NGMEDICARE &

CALCUTTA HOPE INFERTILITY CLINIC

Daily Nursing Assessment
Name:| Hotsek kuma Age: Sex: M/F
Registration No:
Baneye ID No:
Ward:
Consultant: DySupral Somotani Date of Bed No: |
EMOTIONAL STATE admission: 0602-94
M E
(Anxious/calm/angry/ co-operative M
fearful / restless / withdrawn) Neck vein distension (V/x)
CENTRAL NERVOUS SYSTEM
Level of consciousness Chest pain
(Alert / drowsy /confused
(V/x)
Pacemaker
semiconscious / comatose) (Permanent /Temporary /Pacing wire
GASTRO INTESTINAL SYSTEM
Oriented to (V/x) Mouth (clean /sordes / halitosis )
Time
Teeth (clean / plaque / loose )
Place Tongue ( clean / coated )
Oral ulcers, (V/x)
Person Peristalsis (V/x)
Speech (Relevant / irrelevant/ Abdominal distension
Slurred / Aphasia) Ag ( incms (V/x)
Nausea (V/x)
Hemiplegia /Paraplegia
Quardriplegia ) Vomiting
RESPIRATORY SYSTEM
(specify no. of times ) (/x)
Chest movement
NB M (V/x)
(Unilateral / Bilateral / Absent ) Nutrition Route
(oral /tube feeding
Respiratory pattern Parenteral
(Normal /Dyspnoea /Orthopnoea/ Bowel opened (V/x)
Paroxysmal nocturnal dyspnoea Constipation
Tachypnoea / Bradypnoea) (V/x)
Air entry (Bilaterlly equal Diarrhoea (V/x)
Diminished - specifyR/L-Lung ) Malena (V/x)
GENITOURINARY SYSTEM
Breath sounds Voids freely / Catheter
(Normal /Rales / Ronchi / wheeze ) Urine :Colour
Cough (N/x ) :Sediments (V/x)
Oxygen on flow (L/min ) Hematuria (V/x)
Chest drains (L-Pleural / Retention/ Incontinence / not applicable
R- Pleural / mediastinal)
INTEGUMENTARY SYSTEM
Fluid column Fluctuating (V / x) Skin (intact / break down /rash / blister /
(L) Pleural Infection- specify site )
(R) Pleural Cyanosis ( peripheral / central )
Mediastinal Peripheries ( warm / cold )
CARDIOVASCULAR SYSTEM Nails -Clubbing
Normal /Tachyarrythmia /
(V/x)
Bradyarrythmia Capillary - refill (V/x)
(<3 seconds)
Normotension / Hypertension / Odema -Site
Hypotension lcterus
Peripheral pulses (V/x)
(Present/ Feeble / Absent )
TEMPERATURE (Afebrile / Febrile)
-Radial
SCALP (clean / pediculi / dandrutt)
EYES (Clean / discharge / icterus )
- Popliteal NOSE (clean / discharge)
- Post tibial
EAR (clean / discharge)
DorsalisPedis SLEEP (Adequate /disturbed)
 INFERTILITY CLINIC
CALCUTTA HOPE
NG MEDICARE &
Daily NursingAssessment
10pm
pm
PAIN -ASSESSMENT
Heart Sounds
:Si
(over 2 hourly)

:S2 Rating ( on a scale of

:S3 0- 10)

: S4
Murmur

MUSCULO SKELETAL SYSTEM M N INVESTIGATION

M
Joints (Mobile / Stiff/
Painful /contractures

Ambulant /Bed to chair or Done

toilet /ridden

INVASIVELINES
Central Line :site
condition
Peripheral Line: site
Due
: condition
Arteril Line : site
: condition

Any other Line : site

: condition

Reports
INSCISIONAL Awaited
WOUND Seterotomy Graft Drain Site

M EN M NI ME N

Healthy (V/x)
Oozing
(sanguineous/
serosanguinous/
serous / pus
Gaping ( incms )
Dressing Abnormal
ANY OTHER
WOUND
Site
Size (cms):
*Stage

MISCELLANEOUS (Mention important findings not included in the above assessment)

M

Signature of Nurse (Morning) Signature of Nurse (Evening) Signature of Nurse (Night)