ࡱ> y :bjbj 4@{{B*****>>>8v <>z+zFFFFF!!!*******$-0*9*!!!!!***FF4+!*F*F*!*(|9*F  4k'a)*J+0z+s)J1J1$9*J1*9*!!!!!!!**!!!z+!!!!J1!!!!!!!!! : 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:Ht:Neurological (Consciousness, orientation, pupils speech, sensation)Awake/alert/oriented/confused/lethargic/ unresponsive/sedated. Eyes: clear/redness/discharge__________ Pupils: ___________, non-reactive, sluggish Speech: clear,/slurred/non-audible Sensation: Intact/Tingling/Numbness Cardiovascular (Heart sounds, rate, rhythm, pulses, capillary refill, neck veins, edema)S1/S2 Extra Sounds Rate/Rhythm: Regular, Irregular Pacemaker Y/N Implanted Defibrillator: Y/N Pulses: Radial Pedal Carotid (+1 +2 +3) Cap refill: UE/LE_______________ JVD: Y/N Edema: Non-Pitting, Pitting_______ Site:_________________ (1+ 2+ 3+)Respiratory (Effort, rate, depth, use of accessory muscles, Lung sounds, cough, tracheal position, chest tubes or incisions, supplemental oxygen, treatments)Respiratory Effort: Even, irregular, labored, unlabored Lung Sounds: CTA Ant/Post Absent/Diminished/Crackles/Wheezes/Rales/Pleural Rub: (Specific) _______________________________ Supplemental O2_________Cough: Non Productive /Productive (Describe)_______________ Tracheal Position_______________Gastrointestinal (Mouth, abdomen, bowel sounds, bowel habits, Tubes/drains (what kind & location) Diet:Mouth: Moist/Dry/Lesions _________ Dentition _____________ Abdomen: Distended/Non-distended, Soft/Firm, Tender/Non-tender__________. BS: Present/Absent ___quadrants 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 pigmentation)Tolerating ambient temperature Y/N c/o Cold/Warm/Hot Skin-Appropriate to Race Y/N______________ Goiter/Bulging eyesReproductive (Breast, , testes, discharge)Breast: Mass _________Discharge _________ Testes: Mass _________Discharge _________Integumentary (turgor, lesions, abrasions, lacerations, bruising, rashes, scars, nails, hair) Skin: warm/cool/moist/dry. Skin Turgor: Tenting/Non-Tenting Incision/Lesions/Lacerations/Scars/Brusing/Rash:_________________ Nails: Smooth/Brittle/Clubbing Hair: Well distributed/Clean/BaldingPsychological (Self concept, behavior/affect, communication, coping, ability to function) Cultural/Spiritual Needs:Understands Illness: Y/N Coping w/ Hospitalization: Y/N __________ Affect: Animated/flat/labile/inappropriate/_____________ Behavior: calm/agitated/anxious/tearful/restless/________ *Medications (Scheduled Meds/PRN if administered) +Dx#*Medication*Classification *Dose*Frequency*Route+Side effects *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) DateLabResultsNormal RangeSignificance to Nursing Care +Diagnostics(X-ray, MRI, CT etc.) DateStudyImpression(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 patients 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. HTN List the top 3 priority Nursing Diagnosis that pertain to this Medical Diagnosis: 1. 2. 3. Textbook References: -Medications Example MEDICATION NAME (Brand & Generic) CLASSIFICATION DOSE ROUTE FREQUENCY SIDE EFFECTSNURSING INTERVENTION Ibuprofen (Motrin) Analgesia, antipyretic NSAID=Anti-inflammatory 800mg PO Q 8hrsBleeding, GI upset, acute renal failure Monitor for effectiveness and bleeding (list most Important interventions  -Lab/Diagnostics Example DateStudy DoneResultsNormal RangeSignificance to Nursing CarePlatelet count (PLT)80,0000150,000-400,000Low 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:  ASSESSMENTObjective DataSubjective Data Outcome Goal:  NURSING INTERVENTIONSInterventionsRationale    Evaluation of Outcome Goal:  <>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: ___________________________ Todays Date: _____________ 1) Share your overall feelings about the day.2) List the goals you attempted to achieve today?3) What were you alert for today with your patients?4) What were the important assessments you made?5) What complications could have occurred and what interventions prevented them?6) List situations you encountered with staff, peers, patients and/or family.Continue on reverse side if needed BRADEN SCALE FOR PREDICTING PRESSURE SORE RISKPatients Name: Evaluators Name: DATE OF ASSESSMENT:Sensory perception Ability to respond meaningfully to pressure-related discomfort1. Completely limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation, OR Limited ability to feel pain over most of body surface2. Very limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, OR Has a sensory impairment which limits the ability to feel pain or discomfort over of body.3. Slightly limited: Responds to verbal commands but cannot always communicate discomfort or need to be turned, OR Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities.4. No impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.Moisture Degree to which skin is exposed to moisture1. Constantly moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.2. Moist: Skin is often but not always moist. Linen must be changed at least once a shift.3. Occasionally moist: Skin is occasionally moist, requiring an extra linen change approximately once a day.4. Rarely moist: Skin is usually dry; linen requires changing only at routine intervals.Activity Degree of physical activity1. Bedfast: Confined to bed.2. Chairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.3. Walks occasionally: Walks occasionally during day but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.4. Walks frequently: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours.Mobility Ability to change and control body position1. Completely Immobile: Does not make even slight changes in body or extremity position without assistance.2. Very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.3. Slightly limited: Makes frequent though slight changes in body extremity position independently.4. No limitations: Makes major and frequent changes in position without assistance.Nutrition Usual food intake pattern1. Very poor: Never eats a complete meal. Rarely eats more than S! of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement, OR Is NPO1 and/or maintained on clear liquids or IV2 for more than 5 days.2. Probably Inadequate: Rarely eats a complete meal and generally eats only about of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement, OR Receives less than optimum amount of liquid diet or tube feeding.3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement of offered, OR Is on a tube feeding or TPN3 regimen, which probably meets most of nutritional needs.4. Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.Friction and Shear1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequent slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures, or agitation leads to almost constant friction.2. Potential problem: Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.3. No apparent problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in be or chair at all times.ADOPTED 1997TOTAL SCORE: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 patients 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 Bed rest/nurse assist Crutches/cane/walker Furniture 0 15 30 ______ 4. IV/Heparin Lock No 0 Yes 20 ______ 5. Gait/Transferring Normal/bedrest/immobile Weak Impaired 0 10 20 ______ 6. Mental status Oriented to own ability Forgets limitations 0 15 ______  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 patients head is down, and he or she watches the ground. Because the patients 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 patients 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 patients 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 patients response is not consistent with the nursing orders or if the patients 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 patients chart. 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