SAINT FRANCIS OF ASSISI COLLEGESCHOOL OF NURSING

DAILY GENERAL ASSESSMENT TOOL

ACTIVITY VASCULAR ACCESS

TYPE OF ACTIVITY IV #1 SIDE DRIP
BR
DANGLE
CHAIR IV #2 HEPLOCK
AMB
BRP IV #3
BSC
HOW ACCOMPLISHED SAFETY
SELF BED IN LOWEST POSITION
Q2 ASSISTED CALL BELL WITHIN REACH
RANGE OF MOTION SEIZURE PRECAUTION
PASSIVE ASPIRATION PRECAUTION
ACTIVE
DEEP BREATH AND COUGH SKIN BREAKDOWN SCREEN/BRADEN SCALE

SENSORY PERCEPTION
HYGIENE Ability to respond to 1. completely limited
BED BATH OR SHOWER discomfort 2. very limited
SELF 3. slightly limited
WITH ASST 4. no impairement
COMPLETE MOISTURE
ORAL CARE degree to which skin is 1. constantly moist
PERI CARE exposed to moisture 2. very moist
SITZ BATH
3. occassionally moist
CATH CARE 4. rarely moist
LINEN CHANGE
AM/PM CARE ACTIVITY
degree of physical 1. bed fast
activity 2. chair fast
NUTRITION 3. walks occasionally
MEALS TAKEN BY NPO 4. walks frequently
SELF FEED MOBILITY
ASST/ SUPERVISION ability to change and 1. completely immobile
AMOUNT OF MEAL(S) control body position 2. very limited
TAKEN TOTAL FEED 3. slightly limited
100% 4. no limitations
50% NUTRITION
Less than 50% usual food intake pattern 1. very poor
SUPPLEMENT TAKEN 2. probably inadequate
PER ORDER 3. adequate
REFUSED 4. excellent
FRICTION AND SHEAR 1. problem
ELIMINATION 2. potential problem
URINE VOID AD LIB 3 no apparent problem
FOLEY CATH
CONTINENT TOTAL SCORE
INCONTINENT
STOOLS CONTINENT
INCONTINENT
# OF STOOLS
CHEST TUBE TO SUCTION
R OR L OFF SUCTION
SUCTION
DRAINS TYPES CLAMPED
SUCTION
NGT CLAMPED
PLACEMENT/ RESIDUAL
SUCTION (ENTER # TRACH
NT
TIMES/SHIFTS ORAL
 SAINT FRANCIS OF ASSISI COLLEGESCHOOL OF NURSING

NEUROLOGICAL
NO PROBLEMS IDENTIFIED ALERT, ORIENTED X3, RESPIRATORY
SPEECH CLEAR, STRENGTH NO PROBLEMS IDENTIFIED NO DISTRESS, LUNGS CLEAR
BILATERALLY, NO COUGH
EQUAL IN ALL EXTREMETIES
PERRLA RESPIRATIONS NO DISTRESS
DYSPNEA
LOC ALERT
COMA BREATH SOUNDS
LETHARGIC RIGHT CLEAR LEFT CLEAR
OBTUNDED RHONCHI RHONCHI
ORIENTATION SPEECH PERSON UNTESTABLE WHEEZES WHEEZES
PLACE SLURRED CRACKLES CRACKLES
TIME APHASIC DIMINISHED DIMINISHED
CLEAR MUTE ABSENT ABSENT
DIZZINESS NO COUGH NONE
YES DRY
ATAXIA NO PRODUCTIVE
YES SPUTUM NONE
PUPIL REACTION CLEAR YELLOW
RIGHT BRISK LEFT BRISK WHITE BROWN
SLUGGISH SLUGGISH GREEN BLOODY
FIXED FIXED O2 DEVICE NONE
VISION CLEAR NC
BLURRED MASK
FIXED COLLAR
EXTREMITY STRENGTH ARTIFICIAL AIRWAY NONE
RUE STRONG RLE STRONG TRACH
RESP. COMMENTS
WEAK WEAK
FLACCID FLACCID
LUE STRONG LLE STRONG
WEAK WEAK
FLACCID FLACCID GENITOURINARY
NEURO COMMENTS: URINE COLOR YELLOW
AMBER
BLOODY
CARDIOVASCULAR CHARACTER CLEAR
CLOUDY
CLOTS
VOIDING CONTINENT
NO PROBLEMS NORMAL HS, SKIN COLOR PINK
INCONTINENT
IDENTIFIED REGULAR RHYTHM PALE
FREQUENT
COLOR PINK DUSTY
FLUSHED URGENT
SKIN WARM/DRY
NO EDEMA BURNING
SKIN TEMPERATURE WARM ANURIA
RHYTHM REGULAR HOT
IRREGULAR GU TUBE TYPE FOLEY
COOL
HEART SOUNDS NORMAL COLD SUPRAPUBIC
ABNORMAL CAPILLARY REFILL BRSIK EXTERNAL
PROLONGED UROSTOMY
EDEMA NONE
YES, LOCATION JVD NO FEMALE VAGINAL DRAINAGE NO
PULSES ABNORMAL. FINDINGS: YES YES
MALE PENILE ILE DISCHARGE NO
CV COMMENTS: YES
GU COMMENTS

GASTROINTESTINAL PSYCHOLOGICAL
NO PROBLEMS INDENTIFIED BOWEL SOUN UNDS NORMAL NO PROBLEMS IDENTIFIED NORMAL AFFECT, INTACT
ABDOMEN SOFT, NON TENDER THOUGHT PROCESSES,
NON DISTENDED UNDERSTANDS HOSPI
ABDOMEN SOFT NON TENDER TALIZATION/FX
FIRM TENDER AFFECT/MOOD NORMAL
HAR NON DISTENDED ANGRY/HOSTILE AGITATED
D DISTENDED FLAT WITHDRAWN
BOWEL SOUNDS NORMAL UNABLE TO ASSESS
HYPOACTIVE THOUGHT PROCESS INTACT
HYPERACTIVE UNABLE TO ASSESS
ABSENT ABNORMAL FINDINGS
NAUSEA NO VOMITING NO INSIGHT UNDERSTANDS HOSPI
YES YES TALIZATION/FX
STOOL NORMAL TARRY DOES NOT UNDERSTAND HOSPI
DIARRHEA INCONTINENT TALIZATION/FX
CONSTIPATION BRIGHT RED UNABLE TO ASSESS
GI TUBE TYPE PSYCH COMMENTS:
OSTOMY TYPE
GI COMMENTS