Patient Care Suzanne Gordon DOB 09/27/1988
Daily Assessment Record
| Legend: | X= Yes | Date:__________________________ | |||||||||
| System | Normal Criteria | Form | Notes | ||||||||
| Safety: | QPA ☐ | Bedside Safety ☐ | Falls Risk Assessment ☐ | 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 ☐ | |||||||||
| Cardiovascular: | Regular apical/peripheral pulse, no chest pain, peripheral pulses palpable, no calf redness, extremities pink and warm ☐ | Telemetry Monitoring ☐ Vascular Form ☐ | |||||||||
| 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 ☐ | |||||||||
| 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 ___________________ | |||||||||
| Genitourinary: | Urinates without pain, voiding pattern is usual, urine clear, yellow ☐ | Urostomy ☐ Foley ☐ | |||||||||
| Gynecology/Urology | Skin intact ☐, no lesions or discharge ☐, no itch or odor ☐ | STI Screening ☐ LMP ____________ | |||||||||
| Musculoskeletal: | Steady gait, no fractures/sprains/strains ☐ | Total Care ☐ 1Person Assist ☐ 2Person Assist ☐ | |||||||||
| Psychosocial: | Interacts and communicates in an appropriate manner with others, demonstrates effective coping skills ☐ | MSE ☐ | |||||||||
| Integumentary: | Color normal, warm, dry and intact, moist mucus membranes ☐ | Braden ☐ Wound Care ☐ Drain_____________ | |||||||||
| Pain: | Denies pain ☐ | Pain assessment ☐ | |||||||||
| Other: | |||||||||||
| IV: | Free inflammation, patent, no pain, dressing intact, flushes well ☐ | Type_______ Gauge_______ Location_________ Lumen #____________ | |||||||||
| Date | Nurses Notes (Data/Action/Response/Notes) | Provider | |||||||||
Vital Signs
| DAY | ||||||||
| TIME | ||||||||
| TEMPERATURE | ||||||||
| PULSE | ||||||||
| RESPIRATION | ||||||||
| BLOOD PRESSURE | ||||||||
| O2 SAT | ||||||||
| WEIGHT | ||||||||
| Initials | ||||||||
| DAY | ||||||||
| TIME | ||||||||
| TEMPERATURE | ||||||||
| PULSE | ||||||||
| RESPIRATION | ||||||||
| BLOOD PRESSURE | ||||||||
| O2 SAT | ||||||||
| Weight | ||||||||
| Initials | ||||||||
| DAY | ||||||||
| TIME | ||||||||
| TEMPERATURE | ||||||||
| PULSE | ||||||||
| RESPIRATION | ||||||||
| BLOOD PRESSURE | ||||||||
| O2 SAT | ||||||||
| Weight | ||||||||
| Initials | ||||||||
SBAR Report
Wound Care
Mental Status Exam
| Date Time | Mental Status Exam (MSE) | Notes Required |
| General Appearance: Age Hygiene/Grooming Build | ☐ Appears stated age ☐ Appears younger than age ☐ Appears older than age ☐ Clean ☐ Body odor ☐ Tattoos ☐ Dressed appropriately to season ☐ Unkempt ☐ Average ☐ Frail ☐ Obese ☐ Muscular ☐ Petite ☐ Stocky | |
| Behavior: Eye contact Attitude LOC Activity Level Posture | ☐ Poor ☐ Adequate ☐ Good ☐ Intense ☐ Engaging ☐ Disengaged ☐ Cooperative ☐ Guarded ☐ Open ☐ Fearful ☐ Demanding ☐ Defensive ☐ Suspicious ☐ Alert ☐ Confused ☐ Sedated/drowsy ☐ Hyper alert ☐ Fluctuating ☐ Normal ☐ Pacing ☐ Posturing ☐ Apraxia ☐ Wringing hands ☐ Wandering ☐ Relaxed ☐ Rigid ☐ Slumped ☐ Erect | |
| Mood: (reported by client) | ☐ Afraid ☐ Angry ☐ Anxious ☐ Depressed ☐ Energetic ☐ ☐ Frustrated ☐ Happy ☐ Upset ☐ Overwhelmed ☐ Lonely ☐ Worried ☐ Normal | |
| Affect: Stability/Range Congruency | ☐Angry ☐ Depressed ☐ Anxious ☐ Euphoric ☐ Fearful ☐ Irritable ☐ Suspicious ☐ Euthymic ☐ Labile ☐ Blunted ☐ Flat ☐ Full ☐ Range Is Affect congruent with content of speech and circumstances? ☐ Yes ☐ No | |
| Risk: Suicide Risk Prior Suicide Behavior Level of risk to client Safety Plan completed? Homicidal Ideation | Ideation: ☐ Yes ☐ No ☐ Unknown Plan: ☐ Yes ☐ No ☐ Unknown Resources: ☐ Yes ☐ No ☐ Unknown Means: ☐ Yes ☐ No ☐ Unknown Distress/Pain: ☐ Yes ☐ No ☐ Unknown Triggers: Yes No Unknown Lost someone close to suicide: ☐ Yes ☐ No ☐ Unknown ☐ Yes ☐ No ☐ Unknown Details: Has patient made a suicide attempt or engaged in significant intentional self-harm behaviour within the past 24 hours? ☐ Yes ☐ No ☐ Unknown Comments: (observed by clinician) ☐ None ☐ Mild ☐ Moderate ☐ High/Imminent ☐ Yes ☐ No Details ☐ Yes ☐ No ☐ Unknown Details: | |
| Thought Process: | ☐ Disorganized ☐ Normal ☐ Spontaneous ☐ Poverty ☐ Thought Blocking ☐ Vague ☐ Logical ☐ Perseverative | |
| Speech: Amount Rate Pressure Associations Rhythm | ☐ Normal ☐ Mute ☐ Monosyllabic Clarity: ☐ Clear ☐ Incoherent ☐ Slurred ☐ Normal ☐ Controlled ☐ Slowed ☐ Rapid Volume: ☐ Loud ☐ Moderate ☐ Soft ☐ Normal ☐ Low ☐ Pressured ☐ Explosive ☐ Normal ☐ Loose ☐ Flight of ideas ☐ Word Salad ☐ Tangential ☐ Normal ☐ Even ☐ Hesitant ☐ Stuttering | |
| Thought Content: Delusions Unusual content ??? | ☐ Compulsion ☐ Depressive ☐ Risk to self/others ☐ Thoughts about future ☐ Control ☐ Somatic ☐ Mind reading ☐ Persecution ☐ Grandiosity ☐ Thought broadcasting ☐ Obsessions ☐ Phobias ☐ Preoccupations ☐ Ruminations ☐ Congruent to situation | |
| Perceptual Abnormalities: Hallucinations | ☐ Depersonalization ☐ De-realization ☐ Illusions ☐ None observed ☐ Auditory (command) ☐ Auditory (non-command) ☐ Visual ☐ Denies | |
| Cognition: Memory Attention Orientation Concentration | ☐ Intact ☐ Deficits ☐ Good ☐ Mildly distracts ☐ Unable to attend ☐ Person ☐ Place ☐ Time ☐ Good ☐ Fair ☐ Poor | |
| Insight Reasoning/Judgement | ☐ Full ☐ Partial ☐ Limited ☐ Minimal ☐ Absent ☐ Intact ☐ Mild impairment ☐ Moderate impairment ☐ Severe impairment | |
| Notes: |
In/Out Record
| INTAKE | SHIFT: Day | ||||
| Time: | ORAL | IV | TUBE FEED | Other | |
| 12 Hr Total Intake | |||||
| OUTPUT | |||||
| TIME: | Urine | Emesis | NG | Stool | Other |
| 12 Hr Total Output | |||||
| 12 HR Balance |
| INTAKE | SHIFT: Night | ||||
| Time: | ORAL | IV | TUBE FEED | Other | |
| 12 Hr Total Intake | |||||
| OUTPUT | |||||
| TIME: | Urine | Emesis | NG | Stool | Other |
| 12 Hr Total Output | |||||
| 12 Hr Balance |
Blood Glucose Record
| 0200 | Breakfast | Lunch | Dinner | HS | ||
| Date: Day of C/S | ||||||
| Time: | 1230 | 1700 | 2200 | |||
| Reading: | 5.6 | 9.8 | 8.7 | |||
| Comments: | ||||||
| Date: 1 day Post C/S | ||||||
| Time: | 0140 | 0800 | ||||
| Reading: | 6.0 | 9.2 | ||||
| Comments: | ||||||
| Breakfast | Lunch | Dinner | HS | ||
| Date: | |||||
| Time: | |||||
| Reading: | |||||
| Comments: | |||||
| Date: | |||||
| Time: | |||||
| Reading: | |||||
| Comments: | |||||
Braden Scale
| DATE/TIME OF ASSESSMENT: | ||||||||
| Sensory perception Ability to respond meaningfully to pressure-related discomfort | 1. 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 surface | 2. 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 ½ 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 moisture | 1. 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 activity | 1. 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 position | 1. 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 pattern | 1. Very poor: Never eats a complete meal. Rarely eats more than ⅓ 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 ½ 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 Shear | 1. 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. | |||||
| TOTAL SCORE: | ||||||||
| Signature | Initials | |||||||
Postpartum Assessment
| Wound Type/Etiology (if known) Pressure ☐ Venous ☐ Arterial ☐ Diabetic ☐ Surgical 2°Intent ☐ Skin Tear ☐ Other ☐ | |||
| If Pressure Ulcer, chart stage: Stage 1_________ Stage 2_________ Stage3_________ Stage 4_________ Stage X(unstageable)_________ Stage SDTI (Suspected Deep Tissue Injury)_________ | |||
| MARK LOCATION OF WOUND/ULCER WITH AN ARROW OR AN ”X” | |||
 |  |  | |
| Legend: X or Blank Space = Not Applicable (as per agency) I * = Assessed/Completed I PN = See Progress Notes | |||
| Wound Location: | Date: | Date: | |
| Time: | Time: | ||
Measurements | Length | ||
| Width | |||
| Depth | |||
| Sinus Tract #1 Depth | |||
| Location (o’clock) | |||
| Sinus Tract #2 Depth | |||
| Location (o’clock) | |||
| Undermining #1 Depth | |||
| Location (o’clock) | |||
| Undermining #2 Depth | |||
| Location (o’clock) | |||
| Wound Bed: Total % must = 100% | % Pink/Red | ||
| % Granulation (red pebbly) | |||
| % Slough | |||
| % Eschar | |||
| % Foreign body (sutures, mesh, hardware) | |||
| % Underlying structures (fascia, tendon, bone) | |||
| % Not visible | |||
| % Other: | |||
| Exudate Amount | None | ||
| Scant/small | |||
| Moderate | |||
| Large/copious | |||
| Exudate Type | Serous | ||
| Sanguineous | |||
| Purulent | |||
| Other: | |||
| Odor | Odour present after cleansing Yes or No | ||
| Wound Edge | Attached (flush w/ wound bed or ”sloping edge”) | ||
| Non-Attached (edge appears as a ”cliff”) | |||
| Rolled (curled under) | |||
| Epithelialization | |||
| Peri-wound Skin | Intact | ||
| Erythema (reddened) in cm | |||
| Indurated (firmness around wound) in cm | |||
| Macerated (white, waterlogged) | |||
| Excoriated/Denuded (superficial loss of tissue) | |||
| Callused | |||
| Fragile | |||
| Other: | |||
| Wound Pain (10 = worst) | Scored from 10 point analogue Pain Scale See Pain Assessment for details | ||
| Treatment | If packing used, indicate # of packing pieces out/in | Out= _____ In=_____ | Out= _____ In=_____ |
| Treatment Plan | |||
| Date Initiated: | |||
| Plan: | |||
| Date D/C: | |||
| Date Initiated: | |||
| Plan: | |||
