Patient Care Adir Azibo DOB 02/02/1968
Daily Assessment Record
| Legend: | X= Yes | Date:_____Yesterday, 2100______ | |||||||||
| System | Normal Criteria | Form | Notes | ||||||||
| Safety: | QPA X | Bedside Safety X | Falls Risk Assessment X | 15 min checks ☐ | |||||||
| Neurological/ Cognition: | Alert & orientated x 3, speech clear and understandable, memory intact, active ROM, sensation intact, no paresthesia ☐ | Delirium Screening ☐ Neuro Vitals ☐ | See notes | ||||||||
| Cardiovascular: | Regular apical/peripheral pulse, no chest pain, peripheral pulses palpable, no calf redness, extremities pink and warm ☐ | Telemetry Monitoring ☐ Vascular Form ☐ | See notes | ||||||||
| Respiratory: | Resting respirations quiet & regular, symmetrical chest wall movement, pink nail beds and mucous membranes, air entry clear to bases on L&R lobe ☐ | Chest ☐ Tube ☐ Suction ☐ Trach ☐ | See notes | ||||||||
| Gastrointestinal | Abdomen soft and non distended, tolerates without nausea, no difficulty swallowing, bowel pattern normal for pt, bowel sounds present ☐ | Last BM ____________ Parenteral Nutrition ☐ Enteral Nutrition ☐ Ostomy ☐ Tube ___________________ | See notes | ||||||||
| Genitourinary: | Urinates without pain, voiding pattern is usual, urine clear, yellow ☐ | Urostomy ☐ Foley ☐ | See notes | ||||||||
| Gynecology/Urology | Skin intact ☐, no lesions or discharge ☐, no itch or odor ☐ | STI Screening ☐ LMP ____________ | See notes | ||||||||
| Musculoskeletal: | Steady gait, no fractures/sprains/strains ☐ | Total Care ☐ 1Person Assist ☐ 2Person Assist ☐ | See notes | ||||||||
| Psychosocial: | Interacts and communicates in an appropriate manner with others, demonstrates effective coping skills X | MSE ☐ | |||||||||
| Integumentary: | Color normal, warm, dry and intact, moist mucus membranes ☐ | Braden ☐ Wound Care ☐ Drain_____________ | See notes | ||||||||
| Pain: | Denies pain ☐ | Pain assessment ☐ | See notes | ||||||||
| Other: | |||||||||||
| IV: | Free inflammation, patent, no pain, dressing intact, flushes well X | Type_______ Gauge_______ Location_________ Lumen #____________ | |||||||||
| Date | Nurses Notes (Data/Action/Response/Notes) | Provider | |||||||||
| Yesterday 2100 | Admitted to unit. Sleepy but rouses easily. States has spent past 18 hours in the ER with little sleep. T 38.0 oral HR 94 RR 18 BP 160/84 SpO2 94% room air. Resps easy. Chest clear with slightly diminished air entry to bases. DB&C reviewed and demonstrated. Abd. Soft, flat. Bowel sounds x4. LBM yesterday. Reported as ‘normal’. Describes some hesitancy with urination. No burning. Denies odor. Takes tamsulosin. Slab / tensor to left lower leg. 2 pins emerging from same. Purulent drainage around each. DP / PT +3 right. DP +3 left. PT left not accessible due to tensor. Denies numbness / tingling to lower extremities. Brisk cap refill to 10 toes. Right leg strong (dorsi / plantar / knee / hip flexion). Wiggles left toes. Crutches at bedside. States feels strong and safe when ambulating independently. Pain to left leg 2/5 declines offer of analgesia. Leg elevated on pillow | T Rex RN | |||||||||
Vital Signs
| DAY Yesterday | ||||||||
| TIME | 2100 | |||||||
| TEMPERATURE | 38.0 oral | |||||||
| PULSE | 94 regular | |||||||
| RESPIRATION | 18 | |||||||
| BLOOD PRESSURE | 160 | |||||||
| 84 | ||||||||
| O2 SAT | 94 RA | |||||||
| WEIGHT | ||||||||
| Initials | T Rex, RN | |||||||
| DAY Today | ||||||||
| TIME | 0600 | |||||||
| TEMPERATURE | 38.0 oral | |||||||
| PULSE | 86 regular | |||||||
| RESPIRATION | 18 | |||||||
| BLOOD PRESSURE | 148 | |||||||
| 78 | ||||||||
| O2 SAT | 96 | |||||||
| Weight | 103 kg | |||||||
| Initials | T Rex, RN | |||||||
| DAY | ||||||||
| TIME | ||||||||
| TEMPERATURE | ||||||||
| PULSE | ||||||||
| RESPIRATION | ||||||||
| BLOOD PRESSURE | ||||||||
| O2 SAT | ||||||||
| Weight | ||||||||
| Initials | ||||||||
In/Out Record
| INTAKE | DATE | Today | 24 Hr Total | |||||
| SHIFT: | Days | Nights | ||||||
| TIME: | 0700 | |||||||
| ORAL | sips | |||||||
| IV | 600 cc | |||||||
| TUBE FEED | ||||||||
| BLOOD | ||||||||
| TPN | ||||||||
| LIPIDS | ||||||||
| Other | ||||||||
| TOTAL | ||||||||
| OUTPUT | DATE | |||||||
| TIME: | ||||||||
| VOID | ||||||||
| FOLEY | ||||||||
| EMESIS | ||||||||
| Other: | ||||||||
| STOOL | ||||||||
| TOTAL | ||||||||
| 24 hr Balance | ||||||||
