DOWNTIME DAILY NURSING ASSESSMENT & CARE PLAN (Patient Label) 1 of 5 Date: Time:
PAIN No Pain Pain Present Other Location: Score: Scale:______Numeric NVPS Pain Description:______Pain Intervention:-______Pain Reassessment:______Sedation Level(ICU Only)______POSS Sedation Assessment: ______Intervention:______POSS Reassessment:______Sedation level > 3 Intervention: ______SAFETY Fall Risk Screen: Unsteady gait 20-up and go takes over 20 seconds 0- steady gait Disoriented 10-disoriented 0- oriented At risk behavior 20-at risk 0- not at risk Assistance w/ BR or has Foley 10- yes 0- no Fall risk meds 10- yes 0- no More than 4 medications 10- yes 0- no 2 or more falls in the last 12 months 20- yes 0- no Total (if 30 or over patient is at risk)______Interventions: Protocol Initiated Protocol Reviewed Protocol Discontinued Fall Risk ID on Bed exit alarm on Safety Checks Near nursing station Toileting assist
Isolation Type______Precautions: ______Restraints Type______NEURO WNL WNL Except Orientation: Oriented:______confused:______LOC: lethargic unresponsive responds to pain follows commands sedated unable to assess___ Pupils R size 1 2 3 4 5 6 shape______reaction ______L size 1 2 3 4 5 6 shape______reaction ______Speech: normal slurred impediment aphasic other ______Sensation: R Arm absent patchy L Arm absent patchy R Leg absent patchy L Leg absent patchy Reflexes corneal R L gag present absent cough present absent Dolls eyes present absent Occulovestibular present absent Babinski R L bilateral Swallow Screen: pass fail Seizures: Type generalized partial/complex partial/simple witnessed y n duration ______min postictal ______min Other:______Interventions neuro checks room darkened seizure precautions 24 h EEG monitoring Other ______SLP notified MUSCULOSKELETAL WNL WNL Except
Activity Restriction: ______Activity Aids:______Motor Strength Extremities: R Arm __/5 L Arm __/5 R Leg __/5 L Leg __/5 Speech:______Support Device: Type:______Location:______Other:______Interventions: ______PT OT Ortho / Vasc WNL WNL Except
Motor, Sensitivity, Color, Pulse, Temp R Arm L Arm R Leg L Leg R Foot L Foot Interventions: ______RESPIRATORY WNL WNL Except Abnormal findings: accessory muscles agonal Cheyne-Stokes irregular Kussmaul labored nasal flaring retractions shallow tachypnea Exceptions: cannot breathe chest tight cough smothering SOB other______Breath Sounds rhonchi R L diminished R L crackles R L wheezes R L stridor absent R L coarse R L Cough description______nonproductive productive______Chest tube: type ______location ______site assess ______suction ______drainage:______air leak yes no Chest tube: type ______location ______site assess ______suction ______drainage______air leak yes no Chest tube: type ______location ______site assess ______suction ______drainage______air leak yes no Other:______Interventions: O2 ______Vent ETT ____size ____cm R L O N Trach ______Type ______size ______Other:______
RN Signature:______*1514* Origin: 9/05 revised: 1/09; 5/09; 7/10; 9/11; 10/14; 1/15; 6/15
DOWNTIME DAILY NURSING ASSESSMENT & CARE PLAN (Patient Label) 2 of 5 Date: Time:
CARDIOVASCULAR WNL WNL Except Heart Sounds: S1 S2 S3 S4 Murmur______irregular distant rub Rhythm:______Ectopy:______Pacemaker: yes no temporary permanent ICD other______Edema: RUE trace 1 2 3 4 pit non-pit LUE trace 1 2 3 4 pit non-pit RLE trace 1 2 3 4 pit non-pit LLE trace 1 2 3 4 pit non-pit generalized sacral facial other______Pulses: R radial 0 1 2 3 4 dop L radial 0 1 2 3 4 dop R dorsalis pedis 0 1 2 3 4 dop L dorsalis pedis 0 1 2 3 4 dop Chest Pain: Rating (0-10):______Location:______Description:______Associated Symptoms:______Intervention:______SCD’s applied R Leg L Leg Tele: Rhythm______Intervention:______Other:______Interventions:______IV CARE WNL WNL Except #1 IV EDP PICC Port HD Site Assessment Dressing Changed V Blood Intervention:______#2 IV EDP PICC Port HD Site Assessment Dressing Changed V Blood Intervention:______#3 IV EDP PICC Port HD Site Assessment Dressing Changed V Blood Intervention:______GI/NUTRITION WNL WNL Except Bowel sounds: hyperactive hypoactive absent Abdomen: soft flat distended tender Exceptions: bleeding incontinent diarrhea emesis nausea other:______C-diff screen: No continued daily assessment C-diff protocol in progress Greater than 3 watery stools Ostomy: type: ______stoma description:______Stool:______Last BM Tube: type ______location ______site assess______suction______drainage______Tube: type ______location ______site assess______suction______drainage______Tube: type ______location ______site assess______suction______drainage______Other: Interventions RD notified GU WNL WNL Except Urinary Symptoms: hematuria incontinent oliguria dysuria frequency nocturia urgency hesitancy spasms other: Urine description: Bladder: Distended Palpable Catheter type______Size______Location:______Date:______Catheter Necessity: acute retention/bladder obstruction accurate urine output surg proc. > 2 hrs healing sacral/perineal wound in incont pt improve comfort of end of life care HD Access type:______location:______assessment:______thrill bruit Peritoneal type:______location:______fluid:______site assess:______Other:______Interventions: REPRODUCTIVE WNL WNL Except Assess: ______Discharge: ______Breast Exam:______Antepartum ______Post Partum:______Infant Feeding Preference ______Mom/emotional Status ______Infant Attachment:______Other:______Interventions: ______SKIN Risk Screen WNL WNL Except Skin Assess: Appearance: dry/flaky petechiae rash ecchymosis Color: pale pink cyanotic ashen mottled jaundiced Temp: warm dry moist clammy other complaints:______Skin Protection:______Daily Skin Risk (Braden Score) - circle Mobility: 1=Completely Immobile 2=Very Limited 3=Slight limited 4=No limitations Sensory Perception 1=Completely Limited 2=Very Limited 3=Slight limited 4=No impairment Nutrition 1=Very Poor 2=Probably Inadequate 3=Adequate 4=Excellent Moisture 1=Constantly Moist 2= Moist 3=Occasionally Moist 4=Rarely Moist Friction and Shear 1=Problem 2=Potential Problem 3=No apparent problem Activity 1=Bedfast 2=Chairfast 3=Walks Occasionally 4=Walks frequently Braden Score If less than <18 = Skin Precautions Interventions:
RN Signature:______Origin: 9/05 revised: 1/09; 5/09; 7/10; 9/11; 10/14; 5/15; 6/15 *1514*
DOWNTIME DAILY NURSING ASSESSMENT & CARE PLAN (Patient Label) 3 of 5 Date: Time:
WOUNDS WNL WNL Except Wound 1: type: location: ______appearance:______closures:______drainage:______intervention:______Wound 2: type: location: ______appearance:______closures:______drainage:______intervention:______Wound 3 type: location: ______appearance:______closures:______drainage:______intervention:______Wound 4: type: location: ______appearance:______closures:______drainage:______intervention:______
DRAINS WNL WNL Except Drain 1: type: location: ______appearance:______closures:______drainage:______intervention:______Drain 2: type: location: ______appearance:______closures:______drainage:______intervention:______Drain 3: type: location: ______appearance:______closures:______drainage:______intervention:______Other:______EMOTIONAL / MENTAL WNL WNL Except
Mood/affect: angry anxious agitated inappropriate response labile sad withdrawn hopeless Intervention: CIWA protocol encourage expression limit visitors active listen reassure reinforce other______Self Harm Screen: irritability uncontrolled symptoms refusing social interaction refusing ordered tx requesting early d/c Current MD Dx/disease dementia chronic pain end stage CA active psych illness new dx of chronic illness late stage chronic illness Self Harm Screen outcome: no risks-cont.daily self harm screen identified risks-complete suicide screen End of life care Interventions:______ENDOCRINE WNL WNL Except diaphoresis blurred vision dizziness hot/cold fatigue polydipsia polyuria other______Assess: diabetes exophthalmos goiter gynecomastia jaundice moon face hirsutism nailbed changes Other:______Interventions:______DTC notified ONCOLOGY WNL WNL Except Infusion: access blood return:______type:______reaction:______interventions:______Adverse Event: ______PATIENT EDUCATION Preferred Methodology: verbal written visual demonstration other Identified barriers none language cognitive hearing/visual physiological psychological culture/ethnic reading difficulty uninterested Taught whom patient significant other family friend other______How provided verbal written other______Learning needs: current new discharge review Content: bathroom equipment room how to call RRT fall prevention/amb hand hygiene resp hygiene contact precautions VTE prevention BSI prevention CAUTI unit/room orientation anticoagulation Other______Understanding: understands need reinforcement Other:______Interventions:______
Special Events:
Critical Results Off Unit Transfer / Handoff Belongings Coordination of Care Rapid Response Other:______Intervention______
D/C Planning: D/C Home D/C Planner Notified Additional Observations (for more notes see Interdisciplinary Progress Notes) : ______
RN Signature:______Origin: 9/05 revised: 1/09; 5/09; 7/10; 9/11; 10/14; 5/15; 6/15 *1514*
DOWNTIME DAILY NURSING ASSESSMENT & CARE PLAN (Patient Label) 4 of 5 Date: Time:
CARE PLANS 1- extreme deviation from normal limit 2- severe deviation from normal limit 3-moderate deviation from normal limit 4-mild deviation from normal limit 5-no deviation from normal limit Pain
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Safety
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Restraint Prevention
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Nutrition
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Neuro/Cognition
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Respiratory
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Cardiovascular
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 GI/Elimination
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 GU/Elimination
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5
RN Signature:______Origin: 9/05 revised: 1/09; 5/09; 7/10; 9/11; 10/14; 5/15; 6/15 *1514*
DOWNTIME DAILY NURSING ASSESSMENT & CARE PLAN (Patient Label) 5 of 5 Date: Time:
CARE PLANS (continued) 1- extreme deviation from normal limit 2- severe deviation from normal limit 3-moderate deviation from normal limit 4-mild deviation from normal limit 5-no deviation from normal limit Reproductive
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Skin/Wound
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Emotional/Mental
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Suicide Prevention
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Activity/Rest
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Health Promotion
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Ped Socialization
Nursing diagnosis: Goal Intervention Evaluation 1 2 3 4 5 Prioritization:
Problem #1 Nursing Diagnosis:
Problem #2 Nursing Diagnosis:
Problem #3 Nursing Diagnosis:
RN Signature:______Origin: 9/05 revised: 1/09; 5/09; 7/10; 9/11; 10/14; 5/15; 6/15 *1514*