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:_______________________________________