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CALHOUN COMMUNITY COLLEGE

NURSING DEPARTMENT

STUDENT NAME____________________
DATE OF EXPERIENCE_______________
PATIENT INITIALS__________________
MEDICAL DIAGNOSES_______________
SURGICAL PROCEDURE______________

DAILY ASSESSMENT GUIDE

DIRECTIONS: FOR ABNORMAL FINDINGS GIVE DETAILS IN NARRATIVE FORM ON
SEPARATE SHEET

How are you feeling?

Are you having any problems?

How was your night?

Are you having any pain?

INTEGUMENTARY SYSTEM:
Color______ Texture_________ Moisture__________ Temperature__________
Turgor_______ Rashes/Lesions__________ Pruritus___________
Bruising________________

CIRCULATORY SYSTEM:
T___________ P/rate________________ Rhythm________________
Strength________________ B/P________
(Describe any abnormals)
(a)Jugular Vein Distension - absent/present
(b)Apical pulse - rate_________ Rhythm___________ Strength__________________
Pedal Pulses: Present Absent
Dorsalis Pedis LR LR
Posterior Tibial LR LR

RESPIRATORY SYSTEM:
Describe Respirations: Rate______ Rhythm____________ Effort_____________
Auscultate Breath Sounds & Describe___________________________________
Respritory Equipment________________________________________________

GASTROINTESTINAL SYSTEM:
Diet(Type, amount eaten)________________
P.O. Fluids(Type, amount)________________ Last Bowel Movement___________
Any changes from normal pattern__________ Any nausea____________________
Vomiting__________ Distension____________ Passing Flatus_________________
Other Observations(tenderness, rigidity)__________________________________
Auscultate bowel sounds & describe______________________________________
Enteral feeings NG____________ Gastro____________ Jejunostomy____________
NG for decompression____________

GENITOURINARY SYSTEM: Are you voiding?________ Is there any pain?___________ Burning?_____________ Urgency?____________ Frequency___________ Amount voided________________ Color of urine______________________ Characteristics_______________________ Foley amount_________________ MUSCULO-SKELETAL SYSTEM: Activity for today_______________________________________________________ Ambulation aids__________________________________Weakness______________ Limited ROM?_________________________________ NEUROLOGICAL SYSTEM: Symmetry/Bilateral_____________________________ Numbness_________________ Dizziness______________________ Tingling_____________ Other________________ Orientation___________________LOC(Level of Consciousness)__________________ HEENT: Discharge/Drainage______________________ Are you able to swallow?____________ Condition of teeth/dentures?_______________Hearing ability_____________________ Vision(glasses)______________________PERRLA Yes__________ No_______________ ASSESS THE FOLLOWING: Type of Fluid________________________Volume of Fluid________________________ Rate of Infusion_______________________Infusing per pump_____________________ Gravity______________________________TPN_________________________________ IV Site___________________ Site Assessment_________________________________ Type of IVPB______________________ Heparin/Saline Lock__________________ Surgical Drainage Tubes__________________ Incision Site________________________ Dressings___________________________Other_________________________________ EKG Report________________________________________________________________ X-Ray Report______________________________________________________________ Allergies_________________________________s/s_______________________________ Current Medications_________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ ADDITIONAL ASSESSMENT DATA: List expected developmental stage and task(Erikson) .