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NUR 263

Student _________________________Instructor_______________ Date__________

DAILY NURSING ASSESSMENT OF HOSPITALIZED PATIENT

Admitting/current DX and Chief complaint on admit:

Date Days since ad Gender Age Height Weight BMI

Chronic Medical Diagnosis (es:

Surgeries or Procedures Dates

Allergies
Diet order

Activity Order
Advanced Resuscitation Status:
Directive Type:

Vitals on Temp HR R BP SaO2 Other:

admission
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I. REVIEW OF SYSTEMS
Date AM Temperature Route

Pain

Character
Onset
Location
Duration
Severity
Pattern
Associated factors
Relief measures
Result

I. Neurological Status:

Previous History

Level of consciousness
Oriented to person, place
and time
Native language

Speech

Voice quality

Equality of hand grasps

Equality of pupil size
(PERLA)
C/O headache, tinnitus,
vertigo ect…
Affect
Memory: Recent,
Remote; how assessed?
Other
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II. Head and Neck

Previous History:

Facial symmetry

Dentures or missing
.
teeth?

Mouth:
Oral mucous membranes
Tongue

Swallowing (CNIX,X)

Hearing aids: Hearing: (CNVIII): Symmetry:

Ears

Eyes:
redness
drainage
glasses
ROM Lumps/Masses CNXI
Neck:
ROM
Lumps or masses

Scars, or other
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III. Cardiovascular Status

Previous History

Left: Right:
Blood pressure

If unable to check in one extremity, state why.

Rate: Strength:
Apical pulse

(L) Rate: (R) Rate:

Radial pulse Strength: Strength:
Rhythm: Rhythm:
(L) Strength: (R) Strength:
Pedal pulse Rhythm: Rhythm:

Color of fingernail beds

Capillary refill time

Upper extremity edema Left: Right:

(0, +1, +2, +3, +4)
Ankle edema Left: Right:
(0, +1, +2, +3, +4)
Jugular vein
distention?

Other:
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IV. Respiratory Status

Previous History

Rate: Rhythm: Depth: SpO2:

Skin color: Skin Temperature:

(R) Superior: (L) Superior:

Congestion in
lungs Middle: Inferior:
(note all lobes)
Inferior:

Cough/sputum

Route:
O2 order Flow Rate:

Chest expansion

Route: Frequency: Secretions:

Suction

Other
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V. GI/GU

Previous History

Appearance of
abdomen

Scars

RUQ: RLQ: LUQ: LLQ:

Bowel sounds

Last bowel movement

Incontinence:
Urine/Feces
Date of application:
Catheter (Texas or
Foley)

Urine characteristics
Urine output
during time you cared for
patient
Drains –
location and output
N/G tube,
G-tube, J-tube :
Amount: Type:
Suction:

Type: Frequency: Amount:

Feeding:

Total Output
for your “shift”
Intake: Oral, IV,
feeding tube etc. for shift
Intake: Output:
Previous 24 o I & O
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VI. Musculoskeletal Status:

Previous History:

ROM of limbs: RUE: RLE: LUE LLE

(Reminder: Do not
move beyond pain or
resistance.)
Address all four
extremities, active or
passive? Full or
limited?

Inflammation of
joints

Use of
mobility/immobility
devices or aids

Posture/gait

Therapeutic
bed/mattress

Right: Left:
Upper extremity
strength

Dorsiflexion and Right: Left:

plantarflexion of
feet against
resistance

Number of assists to
transfer

Other
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VII. Integumentary Systems

Previous History:

Skin Color: Turgor: Temperature: Moisture:

Pink

Length: Texture:
Nails

Hair distribution Body: Scalp:

(Body & Scalp)

Scars

Area(s) of skin
breakdown/stage

Location: Type of Dressing: Description of wound:

Dressings

Total:

Rational:

Braden Scale
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Intravenous Access and therapy

Type of access: Peripheral

or Central or Other

Location Size Gauge

Catheter

Date site last changed

Pump/DAF /controller

Type of Fluid in Type Additives Capacity How much Rate of

maintenance bag: including remains infusion
additives, capacity and how
much remains in the bag and
rate of infusion of
maintenance bag.

Assessment of IV site:-

OTHER ASSESSMENT FINDINGS OR ISSUES OF NOTE

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IX. MEDICATIONS

Dose, Times,
Purpose for Patient- Home
Name of Med Route Days
Therapeutic and Pharmacological Class med??
Frequency given
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Diagnostics
Include abnormal lab and/or labs pertinent to medical diagnoses, or medication
therapy
Test Normal Date Results Relate to patient
ranges

Three Nursing Diagnoses: One must be a psychosocial nursing diagnosis

Write complete NANDA Statements NANDA, R/T, AEB

1._____________________________________________________________________
_______________________________________________________________________

2.______________________________________________________________________
_______________________________________________________________________

3.______________________________________________________________________
_____________________________________________________________

Chart PIE Note on Priority Nursing Diagnosis

P:

I:

E:
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NUR 263
Rubric for Daily worksheet
Daily Worksheet Rubric

Completed Incorrect Comments:

Correctly or
incomplete

No patient names or patient

0.5 0
identifiers on paper
General information clearly 1.0
2.0 incorrect
articulated
0
incomplete

Review of systems clearly 2.0 1.0

incorrect
articulated
0
incomplete

Diagnostics-appropriate 1.5 1.0

incorrect
content gathered
0
incomplete

Meds completed 1.5 1.0

incorrect
0
incomplete

3 NANDA’s identified, correct 2.0 1.0

incorrect
terminology
0
incomplete

PIE note clearly articulated 0.5 0.25

Incorrect
0
incomplete

Total point/s /10