-Pitting, Pitting_______ Site:_________________ |

| |(1+ 2+ 3+) |

|Respiratory (Effort, rate, depth, use of accessory muscles, |Respiratory Effort: Even, irregular, labored, unlabored |

|Lung sounds, cough, tracheal position, chest tubes or |Lung Sounds: CTA Ant/Post |

|incisions, supplemental oxygen, treatments) |Absent/Diminished/Crackles/Wheezes/Rales/Pleural Rub: (Specific) |

| |_______________________________ |

| |Supplemental O2_________Cough: Non Productive |

| |/Productive (Describe)_______________ |

| |Tracheal Position_______________ |

|Gastrointestinal (Mouth, abdomen, bowel sounds, bowel habits, |Mouth: Moist/Dry/Lesions _________ Dentition _____________ |

|Tubes/drains (what kind & location) |Abdomen: Distended/Non-distended, Soft/Firm, |

| |Tender/Non-tender__________. BS: Present/Absent ___quadrants |

|Diet: |Hypo/Hyperactive: _______quadrants Tubes/Drains_____________ |

|Genito-Urinary (Urinary output, color, catheters, genitalia) |Voiding Freely/Urinary Catheter: Clear/Cloudy/Yellow/blood-tinged |

| |bloody/other:_________ Output:_________ |

| |Genitalia: Drainage Y/N Description:_______________________ |

| |Odor: Y/N Description:________________________ |

|Musculoskeletal (Muscle strength, ROM, posture, gait) |Muscle strength: Strong/Weak/Equal/ Bilateral/R/L/Upper/lower |

| |ROM: Active/Passive/Contracted: Which?__________________ |

| |Posture: Erect/Stooped |

| |Gait: Steady/Unsteady Assistive Device:________________ |

|Endocrine (Temp. tolerance, goiters, bulging eyes, skin |Tolerating ambient temperature Y/N c/o Cold/Warm/Hot |

|pigmentation) |Skin-Appropriate to Race Y/N______________ Goiter/Bulging eyes |

|Reproductive (Breast, , testes, discharge) |Breast: Mass _________Discharge _________ |

| |Testes: Mass _________Discharge _________ |

|Integumentary (turgor, lesions, abrasions, lacerations, |Skin: warm/cool/moist/dry. Skin Turgor: Tenting/Non-Tenting |

|bruising, rashes, scars, nails, hair) |Incision/Lesions/Lacerations/Scars/Brusing/Rash:_________________ |

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| |Nails: Smooth/Brittle/Clubbing Hair: Well distributed/Clean/Balding |

|Psychological (Self concept, behavior/affect, communication, |Understands Illness: Y/N Coping w/ Hospitalization: Y/N __________ |

|coping, ability to function) |Affect: Animated/flat/labile/inappropriate/_____________ |

| |Behavior: calm/agitated/anxious/tearful/restless/________ |

|Cultural/Spiritual Needs: | |

*Medications (Scheduled Meds/PRN if administered)

|+Dx# |*Medication |*Classification |*Dose |*Frequency |*Route |+Side effects |

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*Daily +Weekly

Medical and Surgical Hx

(Number the medical problems, so you can match the medication to the problem, if applicable.)

Medical Surgical

1. 1.

2. 2.

3. 3.

4. 4.

*Labs (CBC/Chemistry Profile etc.) (Include: Normal and Abnormal results)

|Date |Lab |Results |Normal Range |Significance to Nursing Care |

+Diagnostics(X-ray, MRI, CT etc.)

|Date |Study |Impression(Results) |Significance to Nursing Care |

*Daily for each patient: Three (3) Primary Nursing Diagnosis with R/T statement

1 – Physiological

1 – Safety

1 - Psychosocial

*(Please use your Ackley Nursing Diagnosis Handbook)

+Teaching-Briefly what did you teach and why (Daily). On final Care Plan you have a Teaching Plan form; it must be complete with all areas addressed. Be specific in all areas.

+Weekly Care Map (Due on Wednesday-8:00am) (choose one patient)

Will include: Assessment Worksheet – the original completed with corrections or additions. Do not redo.

Medical and Surgical History/Labs/Diagnostics/completed medications list/

2 Priority Nursing Diagnosis/3-4 Interventions for each with Rationale and Evaluation)

Nursing Diagnosis: (do not forget your R/T statement)

Subjective data:

Objective data:

Functional Health pattern:

Outcome Goal: Patient will …. (must be a measurable & realistic goal)

Evaluation of outcome goal: Met/Not Met (Evidence)

(Please include your references.)

+Reflective Journal (one for each day of clinical, you may reflect on both days on one sheet)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

END OF THE ROTATION

Final Careplan - Due before end of rotation (one patient) Due Date will be announced.

-Assessment Worksheet (original one)

-Assessment Form (Long form)

-Pathophysiology for primary Medical Diagnosis plus one other Medical Diagnosis that is part of the patient’s medical history. (List 3 Primary Generic Nursing Diagnosis along with each Medical Diagnosis listed)

**Pathophysiology - The study of the biologic and physical manifestations of disease. As they correlate with the underlying abnormalities and physiologic disturbances. It explains the processes within the body that result in the signs and symptoms of a disease. In other words, research it; do not submit a definition straight out of a dictionary use your own words. Your book is a great resource!

Example:

1. Diabetes

List the top 3 priority nursing diagnoses that pertain to this Medical Diagnosis:

1.

2.

3.

2. HTN

List the top 3 priority Nursing Diagnosis that pertain to this Medical Diagnosis:

1.

2.

3.

Textbook References:

-Medications Example

| MEDICATION NAME |CLASSIFICATION |DOSE |ROUTE |SIDE EFFECTS |NURSING INTERVENTION |

|(Brand & | | |FREQUENCY | | |

|Generic) | | | | | |

| Ibuprofen |Analgesia, |800mg |PO Q 8hrs |Bleeding, GI |Monitor for |

|(Motrin) |antipyretic | | |upset, acute |effectiveness and |

| |NSAID=Anti-infl| | |renal failure |bleeding |

| |ammatory | | | |(list most |

| | | | | |Important |

| | | | | |interventions |

-Lab/Diagnostics

Example

|Date |Study Done |Results |Normal Range |Significance to Nursing Care |

| |Platelet count (PLT) |80,0000 |150,000-400,000 |Low platelets could mean hemorrhage, |

| | | | |monitor for bleeding, notify MD |

-Teaching Plan on form provided

-Braden Score with interventions regardless of risk factor

-Morse Scale with interventions regardless of risk factor

-Reference Page

Care Map

SN: Date:

|Nursing Diagnosis r/t: |

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|ASSESSMENT |

|Objective Data |Subjective Data |

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|Outcome Goal: |

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|NURSING INTERVENTIONS |

|Interventions |Rationale |

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|Evaluation of Outcome Goal: |

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Teaching Plan

Student Name: ________________________

Date: _______________________________

Patient # 1, 2, 3

Topic: ___________________________________

Learning Need: (Why teaching)

Patient/Caregiver Behavioral Outcome Objectives: (Patient will demonstrate ….)

Readiness to Learn: Calm/Receptive/Unreceptive/Anxious/Angry/Denies Illness

Critical Element to be reviewed with patient:

Methods/Aids utilized: (Charts, handouts, pamphlets, videos etc.)

Collaboration (other health care professionals):

Evaluation: (Ex. Return Demonstration (verbal/written), additional teaching required and why, anticipated compliance, etc.)

+Reflective Journal

Name: ___________________________ Today’s Date: _____________

|1) Share your overall feelings about the day. |

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|2) List the goals you attempted to achieve today? |

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|3) What were you alert for today with your patients? |

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|4) What were the important assessments you made? |

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|5) What complications could have occurred and what interventions prevented them? |

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|6) List situations you encountered with staff, peers, patients and/or family. |

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Continue on reverse side if needed

|BRADEN SCALE FOR PREDICTING PRESSURE SORE RISK |

|Patient’s Name: |Evaluator’s Name: |DATE OF | | | |

| | |ASSESSME| | | |

| | |NT: | | | |

1 Nothing by mouth

2 Intravenously

3 Total Parenteral Nutrition

SOURCE: Barbara Braden and Nancy Bergstrom. Copyright, 1988. Reprinted with permission

INTERVENTIONS:

Morse Fall Scale

(Adapted with permission, SAGE Publications)

The Morse Fall Scale (MFS) is a rapid and simple method of assessing a patient’s likelihood of falling. A large majority of nurses (82.9%) rate the scale as “quick and easy to use,” and 54% estimated that it took less than 3 minutes to rate a patient. It consists of six variables that are quick and easy to score, and it has been shown to have predictive validity and inter-rater reliability. The MFS is used widely in acute care settings, both in the hospital and long term care inpatient settings.

|Item |Scale |Scoring |

|1. History of falling; immediate or within 3 months |No 0 |______ |

| |Yes 25 | |

|2. Secondary diagnosis |No 0 |______ |

| |Yes 15 | |

|3. Ambulatory aid |0 |______ |

|Bed rest/nurse assist |15 | |

|Crutches/cane/walker |30 | |

|Furniture | | |

|4. IV/Heparin Lock |No 0 |______ |

| |Yes 20 | |

|5. Gait/Transferring |0 10 20 |______ |

|Normal/bedrest/immobile | | |

|Weak | | |

|Impaired | | |

|6. Mental status |0 15 |______ |

|Oriented to own ability | | |

|Forgets limitations | | |

Gait: A normal gait is characterized by the patient walking with head erect, arms swinging freely at the side, and striding without hesitant. This gait scores 0. With a weak gait (score as 10), the patient is stooped but is able to lift the head while walking without losing balance. Steps are short and the patient may shuffle. With an impaired gait (score 20), the patient may have difficulty rising from the chair, attempting to get up by pushing on the arms of the chair/or by bouncing (i.e., by using several attempts to rise). The patient’s head is down, and he or she watches the ground. Because the patient’s balance is poor, the patient grasps onto the furniture, a support person, or a walking aid for support and cannot walk without this assistance.

Mental status: When using this Scale, mental status is measured by checking the patient’s own self-assessment of his or her own ability to ambulate. Ask the patient, “Are you able to go the bathroom alone or do you need assistance?” If the patient’s reply judging his or her own ability is consistent with the ambulatory order on the Kardex®, the patient is rated as “normal” and scored 0. If the patient’s response is not consistent with the nursing orders or if the patient’s response is unrealistic, then the patient is considered to overestimate his or her own abilities and to be forgetful of limitations and scored as 15.

Scoring and Risk Level: The score is then tallied and recorded on the patient’s chart. Risk level and recommended actions (e.g. no interventions needed, standard fall prevention interventions, high risk prevention interventions) are then identified.

Important Note: The Morse Fall Scale should be calibrated for each particular healthcare setting or unit so that fall prevention strategies are targeted to those most at risk. In other words, risk cut off scores may be different depending on if you are using it in an acute care hospital, nursing home or rehabilitation facility. In addition, scales may be set differently between particular units within a given facility.

Sample Risk Level

|Risk Level |MFS Score |Action |

|No Risk |0 - 24 |Good Basic Nursing Care |

|Low Risk |25 - 50 |Implement Standard Fall Prevention |

| | |Interventions |

|High Risk |≥ 51 |Implement High Risk Fall Prevention |

| | |Interventions |

INTERVENTIONS:

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