Daily Assessment Sheet

Student Name(s): ______________________________________________________________________

1. Date of Care: 2. Admission Diagnosis: 3. Age: 4. Gender: 5. Admission Date:

6. Use page 2 to expand on the following:Pathophysiology of diagnosis, Signs and symptoms (Highlight those your patient exhibits), Tentative Nursing diagnoses for Pathophysiology, Reason for hospitalization(what brought them to the hospital) [may be the same as Signs and Symptoms]

7. Chronic illnesses:

_________________________________Previous home management:

8. Surgical procedures:Name of surgical procedure:Describe surgery (use page 2 to expand on this if needed):Key Problem (s): NSG DX:

9. INFORMATION TO OBTAIN DURING REPORT:

Information to Obtain Results of Information

Key Problems NSG DX:

10. TWO MINUTE ASSESSMENT:

Two Minute Assessment Actual Two Minute Assessment Findings

Key Problems: NSG DX:

11. ADVANCE DIRECTIVES:

1

Living Will: Yes No Power of Attorney: Yes No Do not resuscitate (DNR) order: Yes No

Documentation Form (for those things requested in box 6 & 8):

Documentation Form (for narrative charting):

2

3

12. LABORATORY DATA:

4

Test Normal Value

AdmissionDate/Time

2nd valueDate/Time

3rd valueDate/Time

Reason for Abnormal Values

WBCRBCHgbHctPlateletsPTINRPTTSodiumPotassiumChlorideGlucoseBUNCreatininePre-AlbuminAlbuminCalciumPhosphateBilirubinAlkaline PhosSGOTASTCKCK MBTroponinBNP

Key Problems: NSG DX:

13. DIAGNOSTIC TESTS (other than labs):

5

Diagnostic Study Rationale for Study Patient Result Clinical SignificanceExample: Echocardiogram Chest pain and SOB EF 30% Decreased cardiac output, etc.

Key Problems: NSG DX:

14. MEDICATIONS: List all medications. Mark (*) for pertinent medications; mark (H) for home medications and (N) for new medications.

Key Problems: NSG DX:

15. ALLERGIES/PAINS:

Allergies:Type of Reaction:

When was the last time pain medication given on previous shift?

Where is the pain? How much pain is the patient in on a scale from 0-10?

16. TREATMENTS: List treatments and rationales for treatments

6

Treatment Rationale for Treatment Patient Response

Key Problems: NSG DX:

17. DIET/FLUIDS:

Type of diet: Restrictions: Appetite: (circle)Good Fair Poor

Breakfast:_____%

Lunch:____%

Dinner:____%

Prior 24 hoursFluid intake:Fluid output:

Circle those problems that apply:Problems: swallowing, chewing, denturesNeeds assistance with feedingNausea and vomitingOverhydrated or dehydrated

Tube feedings:Type and rate:Key Problems: NSG DX:

18. INTRAVEVOUS FLUIDS:

Type and Rate of Solutions: IV dressing dry, no edema, no redness of site:Yes No

IV site location:Catheter type:

Key Problems: NSG DX:

7Key Problem (system)

Nursing Diagnosis (es):

Supporting Data:

Key Problem (system)

Nursing Diagnosis (es):

Supporting Data:

Key Problem (system)

Nursing Diagnosis(es):

Supporting Data:

8

Key Problem (system)

Nursing Diagnosis (es):

Supporting Data:

Key Problem (system)

Nursing Diagnosis (es):

Supporting Data:

Key Problem (system)

Nursing Diagnosis(es):

Supporting Data:

Key Problem (system)

Nursing Diagnosis(es):

Supporting Data:

Goal:

Reason For Needing Health Care:

Medical Diagnosis/Surgical Procedure:

Key Nursing Diagnoses:

Key Problem (system)

Nursing Diagnosis(es):

Supporting Data:

Goal:

Key Problem (system)

Nursing Diagnosis(es):

Supporting Data:

Goal:

Key Problem (system)

Nursing Diagnosis(es):

Supporting Data:

Goal: